Chapter XII: Preface: iii (11)

PHYSICIANS' TREATMENT for La Grippe.--All discharges from the nose, throat and lungs should be disinfected, for the disease is contagious. Go to bed and stay there. You have no business to be around if you value your health. I am not writing of common cold. A great many people say they have had this disease when they have not had it. One who has had this disease is sick enough to go to bed, and there is where he should be. For the chill a sweat should be produced by putting hot water in fruit jars, wrapping them and placing them around the patient's feet, legs and body. Hot tea drinks can be given; hot lemonade, teas made from hoarhound, ginger, hops and catnip are good.

Corn Sweat.--The corn sweat can be used. Put from ten to twenty-five ears of corn in a boiler, boil thoroughly until the boiled corn smell appears, then put the corn ears into five packs, putting from two to five ears in a pack, according to the age of the patient. Use cloths or towels, but do not put the ears in contact, wrap the cloth between them. Put one pack to the feet and one at each side of the hips, and in each armpit. This will soon cause sweating and restore the external (capillary) circulation. It will generally produce a grateful sweat. Keep the clothes on the patient. After the patient has perspired enough you can remove one pack at a time. Have fresh aired sheets and night dress ready, and after bathing the patient slowly and carefully under the clothes with tepid water and drying all of the body put on the new night-dress and sheets. This remedy is also good for colds and inflammatory diseases of all kinds and when used carefully and thoroughly is always good. Of course, if there is great weakness it cannot be used, for it weakens a patient somewhat. I have saved lives with this sweat, and I know I have cut short many colds and inflammatory diseases. After the sweat the patient should have enough covering to keep comfortably warm and care must be taken to keep from the cold.

Fever.--If the disease goes on and there is high fever, so that the patient suffers from it, it is better to reduce it by cool sponging than by the coal tar products like antipyrin, acetanilid, etc. They are weakening and this is a weakening, prostrating disease. Good, careful cool sponging generally relieves the excessive fever and restlessness. The fever does not continue so long in this disease and it is not, therefore, so harmful. Delirium is present in some cases when the fever is not high.

Irritating Cough.--This can frequently he controlled by steam inhalations as directed under tonsilitis. You can also put in the steaming water one teaspoonful to one tablespoonful of compound tincture of benzoin for this disease. Hoarhound tea can be put in the water and the steam inhaled. If such measures do not stop the cough, medicine will be needed.

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Sore Throat.--Spraying the throat with a solution of boric acid, one dram to one pint of hot water, is good. Listerine is good in the same way and dose.

Bowels.--They should be kept open from the first. Salts are usually handy and good.

Medicines.--Ten grains Dover's powder at night is good; unless there is much weakness. Some give quinine, some salol. Quinine, one to two grains, is given one to three hours. Salol, five grains, every three hours, especially for the backache.

Aspirin in five-grain doses for an adult every four hours is given very much now. The bowels should be kept open with salts.

Diet.--Children should take milk if there is no vomiting or diarrhea. If there is vomiting and diarrhea, give only water or diluted milk, or nothing if they continue. Water can generally be given.

For adults a good, nourishing diet when convalescence commences is necessary. During the sickness, milk, eggs,--raw and soft boiled, broths, soups, milk toast, can be given. A person must be very careful after an attack of the grip. He should remain in the house for some time, a week after he is well and thinks he can go out.

TYPHOID FEVER.--Typhoid fever is an acute infectious disease caused by a (Bacillus) germ, named after the discoverer (Eberth). This germ enters into the system, as stated below, locates itself in different organs, especially in the small intestine. It does its worst work in Peyer's glands, situated in the small intestines. They enlarge, ulcerate, break down and their structure is cast off into the bowel. This eating goes so far, in some cases, that it eats through the tissue to the blood vessels and other bleeding follows. Sometimes it goes through all the coats, the peritoneal being the last one. If this occurs we have what is called perforation of the bowel and the peritoneum around this perforation inflames and there is the dread complication of peritonitis. This is very fatal, as the patient is weakened from the inroads of weeks of fever and from the effects of the poison germ. Typhoid fever is also characterized by its slow (insidious), slyly, creeping onset, peculiar temperature, bloating of the abdomen, diarrhea, swelling of the spleen, rose-colored spots and a liability to complications, such as bleeding from the bowels, peritonitis, bronchitis and pneumonia. Its average duration is three to four weeks, often longer. In order to take this disease there must first be the poison germ and then this enters into the system, generally through water that contains the germ, milk, oysters and other foods, etc.

Cause.--The typhoid bacillus (typhoid). This enters into the alimentary canal usually through contaminated water or with milk directly infected by the milk or by water used in washing cans. Also through food to which the germs are carried from the excreta (discharges) by flies, occasionally through oysters by freshening.

Filth, improper drainage and poor ventilation favor the preservation of the bacillus germ and lower the power of resistance in those exposed.

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Time.--It occurs most frequently between August and November and in those of from fifteen to twenty years of age. The Peyer's patches and solitary glands of the bowel enlarge, become reddish and are somewhat raised. These go on and ulcerate until the blood vessels may be eaten into and bleeding sometimes results, it eats through the bowel, then there is perforation and peritonitis. The spleen is enlarged, the liver shows changes, the kidney functions are also deranged.

Symptoms.--The symptoms are variable. The following gives the symptoms in a typical case:

Incubation.--The period of incubation lasts from eight to fourteen and sometimes to twenty-three days. During the period the patient feels weak, is almost unable to work, has chilly feelings, headache and tiring dreams, does not know what is the matter with him, constipation or diarrhea, has no appetite, may have some pain in the abdomen which is occasionally localized in the right lower side. Soreness on deep pressure is often found there. In some cases there is nosebleed.

First Week.--After the patient is obliged to take to his bed: During the first week there is in some cases a steady rise in the fever each evening showing a degree or degree and one-half higher than the preceding evening, reaching 103 to 104, and each morning showing higher fever than the preceding morning. The pulse is characteristically low in proportion to the temperature, being about 100 to 110, full of low tension, often having double beat. The tongue is coated; there is constipation or diarrhea; the abdomen is somewhat distended and a little tender to the touch in the lower right portion. There may be some mental confusion at night. Bronchitis is often present. The spleen becomes enlarged between the seventh and tenth day and the eruption usually appears during this period on the stomach and abdomen.

Second week.--All the symptoms are intensified in the second week, the fever is always high and the weakening type; the pulse is more frequent; the headache is replaced by dullness; the bowel symptoms increase and we have the "pea soup" discharge if there is diarrhea; there is a listless, dull expression on the face; the tongue is coated in the center, red along the edges and the tip, becomes dry and sometimes cracked and almost useless. It is hard to put it out of the mouth, it sticks to the teeth or lips and curls there, and sometimes the patient allows it to remain partly out of the mouth. There may be bleeding from the bowels and perforation of the bowel, producing peritonitis.

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Third week.--The temperature is lower in the morning with a gradual fall; the emaciation and weakness are marked. Perforation of the bowel or bleeding may occur. Unfavorable symptoms now include low muttering, delirium, shakings of the muscles, twitching of the tendons, grasping at imaginary things, lung complications and heart weakness.

Fourth week.--In a favorable case: The fever gradually falls to normal, the other symptoms disappear. Death may occur at any time after the second week from the disease or complications. The convalescence is very gradual and the appetite is very great.

Special symptoms and variations.--It may come on with a chill sometimes it is observed by nervous symptoms only.

Walking type.--In this type the patient is able to be around and can walk. The temperature is as high, but some of the other symptoms are not so violent. This is a dangerous kind because the patient is able to walk and thinks it foolish to remain quiet in bed. Walking and being around are likely to injure the bowels, and there is then more danger of bleeding from the bowels. A typhoid fever patient should always go to bed and remain there until he has fully recovered.

Digestive Symptoms.--The tongue is coated, white and moist at first, and in the second week it becomes red at the tip, and at the edges. Later it is dry, brown and cracked. The teeth and lips are covered with a brown material, called sordes.

Diarrhea.--In some cases constipation is prominent, in others diarrhea is a prominent symptom. Bloating is frequent, and an unfavorable symptom, when it is excessive. Bleeding from the bowel occurs usually between the end of the second and the beginning of the fourth week. A sudden feeling of collapse, and rapid fall of the temperature mark it. It is not always fatal.

Perforation of the bowel is usually shown by a sudden sharp pain coming in paroxysms generally localized in the right lower side. The death rate varies very much; in hospitals it is seven to eight per cent. Unfavorable symptoms are continued high fever, delirium and hemorrhage. Persons who are hard drinkers do badly and very many of them die.

TREATMENT. Prevention. Sanitary Care.--Do away with the causes. Keep your cellars clean; do not have them damp, filthy, and filled with decaying matter, as these all tend to weaken the system and make you more susceptible to the poison. In the country, no drainings should come near the wells or springs. Not all water that looks clear and nice is pure. The "out-houses" must be kept clean, and emptied at least twice each year. In the small cities, especially, the water should be boiled during the months when the supply is limited and the wells are low. If more attention was paid to our water supply to make certain that it was not contaminated, and to our foods, especially milk, and to keeping our cellars and drains in a good clean and dry condition, we would have little typhoid fever. Carelessness is the real cause of this terrible disease. The milk should be boiled as well as the water when there is an epidemic of typhoid.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Vaccination after exposure to Smallpox.--Vaccination as late as the second day after known exposure to smallpox is believed to have prevented the smallpox; vaccination the third day after exposure has rendered the disease much milder than usual, and in a case in Iowa, vaccination on the seventh or eighth day after exposure to smallpox ran a partial course and was believed to have modified the attack of smallpox, which, however, it did not wholly prevent. A recent case in Michigan was vaccinated three days after exposure, as were also the wife, mother, and two children, both under five years of age; all vaccinated again six days after the exposure. The health officer reported as follows: "The results were gratifying. During the first week of the eruption it was evidently aborting and without doubt as the result of vaccination eight days before the eruption. A complete and fine recovery. Certainly an aborted course, with scarcely a mark left, and not another case in the above family, whom necessity compelled to occupy the same house, the same rooms, continual contact with the contagion, scores one more big credit mark for vaccination."

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With what should one be Vaccinated.--Because the potency of virus depends largely upon its being fresh, and it is so easy to obtain pure and fresh bovine virus, and because such bovine virus is efficient it is better in all cases to use only the pure and fresh bovine virus.

Where should Vaccination be Performed.--In a room or place free from persons suffering from disease, and from dust which may convey to the scratched surface germs of any communicable disease; certainly not in or near a room where there is erysipelas or consumption, nor in the presence of one who has just come from a person sick with erysipelas, diphtheria, or scarlet fever.

By whom should one be Vaccinated.--The operation of vaccination should be performed always by a competent and responsible physician. To try to vaccinate one's self or one's family is poor economy, for it often results not only in a waste of money and of time, but in a false and dangerous feeling of security. To trust to vaccination by nurses and midwives is equally foolish. A well-educated and experienced physician has the skill, and the special knowledge necessary to the best judgment on all of the questions involved, without which the operation may be a failure or worse than a failure. In work of this kind the best is the cheapest, whatever it costs.

After Vaccination.--Let the vaccinated place alone. Do not scratch it or otherwise transfer the virus where it is not wanted. Protect it by a bandage, or cloth which has been boiled and ironed with a hot iron. Try to keep the pustule unbroken, as a protection against germs of diseases and against unnecessary discomfort. A bad sore arm may not be and probably is not true vaccination, but may be due to lack of care during and after vaccination to keep out septic germs.

Common appearances after Vaccination.--For a day or two nothing unusual should appear. A few days after that, if it succeeds regularly, the skin will become red, then a pimple will form, and on the pimple a little vesicle or blister which may be plainly seen on the fifth or sixth day. On the eighth day the blister (vesicle) is, or should be, plump, round, translucent, pearly white, with a clearly marked edge and a depression in the center; the skin around it for about half an inch is red and swollen. This vesicle and the red, inflamed circle about it (called the areola) are the two points which prove the vaccination to be successful. A rash, and even a vesicular eruption, sometimes comes on the child's body about the eighth day, and lasts about a week; he may be feverish, or may remain quite well. The arm may be red and swollen down as far as the elbow, and in the adult there will usually be a tender or swollen gland in the arm-pit, and some disturbance of sleep for several nights. The vesicle dries up in a few days more, and a crust forms which becomes of a brownish mahogany color, and falls off from the twentieth to the twenty-fifth day. In some cases the several appearances described above may be delayed a day or two. The crust or scab will leave a well-marked, permanent scar.

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What to do during and after Vaccination.--Do nothing to irritate the eruption, do not pull the scab off, when it drops off throw it in the fire. When the eruption is at its height show it to the doctor who performed the vaccination. If it is satisfactory, ask him for a certificate stating when and by whom you were vaccinated, whether with bovine or humanized lymph, in how many places and with what result at each place. When the arm is healed, if the vaccination did not work well, be vaccinated again as soon as possible, and in the best manner possible. This will be a test to the protection secured by the former vaccination, and will itself afford increased protection. Do not be satisfied with less than four genuine vaccine scars, or with four if it is possible to secure more than four. This vaccination a second or third time in close succession is believed to be hardly less important than vaccination the first time, and hardly less valuable as a protection against smallpox. Without doubt many persons are living in a false sense of security from smallpox because at some time in their lives they have had a little sore on their arm caused by a supposed or real vaccination, or because an imperfect vaccination failed to work, or because they were successfully vaccinated, or had the varioloid, or the unmodified smallpox many years ago. Until smallpox is stamped out throughout the world so that exposure of the disease shall be practically impossible, the only personal safety is in such perfect vaccination that one need not fear an exposure to smallpox through the recklessness of the foolish.

Make a record of your Vaccination.--Do not fail to procure and preserve the certificate mentioned in the preceding paragraph, and also to make a personal record of the facts with regard to any vaccination of yourself or in your family. From it you may sometime learn that it is ten years since you or some member of your family was vaccinated, when you thought it only five.

Lives saved from smallpox in Michigan.--Since the State Board of Health was established, many thousands of people in Michigan have been vaccinated because of its recommendations; and the statistics of deaths, published by the Secretary of State, show that at the close of the year 1906, the death rate from smallpox in Michigan had been so much less than before the board was established as to indicate that over three thousand lives had been saved from that loathsome disease. The average death rate per year, for the five years, 1869-1873, before the board was established, was 8.5 per 100,000 inhabitants, and since the board was established, for the thirty-three years, 1874-1907, it was only 1.5. Since 1896 an uncommon mild type of the disease has prevailed very extensively, but the death rate has been exceedingly low, being for the eleven years, 1897-1907, slightly less than one death for each 100,000 inhabitants. The great saving of life from smallpox in civilized countries has been mainly because of vaccination and revaccination.

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VACCINATION, Symptoms.--At first a slight irritation at the place of vaccination. The eruption appears on the third or fourth day as a reddish pimple surrounded by a reddened surface. On the fifth or sixth day this pimple becomes a vesicle with a depressed center and filled with clear contents. It reaches its greatest size on the eighth day. By the tenth day the contents are pus-like and the surrounding skin is more inflamed and often quite painful. These symptoms diminish, and by the end of the second week the pustule has dried to a brownish scab, which falls off between the twenty-first and twenty-fifth days, and leaves a depressed scar. Fever and mild constitutional symptoms usually go with the eruption and may last until about the eighth day.

Reliable lymph points should always be used. Clean the skin near the insertion of the deltoid muscle on the arm, and with a clean (sterile) knife or ivory point, a few scratches are made, deep enough to allow a slight flow of liquid, but no bleeding. The vaccine virus moistened, if dried on a point, is rubbed into the wound and allowed to dry. A piece of sterile gauze, or a "shield," is used as a dressing. This shield can be bought at any drug store. One vaccination may give immunity for ten to twelve years, but it is better to be vaccinated every six years at least.

DENGUE. Break-bone Fever, Dandy Fever.--This is an acute infectious disease characterized by pains in the joints and muscles, fever, an initial reddish swollen eruption and a terminal eruption of variable type. It occurs in the tropical regions and the warmer portions of the temperate zone. The disease appears in epidemics, rapidly attacking many persons.

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Symptoms.--Incubation lasts from three to five days without any special symptoms. The onset is marked with chilly feelings, an active fever with temperature gradually rising. There is severe pain in the muscles and in the joints which become red and swollen. There is intense pain in the eyeballs, head, back and extremities. Face looks flushed, eyes are sunken, the skin looks flushed and mucous membrane looks red. This is the beginning rash. The high fever falls quickly after three or four days, sometimes with sweating, diarrhea or nose bleed. The patient feels stiff and sore then, but comparatively well. A slight fever returns after two to four days, although this sometimes remains absent. Pains and eruptions, like scarlet fever or hives, appear. An attack usually lasts seven to eight days. Convalescence is often long and slow, with stiffness and pain in the joints and muscles and great weakness. A relapse may return within two weeks.

PHYSICIANS' TREATMENT for Dengue.--An anti-plague serum is sometimes used, though with doubtful results. The pain is controlled by doses of morphine of one-eighth to one-fourth of a grain every four or five hours. Hyoscin, one hundredth of a grain, is also given for the pain. The high temperature can be relieved by cold and tepid sponging. Tonics are given during the convalescence and continued for some time.

CEREBRO-SPINAL MENINGITIS.--This is an acute infectious disease. It comes in epidemics, when there are many cases, or appears here and there as a separate case (sporadic). It is caused by a specific organism (germ) and the disease attacks the membranes of the brain and spinal cord.

Of late years great progress has been made by patient investigation, and a serum is now prepared for the treatment of this disease. The results of this treatment are better than the treatments formerly used, and there is good reason to believe that in a few years this treatment will be as effective in this disease as antitoxin is in diphtheria.

Cause.--Young adults and children are affected most often. Bad surroundings and over-exertion are predisposing factors.

Conditions.--There is congestion of the membranes of the brain and spinal cord which are covered with an exudate confined on the brain, chiefly to the base.

Symptoms. Ordinary Form.--Incubation is of unknown length and occasionally marked by want of appetite, headache, and pain in the back. The invasion is usually sudden, chill, projectile vomiting, throwing forward, severe headache, pain and rigidity of the back of the neck, pain in various parts of the body, skin over-sensitive, irritable, and temperature about 102 degrees, with all symptoms of an active fever. Later, pains are very severe, especially in the head, neck and back; the head is drawn back; often the back is rigid; the muscles of the neck and back are tender and attempts to stretch them cause intense pain. The vomiting now is less prominent. Temperature is extremely irregular, 99 to 105 degrees or more. Pulse is slow, often 50 to 60, and full and strong at first. The delirium is of a severe and variable type in common, alternating with partial or complete coma, the latter predominating toward the close of fatal attacks. Stimulation of nerve centers causes cross-eyed look, drooping of upper eyelid, movement of eyeballs unequal, contracted, dilated, or sluggish pupils; acute and painful hearing, spasmodic contractions of the muscles followed by paralysis of the face muscles, etc. The disease may last several hours or several months. Many die within five days. In fatal cases the patient passes into seemingly deep sleep with symptoms of a very prostrating and weakening fever, and often retention of urine. Mild cases occur with only a little fever, headache, stiff muscles of the neck, discomfort in back and extremities. The malignant type occurs epidemically or sporadically.

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Malignant type.--Sudden invasion with severe chills, slight rise in temperature, pain in the back of the neck, headaches, stupor, muscular spasms, a slow pulse, often purple bleeding, eruption, coma and death within hours, rather than days. This is a terrible disease, and a physician is needed from the first. The death rate varies from twenty to seventy-live per cent. Treatment must be given by a physician. Spinal meningitis is inflammation of the membrane of the spinal cord along with the accompanying back and extremity symptoms, while the head remains clear and free from complications.

MENINGITIS.--This is an inflammation of the membranes covering the brain alone, and generally commences with fever and severe headaches, with avoidance of light and noise as these are painful. In some cases we have delirium, stupor and coma.

Treatment.--Treatment must be given by a physician, but cold applications to the head and back are generally good. The bowels also must be kept open.

MENINGITIS. Tubercular, (Basilar Meningitis).--This affection which is also known as acute hydrocephalus (meaning water on the brain), is essentially an acute tuberculosis in which the membranes of the brain, sometimes of the cord bear the brunt of the attack. It is more common in children than in adults. It is more frequent between the second and fifth years, than in the first year. It is caused by the tubercular infection, and follows the usual course of this disease. Ordinary meningitis is rapid and well defined in its course, with "high fever," severe pains in the head, intense nervousness, avoidance of light and sound, loss of appetite and constipation. These symptoms are easily understood and are generally clearly read by those around the patient. Unfortunately in tubercular meningitis the clearly defined symptoms are absent in the beginning, and when the physician is called the condition is dangerous. Usually the patient complains but little. There is a slight headache, low fever, no heat in the head, patient is pale most of the time, has little appetite, vomits occasionally and desires to sleep. He is nervous, stupid and lies on his side curled up with eyes away from the light. This disease appears mostly in delicate children, who are poor eaters and fond of books; usually in those inheriting poor constitutions. The mortality is very high. Parents who have thin, pale sallow children with dainty appetites, who frequently complain of headaches and are fond of books, should be afraid of infection from tuberculosis and make the little ones live in the open air and keep away from school. But earlier in the lives of these children care must be taken. A child with that pale, thin, sallow, delicate face and poor body should be fed with the best of food and live in the open air. I once had a family who lost their only two babies through this disease. After the first one died I instructed them carefully how to treat the second child. However, they loved their child foolishly and not wisely and fed it everything it wanted, and you know the children take an advantage of their parents. Give plenty of good, wholesome digestible food. Dress them comfortably and warm and keep them out in the open air. No cakes, candy, peanuts or any food that is not nourishing and easy to digest.

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TUBERCULOSIS. (CONSUMPTION).--Tuberculosis is an infectious disease caused by the bacillus, tuberculosis, and characterized by the formation of nodules or diffuse masses of new tissue. Man, fowls and cows are chiefly affected.

Indians, negroes and Irish are very susceptible. The disease is less common at great altitudes. Dark, poorly ventilated rooms, such as tenements and factories and the crowding of cities favors infection, as do in-door life and occupations in which dust must be inhaled. Certain infections such as measles, whooping-cough, chronic heart, kidney and liver diseases and inflammation of the air tract are predisposing factors. Inhalation is the chief mode of transmission. Hereditary transmission is rare.

Forms. The Lungs.--Consumption. This is caused by a germ. Some have the form called galloping consumption. This person is attacked suddenly, wastes away and dies, in a very short time. There is rapid loss of strength and weight, high fever, night sweats, fast breathing, pains in the chest, cough and profuse expectoration, and rapid loss of strength.

Ordinary Consumption.--Begins slowly and the patient is not aware of the danger. He may have loss of appetite, dyspepsia, diarrhea and distress after meals. He looks pale, is weak and loses flesh. Soon he has a hacking cough, worse in the morning, with a scanty, glairy sputum. His weight continues to decrease, his heart is weak and beats faster. He has pain in his chest below the shoulder blades. He may have a slight bleeding from the lungs. His cough becomes worse, the expectoration gets thicker and more profuse, with night sweats, high fever, and shortness of breath. The eyes are bright; the cheeks are pale or flushed. Chronic looseness of the bowels may be present. Bleeding from the lungs may occur at any time, but it is most frequent and profuse during the last stages. The patient becomes very weak, thin and pale, emaciated. The brain action remains good, and he remains hopeful almost until the last. Tuberculosis may exist in almost every part of the body and we have many forms. It is not necessary to discuss all. It would tend to confusion. I will name the most of them:

1. Acute Miliary Tuberculosis.
(A.) Acute General Miliary Tuberculosis.
(B.) Pulmonary (lung) type.
(C.) Tubercular Meningitis.

2. Tuberculosis of the lymph nodes (glands). This was formerly called
Scrofula. This is more curable and will be treated more fully elsewhere.

3. Tuberculous Pleurisy.

4. Tuberculous Pericarditis.