FOOD CONTAINING PARASITES.—The parasites found in food in this country are echinococcus, guineaworm, hookworm, trichina, and tapeworm. Echinococcus cannot be understood or diagnosed by the layman. Guineaworm is excessively rare in the United States; it gains access into the body through drinking water which contains the individuals. Hookworm is the cause of "miners' anaemia," and is extremely rare in this country.

The entrance of living food parasites can be absolutely prevented by thorough cooking of meats, especially pork and beef. Heat destroys the "measles" and the trichina worms.

TAPEWORM.—This is developed in man after eating "measly" beef or pork. "Measles" are embryo tapeworms called, from their appearance, "bladder worms." In from six to ten weeks after being received into the intestine of a man, these bladder worms become full grown, and measure from ten to thirty feet in length—the tapeworms.

Symptoms.—Vertigo, impairment of sight and of hearing, itching of the nose, salivation, loss of appetite, dyspepsia, emaciation, colic, palpitation of the heart, and sometimes fainting accompany the presence of the tapeworm. Generally the condition becomes known through the passage in the excrement of small sections of the worm. These sections resemble flat portions of macaroni.

Treatment.—This, to be successful, must be directed by a physician. When no physician can be procured, the patient may attempt his own relief. After fasting for twenty-four hours, pumpkin seed, from which the outer coverings have been removed by crushing, are soaked overnight in water and taken on an empty stomach in the morning; a child takes one or two ounces thoroughly mashed and mixed with sirup or honey, and an adult four ounces (see Vol. III, p. 245).

TRICHINIASIS.—This is a dangerous disease caused by the presence in the muscles and other tissues of the trichinae, little worms which are swallowed in raw or partly cooked pork, ham, or bacon. Nausea, vomiting, colic, and diarrhea appear early, generally on the second day after eating the infected meat. Later, stiffness of the muscles occurs, with great tenderness, swelling of the face and of the extremities, sweating, hoarseness, difficult breathing, inability to sleep, bronchitis, and pneumonia.

There is no treatment for the disease. Many cases which are not fatal are probably considered to be obscure rheumatism. Many cases of pneumonia are caused by the worm.

POTATO POISONING.—There remains one variety of food poisoning which needs mention, since it occurs when least expected, and when proper food has been subjected to natural growth. As the potato belongs to the botanical family containing the dangerous belladonna, tobacco, hyoscyamus, and stramonium, it is not surprising that is should also contain a powerful poisonous alkaloid, namely, solanine. Solanine is developed in potatoes, especially during their sprouting stage. Violent vomiting and diarrhea and inflammation of the stomach and bowels are caused by it. Careful peeling of sprouting potatoes, and removal of their eyes, will lessen, if not wholly obviate, the danger from eating them. This form of food poisoning is rare.



CHAPTER VIII

Bites and Stings

Several Kinds of Mosquitoes—Cause of Yellow Fever—Bee, Wasp, and Hornet Stings—Wood Ticks, Lice, and Fleas—Scorpions and Centipedes—Poisonous Snakes—Dog and Cat Bites.

MOSQUITOES.—The female mosquito is the offender. During or after sucking blood she injects a poison into the body which causes itching, swelling, and, in some susceptible persons, considerable inflammation of the skin. The bites of the mosquitoes living on the shores of the Arctic Ocean and in the tropics are the most virulent. The most important relation of mosquitoes to man was only recently discovered. They are probably the sole cause of malaria and yellow fever in the human being. The malarial parasite which lives in the blood of man, when he is suffering from malaria, first inhabits the body of a certain kind of mosquito. The mosquito acquires the undeveloped parasite by biting the human malarial patient, and then acts as a medium of infection by transmitting the active parasite to some healthy man, through the bite.

The more common house mosquito, the Culex, does not carry the parasite of malaria, and it is important to be able to distinguish the Anopheles which is the source of malaria. The Anopheles is more common in the country, while the Culex is a city pest. The Culex has very short palpi, the name given to the projections parallel to the proboscis; while those of Anopheles are so large that it appears to have three probosces. There are no markings on the wings of the ordinary species of Culex, while the wings of Anopheles are distinctly mottled. The Culex, sitting on a wall or ceiling, holds its hind legs above its back and its body nearly parallel to the wall or ceiling, but the Anopheles carries its hind legs either against the wall or hanging down (rarely above the back), and its body, instead of lying parallel to the wall or ceiling, hangs away at an angle of about forty-five degrees from it.

The Culex lays her eggs in sinks, tanks, cisterns, and water about houses, but the Anopheles deposits her ova in shallow pools and sluggish streams, especially those on which is a growth of green scum or algae. Such are the main distinguishing features of the malaria-carrying mosquito, the Anopheles, and the commoner house variety, the Culex.

To prevent malaria, mosquito bites must be prevented by nettings in houses, especially for the protection of sleepers. Pools, ponds, and marshy districts must be drained in order to destroy the breeding places of Anopheles, and in the malarial season, petroleum (kerosene) must be poured on the surface of such waters to arrest the development of the immature insects (larvae).

The mosquito is believed to be the sole cause of yellow fever, being capable of communicating the germ of the disease to man by its bite two weeks after it has itself been contaminated with the germ in feeding on the blood of a yellow-fever patient. This invaluable discovery was made by Dr. Walter Reed, U. S. A., in 1901, as a result of his labors and those of other members of the yellow-fever commission of the U. S. Army in Cuba, involving the death of one of the members of the commission (Dr. Lazear), and utilizing the heroism of a number of our young soldiers who voluntarily offered themselves to be bitten by mosquitoes that had previously bitten yellow-fever patients, and who experimentally occupied premises containing all sorts of articles infected by yellow-fever patients. The result of their research proves that yellow fever is not contagious at all, in the usual sense, but is communicated only through the medium of mosquitoes. This shows the fallacy of many quarantine rules regarding yellow-fever patients, and of the fear of nursing the sick, and will result in controlling the disease.

In the case of malaria or yellow fever, there is a vicious circle into which man and the mosquito enter; malaria and yellow-fever patients contaminate the mosquitoes which bite them, and the mosquitoes in their turn infect man with these diseases. A patient with malaria coming into a nonmalarial place, and being bitten by mosquitoes, may lead to an epidemic of the disorder which becomes endemic. To terminate this condition, it is necessary to prevent the contact of man with mosquitoes and to kill these insects. Both malaria and yellow fever will doubtless be practically eradicated before long through the result of these scientific discoveries.

Treatment of Mosquito Bites.—To prevent mosquitoes, fleas, lice, horseflies, etc., from biting, it is necessary merely to dip the clean hands into a pail of water in which, while hot, one ounce of pure carbolic acid was dissolved, and while they are thus wet rub the solution over all the exposed skin and allow it to dry naturally. A mixture of kerosene (petroleum) and water used in the same way will also afford protection. All poisons introduced into the body by insects are of an acid nature, and to this quality are due the pain and irritation which it is our object to overcome. The best remedy, naturally, is an alkali of some sort. Water of ammonia, diluted, or a strong solution of saleratus or baking soda in water, are the two most successful remedies to apply, either through bathing, or on cloths saturated in one of the solutions. Clean clay, mixed with water to make a mud poultice, is a useful application in emergencies.

BEE, WASP, AND HORNET STINGS.—The pain and swelling are produced by the poison of the insect which leaves the poison bag at the base of the barb at the instant that the person is stung. The bee stings but once, as the sting being barbed is broken off, and is retained in the flesh of the victim. The sting of the wasp and hornet is merely pointed, and is not lost during the stinging process so that they can repeat the act. Bee keepers, after being stung a number of times, usually become immune, i. e., they are no longer poisoned by bites of these insects.

It is well to extract the sting of bees before all of the poison has come away. A fine pair of forceps is useful for this purpose; or, by pressing the hollow tube of a small key directly down over the puncture made by the sting, it may be squeezed out.

Ammonia water, as recommended for mosquitoes, is the best remedy to relieve the pain.

WOOD TICKS.—Ticks inhabit the woods and bushes throughout the temperate zone, and at certain periods during the summer season attack passing men and animals.

The common tick is nearly circular in shape, very flat, with a dark, brown, horny body about one-sixteenth to one-eighth inch in diameter. Each of its eight legs possesses two claws, and the proboscis incloses feelers which are similarly armed. The beetle plunges its barbed proboscis into the flesh of man or animals, and holds on very firmly with its other members till it is gorged with blood, growing as large as a good-sized bean, when it drops off. The bite is painless, and it is not until the insect is engorged with blood that it is perceptible; if, however, attempts are made to remove the tick before it is ready to let go, the proboscis may be torn off and left in the skin, when painful local suppuration will follow.

Treatment.—As the presence of tick is far from agreeable, the insect may often be removed by painting it with turpentine, which either kills it or causes the claws to be relaxed; in either case the tick loosens its hold and drops to the ground. A tropical variety, carapato, buries the whole head in the flesh of its host before it is perceived, and if turpentine does not loosen its hold, the head must be dug out with a clean needle or knife blade.

LICE (Pediculi).—Head lice are most common. They are gray with black margins, about one-twenty-fifth to one-twelfth inch long, and wingless. The color changes with the host, as the lice are black on the negro, and white in the case of the Eskimos. The female lays fifty to sixty eggs ("nits"), seen as minute, white specks glued to the side of a hair; usually not more than one or two on a single hair. The eggs hatch in six days.

The irritation produced by the presence of the parasites on the head leads to general itching, more particularly on the lower part of the back of the head. The constant scratching starts an inflammation of the skin with the formation of pimples, weeping spots, and crusts, from the dried discharge, possessing a bad odor. The denuded spots becoming infected, the neighboring glands enlarge and are felt as tender lumps beneath the skin at the back of the neck, under the jaw, or at either side of the neck. Whenever there are persistent itching and irritation of the scalp, particularly at the back of the head, lice or "nits" should be sought for. Sometimes it is more easy to find them on a fine-tooth comb passed through the hair. Lice are very common in dirty households, and are occasionally seen on the most fastidious persons, who accidentally acquire them in public places or conveyances.

Treatment.—The hair should be cut short when permissible. Any crusts on the head should be softened by the application of sweet oil, and then removed by washing in soap and warm water. Petroleum or kerosene is a good remedy. It must be rubbed on the head two successive nights, the head being covered by a cap, and washed off each morning with hot water and soap. The patient must be cautioned not to approach an open flame after kerosene has been put on his head.

The eggs or "nits" are next to be attacked with vinegar, which is sponged on the hair and the fine-tooth comb plied daily for a week. The remaining irritation of the scalp can be cured by washing the head daily and applying sweet oil.

A simpler plan consists of drenching hair and scalp twice with cold infusion of (poisonous) larkspur seed, made by steeping for an hour an ounce of the seed in six ounces of hot water.

This treatment will destroy both insects and eggs. After twenty-four hours the hair and scalp must be shampooed with warm water thoroughly.

CLOTHES LICE.—These insects are a trifle larger than the head lice, being one-twelfth to one-eighth inch long, of a dirty, yellowish-gray color, and only infesting the most filthy people. The lice are generally only seen on the clothes, where they live, coming out on the body only to feed. The visible signs on the body are varying degrees of irritation from redness to ulceration, due to scratching. The treatment is simply cleanliness of the body and clothes.

CRAB LICE.—The crab louse or "crab" inhabits the skin covered by hair about and above the sexual organs most frequently, and from thence spreads to the hairy region on the abdomen, chest, armpits, beard, and eye lashes. Itching and scratching first call attention to the presence of the parasites, which are even more troublesome than the other species.

Application of kerosene to the part is sufficient to kill the lice, but this treatment must be repeated several times at intervals of a week, in order to kill the parasites subsequently hatched.

FLEA.—Flea bites are recognized by the itching caused by the poison introduced by the insect, and by points of dried blood surrounded for a little while by a red zone. In the case of children and people with delicate skins, red or white lumps appear resembling nettlerash. Generally the skin is simply covered with minute, red points, perhaps raised a little by swelling above the surface, and when very numerous may remotely resemble the rash of measles. Fleas, unlike lice, do not breed on the body, but as soon as they are satiated leave their host. Their eggs are laid in cracks in floors, on dirty clothes and similar spots, and it is only the mature flea which preys upon man. The human flea may infest the dog and return to man, but the dog flea is a distinct species, and never remains permanently on the human host. For these reasons it is not difficult to get rid of fleas after they have attacked the body, unless continually surrounded by them.

JIGGER OR SAND FLEA.—Also called chique, chigo, and nigua. It is common in Cuba, Porto Rico, and Brazil. About one-half the size of the ordinary flea, it is of a brownish-red color with a white spot on the back. The female lives in the sand and attacks man, on whom she lives, boring into the skin about the toe nail, usually, and laying her eggs under the skin, which gives rise to itching at first and then violent pain. The insect sucks blood and grows as it gorges itself, producing a white swelling of the skin in the center of which is seen a black spot, the front part of the flea. The flea after expelling its eggs drops off and dies. People with habitually sweaty feet are exempt from attacks of the pest.

Unless the flea is unattached, one must either wait until the insect comes away of its own free will, or remove it with a red-hot needle in order to destroy the eggs. The negroes peel the skin from the swelling with a needle and squeeze out the eggs. Ordinarily the bites do no permanent injury, but occasionally if numerous, or if the insect is pressed into the skin in the efforts to remove it, or if sores resulting from bites are neglected, then violent inflammation, great pain, and even death of the part may result. Sound shoes and a night and morning inspection of the feet will protect against the inroads of the sand fleas.

FLIES.—The common housefly does not bite, but is constantly inimical to human health by conveying disease germs of typhoid fever, cholera, and other disorders from bowel discharges of patients suffering from these diseases to articles of food on which the insects light. Flies have been a fruitful source of sickness in military camps, as evidenced in the recent Spanish-American and Anglo-African campaigns. The bites of the sandfly, gadfly, and horsefly may be both relieved and prevented by the same means recommended in the case of mosquitoes for these purposes.

SCORPION OR CENTIPEDE STING.

First Aid Rule.—Squeeze lemon juice on wound.

SPIDER OR TARANTULA BITE.

First Aid Rule.—Pour water of ammonia on bite. If patient is depressed, give strong coffee.

SCORPIONS AND CENTIPEDES.—These both inhabit the tropics and semitropical regions, and lurk in dark corners and out-of-the-way places, crawling into the boots and clothing during the night. Scorpions sting with their tails, which are brought over the head and back for the purpose, while holding on to the victim with their lobsterlike claws. The poisonous centipede has a flattened brownish-yellow body, with a single pair of short legs for each body segment, and long, many-jointed antennae.

The wounds made by either of these pests are rarely dangerous, except in young children and those in feeble health. The stings are usually relieved by bathing with a two per cent solution of carbolic acid, with rum, or with lemon juice.

SPIDERS.—Many of the tropical spiders bite the human being. Trapdoor spiders are among the commonest of these pests. Their bodies grow to great size, two to two and a half inches long, and are covered with hair giving them a horrid appearance. They live in holes bored in the ground, and provided with a trapdoor contrivance which is closed when the insect is at home.

The trapdoor spider resembles the tarantula, by which name it is usually known in Cuba and Jamaica, but is somewhat smaller and commoner. Neither the stings of the trapdoor spider nor true tarantula are usually dangerous although the wounds caused by the bites may heal slowly.

Application of water of ammonia and of the other remedies recommended for mosquito bites (p. 158) are indicated here, and if the patient is generally depressed by the poison, strong coffee forms a good antidote.

SNAKE BITE.

First Aid Rule 1.—Make the wound bleed. Cut slit through the wound, lengthwise of limb, two inches long and half an inch deep. Squeeze tissues. DO NOT SUCK THE WOUND.

Rule 2.—Keep poison out of general circulation. Tie large cord or bandage tightly about part between wound and heart. Loosen in fifteen minutes.

Rule 3.—Use antidote. Wash wound and cut with fresh solution of chloride of lime (one part to sixty parts of water). Inject anti-venene with hypodermic syringe, ten cubic centimeters, as on label. Or, inject with hypodermic syringe thirty minims of solution of permanganate of potash (five grains to two ounces of water), three times in different places. If no syringe at hand, pour permanganate solution into wound.

Rule 4.—Support heart if weak. Inject with hypodermic syringe one-thirtieth grain of sulphate of strychnine into leg. Repeat as needed every thirty minutes with caution.

Rule 5.—Give no whisky or other liquor. Do not burn the wound.

SNAKE BITE.—There are many different species of poisonous snakes in the United States. The more common are the rattlesnake, the moccasin, the copperhead, and the common viper.

All the venomous snakes have certain characteristics by which they may be distinguished from their harmless brethren. The head is generally broad and flat and of a triangular shape, the wide, heavy jaws tapering to a point at the lips. There is a depression or pit between the nostril and eye on the upper lip, hence the name "pit vipers" given to poisonous snakes. The pupil of the eye is long and vertical, of an oval or elliptical shape.

Venomous snakes are thicker in proportion to their length than harmless snakes, the surface of their bodies is rougher, and their tails are blunt or club-shaped. Conversely, harmless snakes possess long narrow heads, the pupils of their eyes are round, not vertical slits, and their bodies are not thick for their length, but long and slim with pointed tails. The bite of vipers of all kinds is much more poisonous in tropical regions, and in the North fatal snake bite is a rare occurrence.

If there is a doubt whether a snake is poisonous, the neck may be pressed down against the ground between the jaws of a forked stick, and the poison fangs looked for without danger. These hang directly down from the front part of the upper jaw, or are thrust horizontally forward just in front of the upper lip, and may drip saliva and venom.

In Cuba and Porto Rico there is a viper called Juba, or Boaquira, which is a counterpart of the Northern rattlesnake, and the most poisonous of the many species in that region. Among venomous species of the Philippines are two boas and also a viper from nine to ten feet long, which exceptionally pursues and attacks man. This snake is easily killed by a blow on the neck. Another small viper with a club-shaped tail, inhabiting these islands, is nocturnal in its habits, and may get into boots at night. Boots, therefore, should always be inspected before one puts them on in the morning.

Usually it is only the young, old, and weak who succumb to snake bite.

Symptoms.—The symptoms of snake bite of all poisonous species are similar. At first there is some pain in the wound, which rapidly increases together with swelling and discoloration until death of the part may ensue. The vital centers in the brain controlling the heart and breathing apparatus, are paralyzed by the poison. There is often drowsiness and stupor, and the breathing is labored and the pulse weak and irregular, with faintness and cold sweats.

Treatment.—The treatment consists first in keeping the poison out of the general blood stream. With this purpose in view a handkerchief, piece of cotton clothing, string, or strap should be immediately wound about the bitten limb above the wound, between it and the heart. This will retard absorption of the poison only for a time; it is said twenty-five minutes. The knife is the most effective means of removing the poison by making an oval cut on each side of the wound so that the two incisions meet and remove all the flesh below and around the wound. Bleeding should be encouraged to drain out the poison. The skin containing the wound may be lifted up, and the whole wound cut out by one snip of the scissors where this is practicable.

Some advocate burning out the wound with a red-hot wire, or darning needle, instead of cutting, but the treatment is less effective and more painful. Rambaud forbids burning. As to the general condition: if stupor is a prominent symptom the patient must be made to move about and exercise to keep alive his nerve centers. Otherwise one tablespoonful of whisky may be given in half a cup of hot water hourly, to sustain the weakened heart and respiration until recovery ensues.

The most effective treatment, according to Dr. George Rambaud, Director of the Pasteur Institute of New York City, is thorough washing of the wound (after it has been opened with the knife) with freshly prepared solution of chloride of lime, in the proportion of one part of lime to sixty of water. The burning of a wound is bad practice. If necessary, chloride-of-lime solution should be injected into the tissues around the wound. One about to go into a place where the most venomous snakes are found should inject into himself a dose of Calmette's antivenomous serum every two or three weeks as a means of prevention. If the serum is used, whisky should not be given in the treatment of one who has been bitten, for the anti-venene is a powerful cell stimulator.

Calmette, the Director of the Pasteur Institute in Lille, France, several years ago discovered antivenomous serum. That serum is efficient for the bites of most of the venomous snakes of different countries, including the rattlesnake, cobra, python, etc.

It is prepared in the dry form so that it can be carried easily, and will keep almost indefinitely. The proper course to be followed by persons going into countries infested by venomous snakes is always to have on hand a few doses of it. Its value has been positively demonstrated within the last few years in India, where it is used in the British Army, as well as in other countries.

In the fluid form it should be used hypodermically, a dose of ten cubic centimeters being injected within eighty or ninety minutes of the reception of the poison.

DOG BITE OR CAT BITE. (See Hydrophobia, Vol. V, p. 264.)

First Aid Rule 1.—Make sure animal is mad. Send patient to Pasteur institute if one is within reach.

Rule 2.—Remove poison from wound. Encourage bleeding by squeezing tissue about wound. Suck wound, if you have no cracks in lips, and spit out fluid. Pour hot carbolic solution into wound (a third of a teaspoonful of carbolic acid to a pint of hot water).

Rule 3.—Cauterize. Dip wooden meat skewer, or lead pencil, into pure nitric acid, and rub into wound. Or, use red-hot poker, or red-hot nail grasped by tongs or pincers, or red coal from fire.

Rule 4.—Do not kill the animal. If he is alive and well at the end of a week, he was not mad.



CHAPTER IX

Burns, Scalds, Frostbites, Etc.

Classes of Burns—Treatment—Burns Caused by Acids and Alkalies—First Aid Rules for Frostbites—Real Freezing—Ingrowing Toe Nail—Fainting—Suffocation—Fits.

BURNS AND SCALDS.—If slight, skin very red, unbroken.

First Aid Rule.—Cover with cloths wet in strong solution of baking soda in cold water. Dry gently, and spread with white of egg, thick.

If deeper, blisters, skin broken, thick swelling; there may be some bleeding.

First Aid Rule 1.—Stop pain quickly. Cut away clothing very gently. Break no blisters. Cover with Carron oil (equal parts of limewater and linseed or olive oil) and light bandage. Give fifteen drops of laudanum[9] every half hour in tablespoonful of water, till relieved in part or three doses are taken.

Rule 2.—Combat shock. If patient is cold, pulse weak, head confused, give tablespoonful of whisky in a quarter of a glass of hot water. Put hot-water bottles at feet.

Rule 3.—Quench thirst with pieces of ice held in mouth or a swallow of cold milk.

See page 174 for subsequent treatment.

A burn is produced by dry heat, a scald by moist heat; the effect and treatment of both are practically identical. Burns are commonly divided into three classes, according to the amount of damage inflicted upon the body.

First Class.—There is redness, pain, and some swelling of the skin, followed, in a few days, by peeling of the surface layer (epidermis) and recovery. Sunburn and burns caused by slight exposures to gases and vapors fall into this category.

Treatment.—The immediate immersion of the part in cold water is followed by relief, or the application of cloths wet with a saturated solution of saleratus or baking powder is useful. Anything which protects the burned skin from the irritating effect of the air is efficacious, and in emergencies any one of the following may be applied: starch, flour, molasses, white paint, or a mixture of white of egg and sweet oil, equal parts. Usually after the first pain has been relieved by bathing with soda and water, or its application on cloths, the employment of a simple ointment suffices, as cold cream or vaseline.

Second Class.—In this class of cases the inflammation is more severe and the deeper layers of the skin are involved. In addition to the redness and swelling of the skin there are present blisters which appear at once or within a few hours. The general condition is affected according to the size of the burn. If half of the body is only reddened, death usually results, and a burn of a third of the body is often fatal. The shock is so great at times that pain may not be at once intense. Shock is evidenced by general depression, with weakness, apathy, cold feet and hands, and failure of the pulse. If the patient rallies from this condition, then fever and pain become prominent. If steam has been inhaled, there may be sudden death from swelling of the interior of the throat, or inflammation of the lungs may follow inhalation of smoke and hot air.

Third Class.—In this class are included burns of so severe a nature that destruction and death of the tissues follows; not only of the skin but of the flesh and bones in the worst cases. It is impossible to tell by the appearance of the skin what the extent of the destruction may be until the dead parts slough away after a week or ten days. The skin is of a uniform white color in some cases, or may be of a yellow, brown, gray, or black hue, and is comparatively insensitive at first. Pus ("matter") begins to form around the dead part in a few days, and the dead tissue comes away later, to be followed by a long course of suppuration, pain, excessive granulations ("proud flesh"), and, unless skillfully treated, by contraction of the surrounding area, leaving ugly scars and interfering with the appearance and usefulness of the parts. The treatment of such cases after the first care becomes that to be pursued in wounds generally (p. 50), and belongs within the domain of the surgeon.

Treatment of the More Severe Burns.—If the patient is suffering from shock he should receive some hot alcoholic drink, as hot water and whisky, and be put to bed under warm coverings with hot-water bags or bottles at his feet.

The clothing must be cut away from the burned parts with the greatest care, and only a portion of the body should be uncovered at a time and in a warm room. Pain may be subdued by laudanum[10]; fifteen drops may be given to an adult, and the drug may be repeated at hour intervals in doses of ten drops until the suffering has been allayed. Lumps of ice held in the mouth will quench thirst, and the diet should be liquid, as milk, soups, gruels, white of egg, and water. The bowels should be moved daily by rectal injections of soap and warm water. As a matter of local treatment, the surface layer of the skin should be kept intact if possible. Blisters are not to be disturbed unless they are large and tense; if so, their bases may be pricked with a needle sufficiently to let out the fluid contents.

Carron oil (equal parts of olive oil and limewater) has been the common remedy for burns, and it is an efficient, though very dirty, dressing, useful if the skin is generally unbroken. It should be applied on clean, soft linen or cotton cloth, which is soaked in the oil, laid over the burned area, and covered with a thick layer of cotton batting and a bandage. When the skin is denuded, leaving a raw surface exposed, the burn must be treated on the same plan as wounds, and should be kept as clean and free from germs as possible. An ointment made of equal parts of boric acid and vaseline, spread thickly on clean cloth, is a good antiseptic preparation in cases where the skin is broken. It is best not to change the dressing oftener than once in two or three days, unless the discharge or odor are considerable. Fresh dressing is very painful and often harmful.

When the dressing is removed, warm saline solution (one teaspoonful of common salt in a quart of water) is allowed to flow over the burn until all discharge is washed off. Then the raw surface is dusted over with pure boric acid or aristol, and the boric-acid ointment applied as before. The cloth upon which the ointment is spread should be made free from germs by boiling in water, and then drying it in an oven and keeping it well wrapped in a clean towel except when wanted.

The same care is requisite as that described under wounds (p. 50) in regard to cleanliness.

Very extensive burns are most satisfactorily treated by complete immersion of the burned limbs or entire body in salt solution (same strength as above), which is kept at a temperature of from 94 deg. to 104 deg. F., according to the feelings of the patient. The patient lies in a bath tub on horsehair, or better, rubber mattress and rubber pillows; completely covered with water except the head. The urine and bowel discharges must be passed in the water, which is then changed, and the temperature is kept at an even mark by allowing warm water to continually run into the tub to displace that which runs out. The latter can be arranged by siphonage with a rubber tube. While this method requires more care, and running hot and cold water, it is the most comfortable treatment for these cases, usually attended by awful suffering, and at the same time it is most favorable to healing.

It is beyond the scope of this work to describe the various complications and the details of the after treatment in severe burns, including skin grafting, which may tax all the ingenuity of the skilled surgeon. It is hoped that the foregoing may give a clear idea of the treatment to be pursued in emergencies and may prove of some use to those who may unfortunately be compelled to care for burns during a considerable time without the aid of a physician.

BURN BY STRONG ACID.

First Aid Rule 1.—Neutralize the acid. Scatter baking soda thickly over burn, or pour limewater over it.

Rule 2.—Control pain. Wash off soda with stream of water. Apply Carron oil (equal parts of limewater and linseed oil or olive oil). Bandage lightly.

BURN BY STRONG ALKALI.—As ammonia, quicklime, lye.

First Aid Rule 1.—Neutralize the alkali. Pour vinegar over the burn.

Rule 2.—Control pain. Wash off vinegar with stream of water. Dry gently. Apply vaseline or cold cream.

BURNS CAUSED BY STRONG MINERAL ACIDS OR BY ALKALIES.—If acids are the cause, the skin should not be washed at first, but either chalk, whiting, or some mild alkali, as baking soda, should be strewn over the burn, and then after the effect of the acid is neutralized, wash off the soda with stream of warm water. Dry gently with gauze. Apply Carron oil or paste of boric acid and vaseline, equal parts. If strong alkalies have been spilled on the skin, as ammonia, potash, or quicklime, then vinegar is the proper substance to employ, followed by washing. Then dry gently. Vaseline or cold cream is usually sufficient as after treatment. Limewater is useful in counteracting the effect of acids spattered in the eye. In the case of alkalies in the eye, the vinegar used should be diluted with three parts of water. Albolene or liquid vaseline is the best agent to drop in the eye after either accident, in order to relieve the irritation and pain, and the patient should stay in a dark room.

FROSTBITE, REAL FREEZING.—Nose, ears, fingers, toes; insensible to touch, stiff, pale or blue. Person may be unconscious.

First Aid Rule 1.—Restore circulation. Rub gently, then vigorously, with snow.

Rule 2.—Restore heat very gradually. Sudden heat is fatal. Keep in cold room, and rub with cloth wet with very cold water till circulation is established. Then rub with equal parts of alcohol and water and expose gradually to heat of living room.

Rule 3.—If person ceases to breathe, resuscitate as if drowned. Open his mouth, grasp his tongue, and pull it forward and keep it there. Let another assistant grasp the arms just below the elbows and draw them steadily upward by the sides of the patient's head to the ground, the hands nearly meeting (which enlarges the capacity of the chest and induces inspiration.) (See pp. 30 and 31.) While this is being done, let a third assistant take position astride the patient's hips with his elbows resting on his own knees, his hands extended ready for action. Next, let the assistant standing at the head turn down the patient's arms to the sides of the body, the assistant holding the tongue changing hands if necessary to let the arms pass. Just before the patient's hands reach the ground the man astride the body will grasp the body with his hands, the ball of the thumb resting on either side of the pit of the stomach, the fingers falling into the grooves between the short ribs. Now, using his knees as a pivot, he will at the moment the patient's hands touch the ground throw (not too suddenly) his whole weight forward on his hands, and at the same time squeeze the waist between them, as if he wished to force something in the chest upward out of the mouth; he will deepen the pressure while he slowly counts one, two, three, four (about five seconds), then suddenly lets go with a final push, which will send him back to his first position. This completes expiration. (A child or a delicate person must be more gently handled.)

At the instant of letting go, the man at the head of the patient will again draw the arms steadily upward to the sides of the patient's head as before (the assistant holding the tongue again changing hands to let the arms pass, if necessary), holding them there while he slowly counts one, two, three, four (about five seconds).

Repeat these movements deliberately and perseveringly twelve or fifteen times in every minute—thus imitating the natural motions of breathing. Continue the artificial respiration from one to four hours, or until the patient breathes; and for a while after the appearance of returning life carefully aid the first short gasps until deepened into full breaths.

Keep body warm after this with warm-water bottles.

FROSTBITE.—The nose, chin, ears, fingers, and toes are the parts usually frozen, although severe results ending in death of the frozen part occur more often owing to low vitality of the patient than to the cold itself. In the milder degree of frostbite there is stiffness, numbness, and tingling of the frozen member; the skin is of a pale, bluish hue and somewhat shrunken. Recovery ensues with burning pain, tingling, redness, swelling and peeling of the epidermis, as after slight burns. The skin is icy cold, white, and insensitive in severe forms of frostbite, and, if not skillfully treated, becomes, later, either swollen and discolored, or shriveled, dry, and black. In either case the frozen part dies and is separated from the living tissue after the establishment of a sharp line of inflammation which results in ulceration and formation of pus, and thus the dead part sloughs off. It is, however, possible for a part thoroughly frozen to regain its vitality.

Treatment.—The essential element in the treatment is to secure a very gradual return of blood to the frozen tissues, and so avoid violent inflammation. To obtain this result the patient should be cared for in a cold room, the frozen parts are rubbed gently with snow, or cloth wet with ice water, until they resume their usual warmth. Then it is well to rub them with a mixture of alcohol and water, equal parts, for a time and expose them to the usual temperature of a dwelling room. Warm drinks are now administered to the patient. The frozen member, if hand or foot, is raised high in the air on pillows and covered well with absorbent cotton and bandage. If much redness, swelling, and pain result this dressing is removed and the part is wrapped in a single thickness of cotton cloth kept continually wet with alcohol and water.

Subsequent treatment consists in keeping the damaged parts covered with vaseline or cold cream, absorbent cotton, and bandage. If blisters and sores result, the care is similar to that described for like conditions under burns. If death of the frozen part becomes inevitable, the hand or foot should be suspended in a nearly vertical position to keep the blood out, and the part bathed twice daily with a solution of corrosive sublimate (one 7.7 gr. tablet to pint of water), dusted well with aristol, and dressed with absorbent cotton and bandage until the dead tissue separates and comes away. If the frozen part is large it may be necessary to remove it with a knife, but this is not essential when the tips of the fingers or toes are frozen.

General Effect of Cold.—Sudden exposure to severe cold causes sleep, stupor, and death. Persons found apparently frozen to death should be brought into a cold room, which should be gradually heated, and the body rubbed with snow or ice water, and artificial respiration employed, as just directed. Attempts at resuscitation ought to be persistent, as recoveries have been reported after several hours of unconsciousness and apparent death from freezing.

CHILBLAINS AND MILD FROSTBITES.—The effects of severe cold on the body are very similar to those of intense heat, though they are very much slower in making their appearance. After a person has frozen a finger or toe he may not notice much inconvenience for days, when suddenly violent inflammation may set in. The fingers, ears, nose, and toes are the members which suffer most frequently from the effects of cold. Similar symptoms of inflammation, described under burns, also result from cold, that is, redness and swelling of the skin, blisters with more severe and deeper inflammatory involvement, or, in case the parts are thoroughly frozen, local death and destruction of the tissues. But it is not essential that the body be exposed to the freezing temperature or be frozen at all, in order that some harm may result, for chilblains often follow when the temperature has not been lower than 40 deg. F., or thereabouts.

The effect of cold is to contract the blood vessels, with the production of numbness, pallor, and tingling of the skin. When the cold no longer acts then the blood vessels dilate to more than their usual and normal state, and more or less inflammation results. The more sudden the return to warmth the greater the inflammatory sequel.

Chilblains represent the mildest morbid effect of cold on the body. They exist as bluish-red swellings of the skin, usually on the feet or hands, but may attack the nose or ears, and are attended by burning, itching, and smarting. This condition is caused by dilatation of the vessels following exposure to cold. It is more apt to happen in young, anaemic women. Chilblains usually disappear during warm weather. Scratching, friction, or the severity of the attack may lead to the appearance of blisters and sores. In severe cases the fingers and toes present a sausage-like appearance, owing to swelling.

Treatment.—Susceptible persons should wear thick, warm (not rough) stockings and warm gloves. The chilled members must never be suddenly warmed. Regular exercise and cold shower baths are good to strengthen the circulation, but the feet and hands must be washed in warm water only, and thoroughly dried. If sweating of these parts is a common occurrence, starch or zinc oxide should be dusted on freely night and morning. Cod-liver oil is an efficacious remedy in these cases; one teaspoonful of Peter Moeller's pure oil three times daily after meals. The affected parts are bathed twice daily in a solution of zinc acetate (one dram to one pint of water), and followed by the application, on soft linen or cotton, of zinc-oxide ointment containing two per cent of carbolic acid. If this is not curative, iodine ointment mixed with an equal quantity of lard may be tried. Exposure to cold will immediately bring on a recurrence of the trouble. If the affection of the feet is severe the patient must rest in bed. If the parts become blistered and open sores appear, then the same treatment as for burns is indicated. Wash with a weak solution of corrosive sublimate (one tablet for surgical purposes in two quarts of warm water) and apply an ointment of boric acid and vaseline, equal parts, spread on soft, clean cotton or linen. Rest of the part and existence in a warm atmosphere will complete the cure.

INGROWING TOE NAIL.—This is a condition in which the flesh along the edges of the great toe nail becomes inflamed, owing either to overgrowth of the nail or to pressure of the soft parts against it. Improper footgear is the most common cause, as shoes which are too narrow across the toes, or not long enough, or those with high heels which throw the toes forward so that they are compressed by the toe of the boot, especially in walking downhill.

A faulty mode of cutting the toe nails in a healthy foot may favor ingrowing toe nails. Toe nails should be cut straight across, and not trimmed away at the corners to follow the outline of the toes—as then the flesh crowds in at the corners of the nails, and when the nail pushes forward in its growth it presses into the flesh. Nails which have a very rounded surface are more apt to produce trouble, because then the edges are likely to grow down into the flesh. Inflammation in ingrowing toe nail usually arises along the outer edge of the nail. The flesh here becomes red, tender, painful, and swollen so that it overlaps the nail. After a time "matter" or pus forms and finds its way under the nail, and the parts about it ulcerate, and "proud flesh" or excessive granulation tissue springs up and imbeds the edge of the nail. Wearing a shoe, or walking, becomes impossible. The condition may last for months, or even years, if not rightly treated.

Treatment.—Properly fitting footgear must be worn—broad at the toes with low heels and of sufficient length. If pus ("matter") forms, the cut edge should be raised up by pushing in a little absorbent cotton under the nail every day. Hot poultices of flaxseed meal, or other material will relieve any special pain and inflammation. Soaking the foot frequently in hot water, and observing especial cleanliness, will aid recovery. Tannic acid, or some antiseptic powder like nosophen, should be dusted along the edge of the nail, and the flesh crowded away from the nail by pushing in a little cotton with some tannic acid upon it.

If there is a raw surface about the border of the nail, powdered lead nitrate may be dusted upon it each morning for four or five days, till the ulcerated tissue shrinks away and the edge of the nail becomes visible. The toe should be covered with absorbent cotton and a bandage. As soon as the toe is really inflamed the case becomes surgical, and as such demands the care of a surgeon when one can be obtained.

FAINTING.

First Aid Rule 1.—Remove impediments to respiration. Remove collar, loosen all waist bands and cords, unhook corset or cut the laces at person's back.

Rule 2.—Assist heart and brain with blood pressure. Put cushion under buttocks, wind skirt close about legs, and raise feet in air. Wait ten seconds.

Rule 3.—Aid respiration. Put mild smelling salts under nose. Spatter cold water in face.

SUFFOCATION FROM GAS IN WELLS, CISTERNS, OR MINES, OR FROM ILLUMINATING GAS.

First Aid Rule 1.—Remove quickly into pure air.

Rule 2.—Resuscitate as if drowned. Open his mouth, grasp his tongue, pull it forward and keep it there. Let another assistant grasp the arms just below the elbows, and draw them steadily upward by the sides of the patient's head to the ground, the hands nearly meeting, which enlarges the capacity of the chest and induces inspiration. (See pp. 30 and 31.) While this is being done, let a third assistant take position astride the patient's hips with his elbows resting on his own knees, his hands extended ready for action. Next, let the assistant standing at the head turn down the patient's arms to the sides of his body, the assistant holding the tongue, changing hands if necessary to let the arms pass.

Just before the patient's hands reach the ground, the man astride the body will grasp the body with his hands, the ball of the thumb resting on either side of the pit of the stomach, the fingers falling into the grooves between the short ribs. Now, using his knees as a pivot, he will, at the moment the patient's hands touch the ground, throw (not too suddenly) his whole weight forward on his hands, and at the same time squeeze the waist between them, as if he wished to force something in the chest upward out of the mouth; he will deepen the pressure while he slowly counts one, two, three, four (about five seconds), then suddenly lets go with a final push, which will send him back to his first position. This completes expiration. A child or a delicate person must be more gently handled.

At the instant of letting go, the man at the head of the patient will again draw the arms steadily upward, to the sides of the patient's head, as before (the assistant holding the tongue again, changing hands if necessary to let the arms pass, holding them there while he slowly counts one, two, three, four (about five seconds)).

Repeat these movements deliberately and perseveringly twelve or fifteen times in every minute, thus imitating the natural motions of breathing. Continue the artificial respiration from one to four hours, or until the patient breathes; and for a while after the appearance of returning life, carefully aid the first short gasps until deepened into full breaths.

Keep the body warm with hot-water bottles and blanket.

Rule 3.—Give oxygen to breathe from a cylinder, for two days, at short intervals, in the case of illuminating gas.

FIT; CONVULSION.

First Aid Rule 1.—Aid breathing. Loosen collar, waist bands, and unhook corset, or cut the laces behind.

Rule 2.—Protect from injury. Gently restrain from falling or rolling against furniture; lay flat on bed.

Rule 3.—Protect tongue from being bitten. Open jaws and put between teeth rubber eraser tied to stout string, or rubber stopper tied to stout string.

Rule 4.—Crush pearl of amyl nitrite in handkerchief, and hold close to patient's nose and mouth, till face is red and patient relaxes.

Rule 5.—Let patient sleep after fit without rousing.

FOOTNOTES:

[9] Caution. Dangerous. Use only on physician's order.

[10] Caution. Dangerous. Use only on physician's order.



Part II

GERM DISEASES

BY

KENELM WINSLOW



CHAPTER I

Contagious Diseases

Scarlet Fever—Symptoms and Treatment—Precautions Necessary—Measles—Communicating the Disease—Smallpox—Vaccination—How to Diagnose Chickenpox.

ERUPTIVE CONTAGIOUS FEVERS (including Scarlet Fever, Measles, German Measles, Smallpox, and Chickenpox).—These, with the exception of smallpox, attack children more commonly than adults. As they all begin with fever, and the characteristic rash does not appear for from one to four days after the beginning of the sickness, the diagnosis of these diseases must always be at the onset a matter of doubt. For this reason it is wise to keep any child with a fever isolated, even if the trouble seems to be due to "a cold" or to digestive disturbance, to avoid possible communication of the disorder to other children. While colds and indigestion are among the most frequent ailments of children, they must not be neglected, for measles begins as a bad cold, smallpox like the grippe, and scarlet fever with a sore throat or tonsilitis, and vomiting.

By isolation is meant that the sick child should stay in a room by himself, and the doors should be kept closed and no children should enter, nor should any objects in the room be removed to other parts of the house after the beginning of its occupation by the patient.

The services of a physician are particularly desirable in all these diseases, in order that an early diagnosis be made and measures be taken to protect the family, neighbors, and community from contagion. The failure of parents or guardians to secure medical aid for children is regarded by the law as criminal neglect, and is subject to punishment. Boards of health require the reporting of all contagious diseases as soon as their presence is known, and failure to comply with their rules also renders the offender liable to fine or imprisonment in most places.

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

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

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

Complications and Sequels.—These are frequent and make scarlet fever the most dreaded of the eruptive diseases, except smallpox. Enlarged glands under the jaw and at the sides of the neck are common, and appear as lumps in these sites. Usually not serious, they may enlarge and threaten life. Pain and swelling in the joints, especially of the elbows and knees, are not rare, and may be the precursors of serious inflammation of these parts. One of the most frequent and serious complications of scarlet fever is inflammation of the kidneys, occurring more often toward the end of the second week of the disease. Examination of the urine by the attending physician at frequent intervals throughout the course of the disorder is essential, although puffiness of the eyelids and face, and of the feet, ankles, and hands, together with lessened secretion of urine—which often becomes of a dark and smoky hue—may denote the onset of this complication. The disease of the kidneys usually results in recovery, but occasionally in death or in chronic Bright's disease of these organs. Inflammation of the middle ear with abscess, discharge of matter from the ear externally, and—as the final outcome—deafness, is not uncommon. This complication may be prevented to a considerable extent by spraying the nose and throat frequently and by the patient's use of a nightcap with earlaps, if the room is not sufficiently warm. Inflammation of the eyelids is an occasional complication. The heart is sometimes attacked by the toxins of the disease, and permanent damage to the organ, in the form of valvular trouble, may result. Blindness and nervous disorders are among the rarer sequels including paralyses and St. Vitus's dance.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The patient is stripped and wrapped from feet to neck in a blanket wrung out of hot water containing two teaspoonfuls of mustard stirred into a gallon of water. This is then covered with two dry blankets and the patient allowed to remain in the blankets for two or three hours, when the application may be repeated. It is well to keep a cold cloth on the head during the process. Cough is also relieved by a mixture containing syrup of ipecac, twenty drops; paregoric, one teaspoonful, for an adult (or one-third the dose for a child of six), which should be given in one-quarter glass of water and may be repeated every two hours. If there is hoarseness, the neck should be rubbed with a mixture of sweet oil, two parts; and oil of turpentine, one part, and covered with a flannel bandage. The cough mixture will tend to relieve this condition also. A solution of boric acid (ten grains of boric acid to the ounce of water) is to be dropped in both eyes every two hours with a medicine dropper. Although usually mild, the eye symptoms may be very severe and require special treatment, and considerably impaired vision may be the ultimate result. Severe diarrhea is combated with bismuth subnitrate, one-quarter teaspoonful, every three hours. For adults, the diet consists of milk, broths, gruels, and raw eggs. Young children living on milk mixtures should receive the mixture to which they are accustomed, diluted one-half with barley water. Nourishment must be given every two hours except during sleep. The patient should be ten days in bed, and should remain three days in his room after getting up (or three weeks in all, if there are others who may contract measles in the house), and after leaving his room should stay in the house a week longer. The principal danger after an attack of measles is of lung trouble—pneumonia or tuberculosis (consumption)—and the greatest care should be exercised to avoid exposure to the wet or to cold draughts.

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

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

Symptoms.—The rash may be the first sign of the disease and more frequently is so in children. In others, for a day or two preceding the eruption, there may be headache, soreness, and redness of the throat, the appearance of red spots on the upper surface of the back of the mouth, chilliness, soreness in the muscles, loss of appetite, watering of the eyes. Catarrhal symptoms are most generally absent, an important point in diagnosis. When present, they are always mild. These preliminary symptoms, if present, are much milder and of shorter duration than in measles, where they last for four days before the rash appears; and the hard, persistent cough of measles is absent in German measles. Also, while there is sore throat in the latter, there is not the severe form with swollen tonsils covered with white spots so often seen in scarlet fever. Fever is sometimes absent in German measles; usually it ranges about 100 deg. F., rarely over 102 deg. F. Thus, German measles differs markedly from both scarlet fever and measles proper. The rash usually appears first on the face, then on the chest, and finally covers the whole body, in the space of a few hours—twenty-four hours at most. The eruption takes the form of rose-red, round or oval, slightly raised spots—from the size of a pin head to that of a pea—sometimes running together into uniform redness, as in scarlet fever. The rash remains fully developed for about two days, and often changes into a coppery hue as it gradually fades away. There are often lumps—enlarged glands—to be felt under the jaw, on the sides and back of the neck, which occur more commonly in German than in true measles. The glands at the back of the neck are the most characteristic. They are enlarged in about two-thirds of the cases.

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

German measles differs from true measles in the following points: the preliminary period—before the rash—is mild, short, or absent; fever is mild or absent; the cold in the nose and eyes and cough are slight or may be absent, as contrasted with these symptoms in measles, while the enlarged glands in the neck are more pronounced than in measles. The onset of German measles is not so sudden as in scarlet fever and not accompanied with vomiting as in the latter, while the sore throat and fever are much milder in German measles. The peeling, which is so prominent in scarlet fever with the disappearance of the rash, is not infrequently present. It may be absent. Its presence or absence seems to depend upon the severity of the eruption. The desquamation when present is finer than in either measles or scarlet fever.

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

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

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

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

Symptoms.—There is a preliminary period of from twenty-four to forty-eight hours after the beginning of the disease before an eruption occurs. The onset is ushered in by a set of symptoms simulating those seen in severe grippe, for which smallpox is often mistaken at this time. The patient is suddenly seized with a chill, severe pains in the head, back, and limbs, loss of appetite and vomiting, dizziness on sitting up, and fever—103 deg. to 105 deg. F. In young children convulsions often take the place of the chill seen in adults. On the second day a rash often appears on the lower part of the belly, thighs, and armpits, which may resemble that characteristic of measles or scarlet fever, but does not last for over a day or two. It is very evanescent and, consequently, rarely seen. Diarrhea often occurs, as well as vomiting, particularly in children. On the evening of the fourth day the true eruption usually appears; first on the forehead or face, and then on the arms, hands, and legs, palms, and soles. The eruption takes successively four forms: first, red, feeling like hard pimples or like shot; then, on the second or third day of the eruption, these pimples become tipped with little blisters with depressed centers, and surrounded by a red blush. Two or three days later the blisters are filled with "matter" or pus and present a yellowish appearance and are rounded on top. Finally, on about the tenth day of the eruption, the pustules dry up and the matter exudes, forming large, yellowish or brownish crusts, which, after a while, drop off and leave red marks and, in severe cases, pitting. The fever preceding the eruption often disappears upon the appearance of the latter and in mild cases does not reappear, but in severe forms the temperature remains about 100 deg. F., and when the eruption is at its height again mounts to 103 deg. to 105 deg. F., and gradually falls with convalescence. The eruption is most marked on the face, hands, and forearms, and occurs less thickly on the body. It appears also in the mouth and throat and when fully developed on the face gives rise to pain and considerable swelling and distortion of the features, so that the eyes are closed and the patient becomes frightfully disfigured and well-nigh unrecognizable. Delirium is common at this time, and patients need constant watching to prevent their escape from bed. In the severe forms the separate eruptive points run together so that the face and hands present one distorted mass of soreness, swelling, and crusting. In these, pitting invariably follows, while in those cases where the eruption remains distinct, pitting is not certain to occur. A still worse form is that styled "black smallpox," in which the skin becomes of a dark-purplish hue, from the fact that each pustule is a small blood blister, and bleeding occurs from the nose, mouth, etc. These cases are almost, without exception, fatal in five to six days.

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

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

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

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

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

The period of protection afforded by a successful vaccination is uncertain, because it varies with different individuals. In a general way immunity for about four or five years is thus secured; ten or twelve years after vaccination the protection is certainly lost and smallpox may be then acquired. Every individual should be vaccinated between the second and third month after birth, and between the ages of ten and twelve, and at other times whenever an epidemic threatens. An unvaccinated person should be vaccinated and revaccinated, until the result is successful, as immunity to vaccination in an unvaccinated person is practically unknown. When unsuccessful, the vaccine matter or the technique is faulty. A person continuously exposed to smallpox should be vaccinated every few weeks—if unsuccessful, no harm or suffering follow; if successful, it proves liability to smallpox. A person previously vaccinated successfully may "take" again at any time after four or five years, and, in event of possible exposure to smallpox, should be revaccinated several times within a few weeks—if the vaccination does not "take"—before the attempt is given up. An unvaccinated person, who has been exposed to smallpox, can often escape the disease if successfully vaccinated within three days from the date of the exposure, but is not sure to do so.

Diseases are not introduced with vaccination now that the vaccine matter is taken from calves and not from the human being, as formerly. Most of the trouble and inflammation of the vaccinated part following vaccination may be avoided by cleanliness and proper care in vaccinating.