The nervous disposition of the child must be taken into consideration and treated if necessary. If bad habits exist they must be stopped. Poor blood and poor nutrition must receive the treatment suggested under these headings.

NIGHTMARE. NIGHT TERRORS

In a nightmare a child wakes suddenly in a state of fright and will inform you that it has had a bad dream. His mind seems clear and he recognizes those about him. He is not easily calmed and may cry for some time; finally he goes to sleep again. The next day he will remember the dream and most of the incidents of the night before. Such cases are quite frequent. They are to be treated in the same way as cases of disturbed sleep, as they really have the same cause. They are mostly due to digestive disturbances and errors of diet.

Night-Terrors.—Cases under this heading form a distinct group by themselves. They are not frequent, but the condition is much more serious. The cause seems to be wholly nervous and may indicate an important nervous derangement. It seems to have some indefinite relation to such conditions as migraine, hysteria, epilepsy, and even insanity. The child wakes suddenly during the night and sits up, evidently in terror; he does not apparently regain his full consciousness. He talks of being scared, calls for his mother, trembles and shakes, cannot answer questions intelligently, and after a time goes to sleep. Next day he remembers nothing of the attack and does not seem to suffer in any way as a result of it.

I am disposed to believe that all of these attacks are not due to a nervous condition. A number of them of exactly this type have been cured by absolutely withdrawing milk from the diet.

It is a good plan to restrict the possibility of excessive play in these children. They are of the type whose play is work, and too much of it is too exhausting. Some person should sleep in the same room with these patients or in an adjoining room with the door open.

If the condition occurs frequently the child should be subjected to a thorough physical examination, because it may be one evidence of a serious ailment.

Sometimes these little patients have to be taken out of school and sent to the country, where they should remain for many months. It is far better to regard the condition as indicating an abnormality,—even though it may not have any deeper significance than that the digestive apparatus of the child is not quite right,—and make every effort to cure it, than to permit the child to go on under what really are unjust and unfavorable conditions.

HEADACHE

Headaches are not common in little children. The most frequent ones are caused by:

1. Chronic indigestion and constipation.

2. Anemia and malnutrition.

3. Nervous disorders.

4. Diseases of the eye, nose, throat.

5. Rheumatism and gout.

6. Disturbances of the genital tract.

Those arising from anemia and poor nutrition are most frequently present in girls from ten to fifteen years of age. They may result from overcrowding of school work, which results in loss of appetite and poor sleep.

Nervous headaches may be hereditary or acquired through unhygienic surroundings. Hysteria, epilepsy, disease of the brain, neuralgia from carious teeth, may result in nervous headaches.

Headaches from disturbances of the genital tract may afflict girls about the time of puberty.

Treatment.—To remove the cause is the only plan that promises any result. Each one must be investigated by itself and dealt with accordingly. For the headache itself a hot foot bath, cold to the head, and small doses of phenacetine (one grain every hour for four doses) are perhaps the most certain of all methods of treatment.

THUMB-SUCKING

The habit of sucking the thumb may be corrected by wearing a pair of white mittens, or gloves tied at the wrist. Should children attempt to suck the thumb with gloves on, as some do, it will be necessary to saturate the thumb and fingers of the gloves with tincture of aloes, or a solution of the bisulphate of quinine, one dram to two ounces of water.

BITING THE FINGER NAILS

Biting the finger nails may be stopped by the use of the same bitter remedies as are used in thumb-sucking.

HOW TO WASH OUT THE BOWELS

COLON IRRIGATION. A HIGH ENEMA

Procure a soft rubber catheter,—No. 18 American is about right. It is not advisable to get too soft rubber for the reason that it will buckle when the child strains and it will be impossible to wash out the bowel. Fill half full an ordinary two-quart douche bag with water that is warm, but not too hot. Dissolve a heaping teaspoonful of table salt in a glass of hot water and add this to the water in the bag. Hang the bag about two feet above the level of the child, so that the water will not flow in with too strong a stream; otherwise the child will immediately try to eject it. If the water flows in gently, the child may not object to it to the extent of making strenuous efforts to force the catheter out.

Use the small sized nozzle that comes with the douche bag. Place the rubber catheter over this nozzle, lubricate the catheter, place the child on its back over a douche pan, insert the catheter about two inches, let the water run and as it runs in push the catheter up gently until it is all in the bowel except the end on the douche tip. The object of letting the water run while pushing in the catheter is because it floats up with the water as it distends the bowel; there is no risk then of pushing the end into the intestinal wall or hurting the child. While the water is flowing into the bowel it is a good plan to compress the buttocks together to aid in holding the water, as the child is very apt to let it run out as soon as it feels uncomfortable.

The temperature of the water for the ordinary rectal injection should be 95 deg. F. When the child is exhausted or very weak, or when the circulation is poor, the temperature of the water may be as high as 110 deg. F. When, on the other hand, the fever is very high, the water may be much cooler; as low as 70 deg. F. has been given with good results on the fever. If the irrigation is given with the intention of reducing the fever, it is best to begin with water around 90 deg. F., and reduce it to 70 deg. F., gradually.

Indications for Irrigation of the Colon.—When it is desired to cleanse the bowel of any collection of matter a colon irrigation is indicated. This matter may be mucus, fecal substance, undigested food, or the decomposing waste products which may remain there as a result of disease or other conditions.

When it is desired to medicate by putting fluids into the bowel we adopt the colon infusion.

Every diseased condition of the bowel does not, however, indicate irrigation. If a child is having frequent loose movements every half-hour it is safe to assume that the bowel is being cleaned out sufficiently without any artificial aid. To irrigate in these cases would only irritate and would not accomplish anything. The cases which are benefited are those in which we have a fever with four or five green stools in the twenty-four hours, or where we have a high fever with no movement at all. To irrigate in these cases we not only get rid of the products of decomposition, but we prevent further decomposition and we reduce the fever, thereby contributing to the general welfare of the child.

When the child is convalescing and when there is only mucus in the stools, with no fever—as in cases of chronic ileo-colitis—the colon irrigations should be stopped, as they tend to keep up the discharge of mucus in these cases. If, however, there is a relapse with fever, which would indicate a fresh infection with more discharging mucus and possibly green stools, the irrigation must be used until the fever subsides.

Colon irrigations should always be given in every case of convulsions in infancy, first to clean out the bowel to prevent putrefaction, and second to empty the bowel on general principles because an overloaded bowel is very frequently the cause of convulsions in children.

When irrigation of the bowel is given at all it must be given thoroughly. Enough water must pass into the bowel to wash it all out. For this reason it is essential that the catheter should be all in and in the bowel—not doubled on itself two or three inches in the bowel. If it is a serious case and the mother nervous, someone else should give the washing—preferably the physician himself. If the child objects strenuously, as often happens, it must be done with greater care to be successful. Remember that a colon irrigation is never given unless it is absolutely necessary and as a consequence it is given to accomplish a certain purpose; it must, therefore, be done thoroughly. If it is not, your child may miss the chance it has of getting over some immediate difficulty and if the moment of the "chance" is wasted or lost, that moment will not return. Be thorough, therefore.

Enema.—Some physicians talk about a high enema and a low enema. A high enema is really an irrigation as described above. The following remarks apply to low enemas only.

A so-called low enema is given to clean out the rectum of constipated matter, or for the introduction of food or medicine by rectum, when for various reasons it is necessary to spare the stomach.

It may be given with the fountain syringe or with the ordinary bulb (baby) syringe. A catheter may be put on the tip of the syringe if it is thought best to inject higher up than in the rectum.

When an enema is used in infants or older children for the relief of constipation, the best medium to use is glycerine. For an infant, one teaspoonful to an ounce of water is sufficient; for older children, one tablespoonful to two ounces of water, given with the bulb syringe, will give prompt results. If the constipation is pronounced, the fecal mass very hard, an enema of sweet oil, allowed to remain in for ten minutes, will soften it and permit a movement.

Soap suds are often used. They are good but not as reliable as the glycerine or oil; if, however, neither of these two are at hand the soap suds may be given.

Enemas should be carefully given and the liquid slowly injected. If the fountain syringe is used care must be exercised in not having the bag too high. If it is too high the liquid will flow in too strongly, either injuring the bowel wall or causing the child to strain immediately and pass out the injection before it has an opportunity of accomplishing its work.

The temperature of the enema should be warm—not hot, and not cold, simply body heat.

METHODS OF REDUCING FEVER

During the course of acute illness it is frequently necessary to reduce the fever, if possible, without the use of drugs. The following means are often adopted. It is desirable that the mother should know just how to carry out these methods:

Ice-Cap.—An ice-cap is used to protect the brain when a child or adult is running a very high fever. It is put on when the fever is above 103 deg. F. It may be used in other conditions—brain disease, or disease of the meninges or cord—in which case the physician will be in attendance and will direct what should be done.

Ice-bags are procured in the drug stores. The best one is the flat French ice-bag. Fill it three-quarters full of finely chopped ice, put the ice-bag in a towel, and place on the patient's head. There should be only one thickness of the towel between the ice-bag and the head.

It will be necessary to keep a record of the fever so that the ice-bag may be withdrawn when it falls below 103 deg. F.

When the ice melts the bag must be at once refilled. This is often overlooked by careless mothers.

Cold Sponging.—Cold sponging is used to reduce fever or to allay nervous irritability. Equal parts of alcohol and water or vinegar and water are used. The temperature of the water should be 80 deg. to 85 deg. F.

Infants to be sponged should be completely undressed and laid upon a blanket. The sponging should be done for about fifteen or twenty minutes, after which the child is wrapped in a dry blanket without further clothing except the diaper. To be effective it must be done frequently.

Cold Pack.—The cold pack is used to reduce fever. It is one of the simplest and one of the best means we have. The child is undressed completely, and laid upon a blanket. It is completely covered with a small blanket (except its head) wrung out of water at 100 deg. F. Outside of this the child is rubbed with a piece of ice, front and back, for a sufficiently long time to render the surface cool, but not cold. Children take kindly to this means of reducing fever; there is no shock and they are quieted by it.

Just how long one will rub with the ice depends upon circumstances. From five to thirty minutes may be employed. The head should be sponged with cold water while this is being done and it is a good plan to have a hot-water bottle at the child's feet.

The Cold Bath.—To reduce fever the cold bath is used in the following way: Water at a temperature of 100 deg. F. is put into the bath and the child is first put into this water, then the water is reduced by putting into it shaved ice until it reaches 80 deg. F. The child's body is well rubbed while it is in the bath and cold water is applied to its head. The bath is continued for five minutes, or sometimes with a robust child to ten minutes. On removal the child should be put into a warm blanket after being thoroughly dried.

Rectal Irrigations.—These are sometimes given to reduce fever. They are very useful and very successful if they are given properly and without exciting the child too much. It is best to give water of an ordinary temperature at first and gradually reduce it to 70 deg. F. It should be continued for ten minutes or longer. It may be repeated every three hours. (See page 586.)

VARIOUS BATHS

Every mother should know how to give any bath that may be directed by the physician.

The Mustard Bath.—Take from three to four tablespoonfuls of English mustard; mix thoroughly in about one gallon of warm water. Add to this about five gallons of plain water at a temperature of 100 deg. F. If it is necessary to raise the temperature of the water higher it may be done by adding water until the temperature reaches 105 deg. or 110 deg. F.

The mustard bath is exceedingly effective in cases of shock, great sudden depression, collapse, heart failure, or in sudden congestion of the lungs or brain. The special use of the mustard bath is in the treatment of convulsions; it is also useful for nervous children who sleep badly. Two or three minutes in the mustard bath, followed by a quick rubbing, will induce refreshing sleep in these children. It is not necessary to have more than one tablespoonful of mustard in these cases.

The Hot Bath.—A bath is prepared of water at a temperature of 100 deg. F. After the child is in the bath the temperature of the water is raised to 105 deg., or to 110 deg. F. It is not safe to go above this point.

The body of the child should be well rubbed while it is in the bath. In most cases it is advisable to apply cold water to the head while the child is in the bath. A bath thermometer should be kept in the water to see that it does not rise above the temperature desired.

The hot bath, like the mustard bath, is used to promote reaction in cases of shock, collapse, etc., and in convulsions.

The Hot Pack.—Remove all clothing from the baby and envelop the body in a sheet wrung out of water at a temperature of 100 deg. F., to 105 deg. F., after which the body should be rolled in a thick blanket. Those hot applications may be changed every twenty minutes until free perspiration is produced. This condition may be kept up as long as is necessary.

The hot pack is used mainly in disease of the kidney.

The Hot-Air or Vapor Bath.—The child is put in bed wholly undressed with the bed clothing raised about twelve inches, and held in that position by a wicker support. The child's head is of course outside the bed clothing. Beneath the bed clothing hot air or vapor from a croup kettle is introduced. This will cause free perspiration in twenty minutes. It may be continued from twenty to thirty minutes at a time.

The vapor bath is used in diseases of the kidney, as a rule.

The Bran Bath.—In five gallons of water place a bag in which is put one quart of ordinary wheat bran. The bag is made of cheese cloth. Squeeze and manipulate the bran bag until the water resembles a thin porridge. The temperature of the water is usually about 95 deg. F., though it may be given with any temperature of water.

The bran bath is of great value in eczema, or in rashes about the buttocks, or in delicate skin conditions when plain water would irritate.

The Tepid Bath.—This bath may be given at a temperature of 95 deg., or 100 deg. F. It is of distinct advantage in extremely nervous children. To induce sleep it is often better than drugs.

The Cold Sponge or Shower Bath.—This bath should be given in the morning in a warm room. A tub should be provided with enough water in it to cover the child's feet. This water should be warm because when the feet are in warm water it prevents the shock which frequently comes when cold water is applied to any other part of the body.

A large sponge is filled with water at a temperature of from 40 deg. to 60 deg. F. This is squeezed a number of times over the child's chest, shoulders, and back. While the cold water is being applied the body should be well rubbed with the free hand of the mother. The bath should not last longer than half a minute. When finished take the child out quickly and stand him on a bath towel and give him a brisk rubbing with a bath towel until the skin reacts. This is an exceedingly valuable tonic for a delicate child. It should not be used on younger children than eighteen months of age. In younger children a cold plunge is preferable.

For the cold plunge water at a temperature of 55 deg. F. is prepared. The child is lifted into this and given a single dip up to the neck. He is then briskly rubbed off as above.

There are a very few children who do not take kindly to either the cold sponge or plunge. These children do not react; they remain pale or blue and pinched for some time after. It may be necessary to discontinue the procedure or to use water of a higher temperature.

POULTICES

Poultices are useful in inflammation and for the relief of pain. To be of any value they should be applied frequently—every ten or twenty minutes—and they should be applied hot.

Ground flaxseed is the best material for poultices. It should be mixed with boiling water until the proper thickness is reached. It may be kept simmering on a fire. When one poultice is taken off it can be scraped into the pot and heated over if there is no discharge. Each poultice should be put into clean muslin, put on the part and covered with oiled silk. This will help to retain the heat and prevent the clothing or bed sheet from becoming wet.

HOT FOMENTATIONS

A hot fomentation is simply a clean poultice. Several thicknesses of flannel are taken, wrung out of very hot water, covered with cotton batting, and then with oiled silk.

How to Make and How to Apply a Mustard Paste.—For infants: Take one part English mustard to six parts flour, mix with lukewarm water, and spread between two layers of cheesecloth.

For older children and adults: Take one tablespoonful English mustard to three or four tablespoonfuls of flour, and mix as above.

Mustard pastes should be made big enough. You can accomplish a great deal more by putting on a sufficiently large mustard paste than by simply putting on one the size of the palm of your hand.

It should be left on until the skin is distinctly red. The length of time will depend, of course, upon the strength of the mustard. Mustard pastes may be put on every three hours, if necessary, and they may be used for a week at this interval if the conditions demand it.

If they are used in pneumonia or other pulmonary diseases, they should be used large enough to go around the whole chest. If they are used in heart failure, they should be big enough to cover the whole trunk.

When made with the white of an egg they will not blister. Or if the part is rubbed with white vaseline before applying, it will not blister and it will be just as effective. When a mustard paste is removed the red area should be rubbed with white vaseline and covered with a clean piece of flannel.

How to Prepare and Use the Mustard Pack.—The child is stripped and laid upon a blanket, and the trunk is surrounded by a large towel or sheet saturated with mustard water. This is prepared as follows: Take one tablespoonful of English mustard and dissolve it in one quart of water, slightly warmed. Saturate a towel in this mixture and apply to the body of the child while it is dripping. The patient is then rolled in a blanket. Keep the child in this pack for ten or fifteen minutes. The mustard pack is not as good as the mustard bath, but it is all that is necessary in a number of various conditions. The physician will, of course, decide these matters. It is simply the duty of the mother to know how to carry out the physician's instructions.

The Turpentine Stupe.—Take a piece of flannel, big enough to cover the area which it is desired to affect, wring it out of as hot water as it is possible. Upon this sprinkle twenty drops of spirits of turpentine. Place the stupe wherever it is desired and cover with a piece of oiled silk or dry flannel. The turpentine stupe is mostly used in pain of the abdominal cavity. In colic from acute indigestion it is a very convenient means of quieting the child by allaying the pain.

Care should be taken not to allow this form of application to remain on too long. Take it off when the skin is red. For continuous use it is not as good as the mustard paste.

OILED SILK. WHAT IT IS, AND WHY IT IS USED

Oiled silk is sold in the drug stores by the yard. It is one yard wide. It is used to cover any local application to prevent evaporation into the air or to prevent the clothing from absorbing the medicament. If a liniment is applied on cloth to effect a certain result, it may take some time to do its work. If the wet cloth is covered with the clothing, the clothing will absorb the medicine quicker than the body will and thereby defeat the object in view, in addition to rendering the clothing wet and nasty. If the application is covered with oiled silk it cannot escape into the clothing, because the oiled silk is impervious. The body will be compelled to absorb the medicine and consequently results will be quicker and more certain. Many liniments are expensive; to permit them to be absorbed by the clothing is needless waste It is therefore economical to apply the oiled silk.



DISEASES OF CHILDREN



The First Blight

This is one of those truly unfortunate cases which, so far as present knowledge goes, cannot be guarded against. Eunice, age 31, mentally 2, is a low-grade imbecile. There is not in the whole family, for generations back, a single case of feeble-mindedness, nor of disease that would undermine the nervous organization. Close scrutiny does not reveal a single assignable cause. She came, as an accident, to blight an otherwise normal family.

Such cases are few, but unfortunately they do occur. It is for Eugenics to materially reduce the possibility of such occurrences.

* * * * *

CHAPTER XXXVIII

INFECTIOUS OR CONTAGIOUS DISEASES

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

RULES TO BE OBSERVED IN THE TREATMENT OF CONTAGIOUS DISEASES

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

DISINFECTING THE SICK-CHAMBER

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

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

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

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

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

MUMPS: EPIDEMIC PAROTITIS

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

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

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

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

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

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

CHICKEN POX. VARICELLA

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

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

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

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

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

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

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

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

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

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

INFLUENZA: LA GRIPPE

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

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

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

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

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

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

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

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

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

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

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

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

DIPHTHERIA

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

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

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

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

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

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

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

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

WHOOPING-COUGH

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

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

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

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

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

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

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

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

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

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

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

MEASLES

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

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

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

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

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

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

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

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

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

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

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

SUMMARY:—

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

c. Paraform, 1,000 grains for every 1,000 cubic feet of air space, 6 hours' exposure.

The following disinfecting solutions may be used for goods, which are afterwards to be washed:

a. Carbolic acid, 2 to 5 per cent.

b. Bichloride of mercury, 1-1,000.

SCARLET FEVER. SCARLATINA.

Scarlet fever is an acute, contagious disease. It begins abruptly. The child may have a severe attack and be quite sick from the beginning, or he may have a mild attack and not be very sick. Usually the fever rises rapidly, the child vomits and complains of a sore throat. If the attack is very mild the throat symptoms may not cause any distress. Frequently, about the third day, there are patches on the tonsils. Prostration may be profound if the fever is very high. Convulsions and diarrhea are sometimes present in very young patients. It takes from two to six days to develop scarlet fever from the time the child is exposed to it. The disease may be caught at any time, but it is most contagious during the time the patient is scaling. It is not as contagious as measles. Some children seem to escape even though directly exposed to it. It is more frequent in the fall and during the winter, and it is more severe during the latter months.

Eruption.—The eruption appears at any time after twelve hours. It may not, however, appear before the third or fourth day. It lasts from three to seven days, and only takes a few hours to cover the whole body after it is first seen. The rash is first seen on the neck or chest; it appears as a red, uniform blush, but, when examined closely, small reddish spots may be seen all over it. If the rash is very faint and of a doubtful character a hot bath may bring it out. A bright red, well-developed rash is a sign of good heart action. In the event of heart failure, the rash fades quickly. Itching is a constant symptom after the rash is fully out.

About the eighth day the rash begins to scale or desquamate. It begins on the neck and chest. It takes from one to three weeks to scale completely, from the time it begins to peel. The hands and feet are the last spots to scale.

It must always be kept in mind that mild cases are just as contagious as severe cases, and that a mild case may cause in another person a very severe attack.

The throat may be mildly affected or it may be the most troublesome feature of the case. It is red and swollen and the child complains of pain during the act of swallowing. Patches may be seen on the tonsils on the third day. There is usually a discharge from the nose and this discharge may be contagious. While the fever is high, the child is restless, complains of thirst, and may be slightly delirious.

One attack is usually all a child has during life, though there are exceptions to this rule. Complications are quite frequent with scarlet fever. Inflammation of the ears and kidneys is most often met.

Measures to be Taken to Prevent Spread of Disease.—Every case, no matter how mild, should be isolated for four weeks. Many cases must be isolated longer,—until scaling is complete. Children should not play or sleep with other children for three or four weeks after all symptoms have been absent. Other children in the family, who have not been exposed, should be sent away. All clothing should be changed and washed in soap and water and then boiled in a carbolic solution. The nurse should not mix freely with other members of the family. The sick room should be kept clean, and well aired. It should be dusted with a wet cloth, and this should afterwards be burned. There should be no furniture, or hangings, or pictures in the room other than are absolutely necessary. The room should not be used after the case is over until it is thoroughly and completely disinfected.

During the period of scaling the patient should be rubbed all over with carbolated vaseline. This allays itching and prevents the scales flying around. The bed sheet can be taken off daily with the scales in it, and immediately put in carbolic water and boiled.

Treatment.—Inasmuch as scarlet fever is one of the most dangerous and one of the most treacherous diseases of childhood, we cannot afford to take any chances with it. Every child with scarlet fever should be put in bed, and kept there during the entire illness,—that is, from four to six weeks. Light, and the free circulation of fresh air are absolutely necessary for the proper care of a scarlet fever case. The child should be clothed only with the usual night gown and a light undershirt. No extra wraps or blankets are required.

The diet should be reduced in quantity and strength. The bowels should move daily. If anything is necessary to accomplish this, citrate of magnesia is quite satisfactory. There is no special medicine for the treatment of this disease. Often it is not necessary to give any. Good nursing is more essential, and with proper attention to the bowels, diet, fresh air, clothing, sleep, and quiet, all will, as a rule, result favorably. Quiet is essential. Consequently, two persons at a time should never be allowed in the room with the little patient.

The family physician will prescribe whatever medicine is necessary in his judgment, and will meet any complication as it arises.

TYPHOID FEVER

Typhoid fever is an acute infectious disease. It is rare in infancy. After the fifth year it is more common. It is caused by drinking infected water or milk. It is not a serious disease in childhood, rarely being fatal.

Symptoms.—It may begin suddenly or it may come on slowly. If suddenly, the child develops what appears to be an attack of indigestion, has fever, vomiting, and is prostrated. In cases developing slowly the child complains of being tired, has a headache, nausea, and fever. Vomiting is the suggestive and important symptom.

Diarrhea is usually present. Constipation, however, may accompany the entire illness. Children may not complain of an excess of gas as do adults. The abdomen is tender. The typhoid eruption is rarely seen in children. They lose flesh steadily and then strength diminishes rapidly. Headache and delirium at night are quite common, and the child is dull and indifferent, and often in a state of semi-stupor.

In order to tell definitely whether the child has typhoid, it is necessary to make a blood examination. There are so many intestinal conditions in children that simulate typhoid, that a blood examination is imperative.

Treatment.—The patient should remain in bed during the time fever is present and for a few days after. A fluid diet, preferably milk, is the most suitable means of nourishing the child. It may be diluted or given plain according to the age of the patient. Water is essential and should be given freely.

The discharges of the patient should be thoroughly disinfected in a solution of carbolic acid, 1-20. All clothing and bed linen should be boiled for two hours. If the fever remains high cold sponging is advisable. The attending physician should instruct regarding this feature, as some children do not stand cold applications well.

The average duration of the disease is about six weeks.

How to Keep From Getting and Spreading Typhoid Fever.—Typhoid fever is a communicable disease, but, if certain precautions are taken, its contraction and spread can almost certainly be prevented.

The disease is caused by a specific germ known as the typhoid bacillus. These germs are found in the excreta (stools and urine) of persons ill with typhoid fever.

Failure to properly disinfect these excreta and carelessness in the care of persons ill with typhoid fever lead to the transmission of the disease from the sick to the well by the infection of water, milk or food with the typhoid bacillus or by direct contact.

The disease is contracted by taking into the mouth in some form the discharges from some previous case. There is no other way. It is, therefore, a disease of filth and someone is at fault somewhere for every case of typhoid fever that occurs.

Bad sanitary conditions, such as lack of drainage, open cess-pools, sewer gas, decaying vegetable matter, etc., may favor the contraction of the disease, but cannot cause it unless the specific germ, the typhoid bacillus, is present.

The water supply of a community becomes infected by the entrance into it of the excreta (stools and urine) of persons suffering from typhoid fever.

Milk (in which typhoid bacilli grow and multiply very rapidly) usually becomes infected by washing out milk cans with water in which these bacilli are present, or from the presence of the bacilli on the hands or persons of those handling milk. Oysters spread the disease when they have been "freshed" in water rich in sewage and containing the typhoid bacillus. Flies, whose bodies have become foul with typhoid excreta, may infect food, milk, etc. Those who take care of typhoid patients may contract the disease if they do not at once disinfect their hands after handling the patient, or clothing or bedding which has become soiled with the discharges.

How to Keep From Getting Typhoid Fever.—If the chance of infection is to be reduced to a minimum, all drinking water, concerning the character of which there may be the slightest doubt, should be boiled, and all milk, the handling and care of which is not absolutely beyond suspicion, should be pasteurized or boiled. All food supplies (meat, milk, vegetables, etc.), should be carefully protected against flies, and flies should not be permitted access to the sick-room, the kitchen nor to the room in which the meals are eaten. Bathing at all beaches which have sewers emptying in their immediate vicinity should be strictly avoided. In the majority of cases it is probable that the system must be slightly below par in order that the disease may be contracted; therefore, all indigestible food, green fruit, etc., which may set up indigestion or diarrhea, and so render the system more susceptible to infection, should be avoided. In addition, the elementary rules of cleanliness and hygiene, both as to the house and person, should be most strictly observed. No member of a household in which a case of typhoid fever occurs should take food in any form without previously washing the hands.

Typhoid bacilli enter the body only through the mouth. If sufficient care be taken to prevent their entrance, the contraction of the disease can be absolutely prevented.

How to Keep From Spreading the Disease.—In order to protect themselves and others in the household, persons caring for or in any way coming into contact with a case of typhoid fever must constantly bear in mind that the secretions and excretions (urine, stools, etc.), of the patient contain typhoid bacilli and are capable of transmitting the disease to others. The person who nurses the patient should not do the cooking for the family. The bedding used by the patient should be washed separately from that used by others. Special dishes, plates, knives, forks, etc., should be kept for the use of the patient alone, and should be washed separately and thoroughly. Particular attention should be paid to immediate disinfection of the stools and urine of the patients until the restoration of health is complete.

The urine is especially dangerous. It may look entirely normal and yet contain typhoid bacilli for some time after recovery is apparently complete. In a few instances the typhoid bacilli may persist in the stools for weeks or months after recovery. Such persons are called "typhoid carriers," and constitute a grave menace to the health of the community. The best disinfectants are carbolic acid and freshly slacked lime; both are effectual, cheap and easily obtained. Urine or stools to which has been added one-third of their volume of a solution of one part of carbolic acid to twenty parts of water are, as a rule, sufficiently disinfected in half an hour, provided the mass of the stool is broken up and thoroughly mixed with the solutions. The best method is to keep the urinal of bed-pan partly filled with the disinfecting solution at all times. In this way any germs present in the urine or stools are almost instantly destroyed. Stools and urine should never be thrown out on the ground. If no system of drainage is at hand, they should be very thoroughly disinfected and emptied into a hole in the ground and covered with earth. All persons nursing or handling the patient in any way should be careful to wash their hands very thoroughly with soap and water before leaving the sick-room. They should never, while in the sick-room, touch any article of food or put their hands to their mouths. Careful observation of the above suggestions and precautions will almost certainly prevent contraction of typhoid fever or the spread of the disease.

VARIOUS SOLUTIONS

Boracic Acid Solution.—In the previous pages mothers are frequently told to use "a saturated solution of boracic acid." A saturated solution means that the water in the solution has dissolved all of the product that is put into it that it is capable of dissolving. When boracic acid is put into water, the water will dissolve it up to a certain point; if you add more the boracic acid will not dissolve; it will float if it is in the form of powder, or it will remain at the bottom of the glass if it is crystal—in other words the water is saturated to its limit and the solution is known as a saturated solution.

The strength of a saturated solution of boracic acid is as follows:—

Boracic Acid Ounces 1-1/2 Hot Sterile Water Pints 2

which means that 2 pints of hot water will completely dissolve 1-1/2 ounces of boracic acid. If any more boracic acid is added the water will not dissolve it because it is already "saturated." Inasmuch, however, as boracic acid is harmless, it is perfectly safe to use the liquid part of a solution which contains some undissolved acid.

A saturated solution is used in the eyes after it is strained.

Normal Salt Solution.—A normal salt solution is made in the following proportions:—

Sodium Chloride (ordinary table salt) Grains 128 Sterile Water Pints 2

Normal salt solution is much used in irrigating the bowel. A mother may safely use it in the proportion of one heaping teaspoonful to two quarts of water—two quarts being the size of the ordinary fountain syringe.

Carron Oil.—Lime water and raw linseed oil, equal parts. This mixture is much used in burns. It should be made fresh.

Thiersch's Solution:—

Salicylic Acid Drams 1/2 Boracic Acid Drams 3 Sterile Water Pints 2

Thiersch's solution is a good, mild antiseptic solution, or wash.

Solution of Bichloride of Mercury (1 to 1000):—

Bichloride of Mercury Grains 15 Common Salt Grains 15 Sterile Water Pints 2

Bichloride of mercury is one of the most powerful and poisonous drugs. Solutions made from it should never be used without special directions from a physician. In much weaker solutions than the above it is one of the best antiseptic washes known. It is used to disinfect wounds, for douches, and for various other purposes, but always by special direction of a physician.

Other solutions.—Frequently mothers are directed to use solutions in the proportion of 1 to 500, or 1 to 1000.

This means that there will be one part of the drug, or of the liquid medicine, to 500, or 1000 parts of water. For example if you were asked to make up a solution of bichloride of mercury in the strength of 1 to 4000, you would use one ounce of bichloride of mercury to four thousand ounces of water, or one grain of the mercury to four thousand drops of water,—one grain being equivalent to one drop.

Sometimes solutions are made up on the percentage basis. For example, a five per cent. solution of carbolic acid. In this case it would be necessary to take five ounces of carbolic to one hundred ounces of water, or five drops of carbolic to one hundred drops of water.

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CHAPTER XXXIX

ACCIDENTS AND EMERGENCIES

Accidents and Emergencies—Contents of the Family Medicine Chest—Foreign Bodies in the Eye—Foreign Bodies in the Ear—Foreign Bodies in the Nose—Foreign Bodies in the Throat—A Bruise or Contusion—Wounds—Arrest of Hemorrhage—Removal of Foreign Bodies from a Wound—Cleansing a Wound—Closing and Dressing Wounds—The Condition of Shock—Dog Bites—Sprains—Dislocations—Wounds of the Scalp—Run-around—Felon—Whitlow—Burns and Scalds

Contents of the Family Medicine Chest.—The family medicine cabinet should contain the following articles: a graduate, medicine droppers, hot water bags, a flat ice bag, a fountain syringe, a Davidson's syringe, a baby syringe, sterile gauze, absorbent cotton, gauze bandages of various widths, a yard of oiled silk, one roll of one inch "Z O" adhesive plaster, a bottle of Pearson's creolin, hydrogen peroxide (fresh), one ounce tincture of iodine in an air-tight bottle, a can of Colman's mustard, two ounces of syrup of ipecac, a bottle of castor oil (fresh), one pound of boracic acid powder, one pound of boracic acid crystal, a bottle of glycerine, a bottle of white vaseline, a bath thermometer, some good whisky or brandy, aromatic spirits of ammonia, smelling salts, pure sodium bicarbonate, oil of cloves for an aching gum or toothache, a bottle of alkolol for mouth wash and gargle, and one ounce of the following ointment for use in the various emergencies which occur in all homes,—

Bismuth subnitrate dram one Zinc oxide dram one Phenol (95%) drops twelve Resinol ointment to make ounce one

This ointment may be applied to all cuts, bruises, skin eruptions, chafings and sores of minor importance. It is one of the best applications for chafing of the skin in babies.

The medicine chest should also contain a small jar of Unguentine for burns; one-tenth grain calomel tablets for a cathartic for baby to be used as explained in the text of the book, or as advised by the physician. It may also contain tablets for colds and for other purposes as suggested by the family physician. It should never contain medicines the use of which is not thoroughly understood by the mother. It is a wrong practice for mothers to keep medicines to use for the same ailment at a subsequent time. The ailment may not be the same and frequently the medicine itself deteriorates, or it may get stronger with age. Many medicines are made with alcohol in them. If kept for some time the alcohol evaporates and leaves a concentrated mixture which, if given in the dose meant for the fresh preparation, may poison a child. Such cases of poisoning are on record. The same argument applies to powders. Certain drugs lose their strength, some absorb moisture, others change their chemical strength if kept mixed with other chemicals. They should be thrown away after the case is over if they have not been used. It is a dangerous practice to keep medicines around if there are children in the family.

Foreign Bodies in the Eye.—Particles which accidentally lodge in the eye are usually located on the under surface of the upper lid. They are sometimes, however, found on the ball of the eye or on the inner aspect of the lower lid. Foreign bodies which are propelled into the eye with great force, as iron specks which railroad men frequently get sometimes imbed themselves into the eye-ball and have to be cut out or dug out. The entrance of the foreign particle is always accompanied by a flow of tears which is nature's way of removing them. The offending object may escape through the tear duct into the nose, or it may be simply washed out with the flow of tears. Rubbing the well eye will cause a flow of tears in both eyes and may facilitate removal of the foreign matter. Blowing the nose may force the particle into the tear duct. The use of the eye cup may help in ridding the eye of the body. The same object may be accomplished if the eyes are immersed in a basin of water and opened wide. Then by moving the eyes around the particle may be washed out. If the particle is located on the under surface of the upper lid it may be promptly removed by pulling the upper lid forcibly down and over the lower lid. The eyelashes of the lower lid act as a brush and as a rule quickly remove the irritant if the procedure is carried out adroitly. Everting the upper lid is a means of locating the body and in making possible its removal by a small camel's hair brush or corner of a handkerchief. To evert the upper lid it is necessary to employ a guide. A match stem may be used in an emergency. This is laid across the middle of the upper lid, the eye lashes are grasped with the fingers of the other hand and the lid is bent over the match stem and turned up thus everting or turning inside out the entire upper lid. The procedure may be facilitated if the patient is instructed to look down while the operator is drawing the eye-lid upward.

If the particle cannot be easily removed by any of the above methods it is not safe for an uninstructed individual to go any further. The eye is an exceedingly delicate organ and may be permanently injured by unnecessary irritation. It is always safer and it may be cheaper in the long run to consult a competent oculist in such cases.

After the removal of any object from the eye, it is desirable to frequently wash it out with a saturated solution of boracic acid. This mixture will allay any inflammation and will tend to restore the normal condition more quickly and more satisfactorily than if the eye were left to heal itself.

Foreign Bodies in the Ear.—When a foreign body gets into the ear mothers are unnecessarily alarmed because of a failure to appreciate that the ear is a closed passage. It is impossible for any object to get into the ear itself; the depth of the external passage is only about one inch in an adult. At this point the passage is completely closed by the drum membrane. Most of the harm is done by ignorant meddling, not by the object itself.

Children frequently put foreign bodies in the ear, as, buttons, pebbles, beans, cherry stones, coffee, etc. The very first thing for the mother to do when she learns that her child has put "something" in its ear is to keep cool, and try to find out what the something is. It is essential to know what the article is because different articles are treated differently. For example if we try to remove a bean or pea with a syringe, the liquid will cause the pea or bean to swell and result in wedging it in so firmly that it will be impossible to dislodge it in this way.

If the object is hard, as a marble, button, pebble, bead, the greatest care must be exercised. Try to make the object fall out. To effect this, turn the child's head downward with the injured ear toward the floor. Then pull the lobe of the ear outward and backward so as to straighten the canal. A teaspoonful of olive oil poured into the ear will aid in its expulsion. If after the oil is poured in, the head is suddenly turned as above described the object will fall out. A very effective way to remove a hard object is to take a small camel's hair brush and coat the end with glue, or any other adhesive substance, then place it in contact with the object and permit it to remain long enough to become firmly attached after which it may be gently pulled out with the object attached. Never employ an instrument in the ear to remove a foreign body.