is sometimes extremely puzzling and demands the skill of an
experienced physician. When one is unavailable, the following points
may serve to distinguish the two disorders: smallpox usually begins
like a severe attack of _grippe_, with pain in the back and head,
general pains and nausea or vomiting, with high fever (103 deg. to 104 deg.
F.) These last two or three days, and may completely subside when the
rash appears. In chickenpox preliminary discomfort is absent, or lasts
but a few hours before the eruption. The eruption of smallpox usually
occurs first on the forehead, near the hair, or on the palms of the
hands, soles of the feet, the arms and legs, but is usually sparse on
the body. The eruption appears about the same time in smallpox and not
in successive crops, as in chickenpox. Chickenpox is more commonly a
disease of childhood; smallpox attacks all ages. The crusts in
chickenpox are thin, and appear in four or five days, while those of
smallpox are large and yellow, and occur after ten or twelve days.
=Outlook.=--Chickenpox almost invariably results in a rapid and speedy
recovery without complications or sequels. The young patients often
feel well throughout the attack, which lasts from eight to twelve
days.
=Treatment.=--Children should be kept in bed during the eruptive stage
until the blisters have dried. To prevent scratching, the calamine
lotion may be used (Vol. II, p. 145), or carbolized vaseline, or
bathing with a solution of baking soda, one teaspoonful to the pint of
tepid water. The diet should be that recommended for German measles.
Patients should be kept in the house and isolated until all signs of
the eruption are passed, and then receive a good bath and fresh
clothing before mingling with others. The sick room should be
thoroughly cleaned and aired; thorough chemical disinfection is not
essential.
The services of a physician are always desirable in order that it may
be positively determined that the disease is not a mild form of
smallpox.
CHAPTER II
=Infectious Diseases=
_Typhoid Fever--How it is Contracted--Complications and Sequels--Rest,
Diet, and Bathing the Requisites--Mumps--Whooping Cough--Erysipelas._
=TYPHOID FEVER (ENTERIC FEVER).=--Through ignorance which prevailed
before the discovery of the germ of typhoid fever and exact methods
for determining the presence of the same, the term was loosely applied
and is to this day. Thus mild forms of typhoid are called gastric
fever, slow fever, malarial fever, nervous fever, etc., all true
typhoid in most cases; while typhoid fever, common to certain
localities and differing in some respects from the typical form, is
often named after the locality in which it occurs, as the "mountain
fever" common to the elevated regions of the western United States.
This want of information is apt to prevail in regions remote from
medical centers, and leads to neglect of the necessary strict measures
for the protection of neighboring communities, for the excretion of
one typhoid patient has led to thousands of cases and hundreds of
deaths.
Typhoid fever is a communicable disease caused by a germ which attacks
the intestines chiefly, but also invades the blood, and at times all
the other parts of the body, and is characterized by continued fever,
an eruption, tenderness and distention of the bowels, and generally
diarrhea. It is common to all parts of the earth in the temperate
zones, and occurs more frequently from July to December in the north
temperate zone, from February to July in the south temperate zone. It
is most prevalent in the late summer and autumn months and after a
hot, dry summer. Individuals between the ages of fifteen and thirty
are more prone to typhoid fever, but no age is exempt. The sexes are
almost equally liable to the disease, although it is said that for
every four female cases there are five male cases. The robust succumb
as readily as the weak.
=Cause and Modes of Communication.=--While the typhoid germ is always
the immediate cause, yet it is brought in contact with the body in
various ways. Contamination of water supply through bad drainage is
the principal source of epidemics of typhoid. Before carefully
protected public water supplies were in vogue in Massachusetts, there
were ninety-two deaths from typhoid fever in 100,000 inhabitants,
while thirty-five years after town water supplies became the rule,
there were only nineteen deaths for the same population. Whenever
typhoid is prevalent, the water used for drinking and all other
household purposes should be boiled, and uncooked food should be
avoided. Flies are carriers of typhoid germs by lighting on the nose,
the mouth, and the discharges of typhoid patients, and then conveying
the germs to food, green vegetables, and milk. Cooking the food,
preventing contact of flies with the patients, and keeping flies out
of human habitations becomes imperative. Milk is a source of contagion
through contaminated water used to wash cans, or to adulterate it, or
through handling of it by patients or those who have come in contact
with patients. Oysters growing in the mouths of rivers and near the
outlets of drains and sewers are carriers of typhoid germs, and, if
eaten raw, sometimes communicate typhoid fever. Dust is an occasional
medium of communication of the germ. It is probable, however, that the
germ always enters the body by being swallowed with food or drink, and
does not enter through the lungs. There is little doubt on this point.
Ice may harbor the germ for many months, for freezing does not kill
it, and epidemics have been traced to this source. Clothing, wood,
utensils, door handles, etc., which have been contaminated by contact
with discharges from patients, may also prove mediums of communication
of the typhoid germ to healthy individuals. Typhoid germs escape from
patients sick with the disease chiefly in the bowel discharges and
urine, sometimes in the sweat, saliva, and vomited matter.
Sewer gas and emanations from sewage and filth will not communicate
typhoid fever directly, but the latter afford nutriment for the growth
of the germ, and after becoming infected, may eventually come in
contact with drinking water or food, and so prove dangerous. Improper
care of discharges of excrement and urine--with the assistance of
flies--are responsible for the enormous typhoid epidemics in military
camps, so that in the late Spanish-American War one-fifth of all our
soldiers in camp contracted the disease. In the upper layers of the
soil typhoid germs may live for six months through frosts and thaws.
The disease is preventable, and will probably be stamped out in time.
In some of the most thickly populated cities in the world, as in
Vienna, its occurrence is most infrequent, owing to intelligent
sanitary control and pure water supply, while in the most salubrious
country districts its inroads are the most serious and fatal through
ignorance and carelessness.
=Development.=--From eight to twenty-three days elapse from the time
of entrance of typhoid germs into the body before the patient is taken
sick. One attack usually protects one against another, but two or
three attacks are not unheard of in the same person.
=Symptoms.=--Typhoid fever is subject to infinite variations, and it
will here be possible only to outline what may be called a typical
case. In a work of this kind the preliminary symptoms are of most
importance in warning one of the probability of an attack, so that the
prospective patient can govern himself accordingly, as in no other
disease is rest in bed of more value. Patients who persist in walking
about with typhoid fever for the first week or so are most likely to
die of the disease.
The average duration of the disease is about one month. During the
first week the onset is gradual, the temperature mounting a little
higher each day--as 99.5 deg. F. the first evening, 101 deg. the second, 102 deg.
the fourth, 104 deg. the fifth, 105 deg. the sixth, and 105.5 deg. the seventh. In
the morning of each day the temperature is usually about a degree or
more lower than that of the previous night. From the end of the first
week to the beginning of the third the temperature remains at its
highest point, being about the same each evening and falling one or
two degrees in the morning. During the third week the temperature
gradually falls, the highest point each evening being a degree or so
lower than the previous day, while in the fourth week the temperature
may be below normal in the morning and a degree or so above normal at
night. So much for this symptom. After the entrance of typhoid germs
into the bowels and before the recognized onset of the disease, there
may be lassitude and disinclination for exertion. The disease begins
with headache, backache, loss of appetite, sometimes a chill in adults
or a convulsion in children, soreness in the muscles, pains in the
belly, nosebleed, occasional vomiting, diarrhea, coated tongue, often
some cough, flushed face, pulse 100, gradually increasing as
described.
These symptoms are, to a considerable extent, characteristic of the
beginning of many acute diseases, but the gradual onset with constant
fever, nosebleed, and looseness of the bowels are the most suggestive
features. Then, if at the end of the first week or ten days pink-red
spots, about as large as a pin head, appear on the chest and belly to
the number of two or three to a dozen, of very numerously, and
disappear on pressure (only to return immediately), the existence of
typhoid fever is pretty certain. Headache is now intense. These rose
spots--as they are called--often appear in crops during the second and
third weeks, lasting for a few days, then departing.
During the second week there is often delirium and wandering at night;
the headache goes, but the patient is stupid and has a dusky, flushed
face. The tongue becomes brownish in color, and its coat is cracked,
and the teeth are covered with a brownish matter. The skin is
generally red and the belly distended and tender. Diarrhea is often
present with three to ten discharges daily of a light-yellow, pea-soup
nature, with a very offensive odor. Constipation throughout the
disease is, however, not uncommon in the more serious cases. The pulse
ranges from 80 to 120 a minute.
During the third week, in cases of moderate severity, the general
condition begins to improve with lowering of the temperature, clearing
of the tongue, and less frequent bowel movements. But in severe cases
the patient becomes weaker, with rapid, feeble pulse, ranging from 120
to 140; stupor and muttering delirium; twitching of the wrists and
picking at the bedclothes, with general trembling of the muscles in
moving; slow, hesitating speech, and emaciation; while the urine and
faeces may be passed unconsciously in bed. Occasionally the patient
with delirium may require watching to prevent him from getting out of
bed and injuring himself. He may appear insane.
During the fourth week, in favorable cases, the temperature falls to
normal in the morning, the pulse is reduced to 80 or 100, the diarrhea
ceases, and natural sleep returns.
Among the many and frequent variations from the type described, there
may be a fever prolonged for five or six weeks, with a good recovery.
Chills are not uncommon during the disease, sometimes owing to
complications. Relapse, or a return of the fever and other symptoms
all over again, occurs in about ten per cent of the cases. This may
happen more than once, and as many as five relapses have been recorded
in one patient. A slight return of the fever for a day or two is often
seen, owing to error in diet, excitement, or other imprudence after
apparent recovery. Death may occur at any time from the first week,
owing to complications or the action of the poison of the disease.
Pneumonia, perforation of and bleeding from the bowels are the most
frequent dangerous complications. Unfavorable symptoms are continued
high fever (105 deg. to 106 deg. F.), marked delirium, and trembling of the
muscles in early stages, and bleeding from the bowels; also intense
and sudden pain with vomiting, indicating perforation of the
intestines. The result is more apt to prove unfavorable in very fat
patients, and especially so in persons who have walked about until the
fever has become pronounced. Bleeding from the bowels occurs in four
to six per cent of all cases and is responsible for fifteen per cent
of the deaths; perforation of the bowels happens in one to two per
cent of all cases and occasions ten per cent of the deaths.
=Detection.=--It is impossible for the layman to determine the
existence of typhoid fever in any given patient absolutely, but when
the symptoms follow the general course indicated above, a probability
becomes established. Unusual types are among the most difficult and
puzzling cases which a physician has to diagnose, and he can rarely be
absolutely sure of the nature of any case before the end of the first
week or ten days, when examination of the blood offers an exact
method of determining the presence of typhoid fever. Typhoid
fever--especially where there are chills--is often thought to be
malaria, when occurring in malarial regions, and may be improperly
called "typhoid malaria." There is no such disease. Rarely typhoid
fever and malaria coexist in the same person, and while this was not
uncommon in the soldiers returning from Cuba and Porto Rico, it is an
extremely unusual occurrence in the United States. Examination of the
blood will determine the presence or absence of both of these
diseases.
=Complications and Sequels.=--These are very numerous. Among the
former are diarrhea, delirium, mental and nervous diseases,
bronchitis, pleurisy, pneumonia, ear abscess, perforation of and
hemorrhage from the bowels, inflammation of the gall bladder, disease
of heart, kidney, and bladder, and many rarer conditions, depending
upon the organ which the germ invades. Among sequels are boils,
baldness, bone disease, painful spine, and, less commonly, insanity
and consumption. While convalescence requires weeks and months, the
patient often gains greatly in flesh and feels made over anew, as in
fact he has been to a great extent, through the destruction and repair
of his organs.
=Outlook.=--The death rate varies greatly in different epidemics and
under different conditions. During the Spanish-American War in the
enormous number of cases--over 20,000--the death rate was only about
seven per cent, which represents that in the best hospitals of this
country and in private practice. Osler states that the mortality
ranges from five to twelve per cent in private practice, and from
seven to twenty per cent in hospital practice, because hospital cases
are usually advanced before admission. The chances of recovery are
much greater in patients under fifteen years, and are also more
favorable between the twenty-second and fortieth years.
=Treatment.=--There is perhaps no disease in which the services of a
physician are more desirable or useful than in typhoid fever, on
account of its prolonged course and the number of complications and
incidents which may occur during its existence. It is the duty of the
physician to report cases of typhoid to the health authorities, and
thus act as a guardian of the public health. If, however, in any
circumstances one should have the misfortune to have the care of a
typhoid patient remote from medical aid, it is a consolation to know
that the outlook is not greatly altered by medicine or special
treatment of any sort. There have been epidemics in remote parts of
this country where numbers of persons have suffered with typhoid
without any professional care, and yet with surprisingly good results.
Thus, in an epidemic occurring in a small community in Canada,
twenty-four persons sickened with typhoid and received no medical care
or treatment whatever, and yet there was but one death. The essentials
of treatment are comprised in _Rest, Diet, and Bathing_. Rest to the
extent of absolute quiet in the horizontal position, at the first
suspicion of typhoid, is requisite in order to avoid the dangers of
bleeding and perforation of the bowels resulting from ulceration of
structures weakened by the disease. The patient should be assisted to
turn in bed, must make no effort to rise during the sickness, and
should pass urine and bowel discharges into a bedpan or urinal under
cover. In case of bleeding from the bowels, the bedpan should not be
used, but the discharges may be received for a time in cloths, without
stirring the patient.
=Diet.=--This should consist chiefly of liquids until a week after
the fever's complete disappearance. A cup of liquid should be given
every two hours except during a portion of the sleeping hours. Milk,
diluted with an equal amount of water, forms the chief food in most
cases unless it disagrees, is refused, or is unobtainable.
In addition to milk, albumen water--white of raw egg, strained and
diluted with an equal amount of water, and flavored with a few drops
of lemon juice or with brandy--is valuable; also juice squeezed from
raw beef--in doses of four tablespoonfuls--coffee, cocoa, and strained
barley, rice, or oatmeal gruel, broths, unless diarrhea is marked and
increased by the same. Soft custard, jellies, ice cream,
milk-and-flour porridge, and eggnog may be used to increase the
variety. Finely scraped raw or rare beef, very soft toast, and
soft-boiled or poached eggs are allowable after the first week of
normal temperature, at the end of the third or fourth week of the
disease, and during the course of the disease under circumstances
where the fluids are not obtainable or not well borne. An abundance of
water should be supplied to the patient throughout the disease.
=Bathing.=--The importance of cold, through the medium of water, in
typhoid fever accomplishes much, both in reducing the temperature and
in stimulating the nervous system and relieving restlessness and
delirium. Bathing is usually applied when the temperature rises above
102.5 deg. F., and may be repeated every two or three hours if
restlessness, delirium, and high temperature require it.
The immersion of patients in tubs of cold water, as practiced with
benefit in hospitals, is out of the question for use by inexperienced
laymen. The patient should have a woven-wire spring bed and soft hair
mattress, over which is laid a folded blanket covered by a rubber
sheet. Sponging the naked body with ice water will suffice in some
cases; in others, when the temperature is over 102-1/2 deg. F., enveloping
the whole body in a sheet wet in water at 65 deg., and either rubbing the
surface with ice or cloths wet in ice-cold water, for ten or fifteen
minutes, is advisable. Rubbing of the skin of the chest and sides is
necessary during the application of cold to prevent shock. The use of
a cold cloth on the head and hot-water bottle at the feet, during the
sponging, will also prove beneficial. In children and others objecting
to these cold applications, the vapor bath is effective. For this a
piece of cheese cloth (single thickness) is wet with warm water--100 deg.
to 105 deg.--and is wrapped about the naked body from shoulders to feet,
and is continually wet by sprinkling with water at the temperature of
98 deg.. The evaporation of the water will usually, in fifteen to twenty
minutes, cool the body sufficiently if the patient is fanned
continuously by two attendants. In warm weather the patient should
only be covered with a sheet for a while after the bath, which should
reduce the temperature to 3 deg.. Hot water at the feet, and a little
brandy or whisky given before the sponging if the pulse be feeble,
will generally prevent a chill. Patients should be gently dried after
the bath and covered with dry bedclothing. The utmost care should be
taken not to agitate a feeble patient during sponging.
The long period of lying in bed favors the occurrence of bedsores.
These are apt to appear about the lower part of the spine, and begin
with redness of the skin, underneath which a lump may be felt.
Constant cleanliness and bathing with alcohol, diluted with an equal
amount of water, will tend to prevent this trouble, while moving the
patient so as to take the pressure off this region and avoiding any
rumpling of the bedding under his body are also serviceable, as well
as the ring air cushion. Medicine is not required, except for special
symptoms, and has no influence either in lessening the severity of or
in shortening the disease. Brandy or whisky diluted with water are
valuable in severe cases, with muttering delirium, dry tongue, and
feeble pulse; it is not usually called for before the end of the
second week, and not in mild cases at any time. A tablespoonful of
either, once in two to four hours, is commonly sufficient. Pain and
distention of the belly are relieved by applying a pad over the whole
front of the belly--consisting of two layers of flannel wrung out of a
little very hot water containing a teaspoonful of turpentine--and
covered by a dry flannel bandage wrapped about the body. Also the use
of white of egg and water, and beef juice, instead of milk, will
benefit this condition.
Diarrhea--if there are more than four discharges daily--may be checked
by one-quarter level teaspoonful doses of bismuth subnitrate, or
teaspoonful doses of paregoric, once in three hours. Constipation is
relieved by injections of warm soapsuds, once in two days. Bleeding
from the bowels must be treated by securing perfect quiet on the
patient's part, and by giving lumps of ice by the mouth, and cutting
down the nourishment for six hours. Fifteen drops of laudanum should
be given to adults, if there is restlessness, and some whisky, if the
pulse becomes feeble, but it is better to reserve this until the
bleeding has stopped. Patients may be permitted to sit up after a week
of normal temperature, but solid food must not be resumed until two or
three weeks after departure of fever, and then very gradually,
avoiding all coarse and uncooked vegetables and fruit.
The greatest care must be exercised by attendants to escape
contracting the disease and to prevent its communication to others.
The bowel discharges must be submerged in milk of lime (one part of
slaked lime to four parts of water), and remain in it one hour before
being emptied. The urine should be mixed with an equal amount of the
same, or solution of carbolic acid (one part in twenty parts of hot
water), and the mixture should stand an hour before being thrown into
privy or sewer. Clothing and linen in contact with the patient must
be soaked in the carbolic solution for two hours. The patient's
expectoration is to be received on old muslin pieces, which must be
burned. The bedpan and eating utensils must be frequently scalded in
boiling water. The attendant should wash his hands always after
touching the patient, or objects which have come in contact with
patient or his discharges, and thus will avoid contagion. If farm or
dairy workers come in contact with the patient, the latter precaution
is especially important. If there is no water-closet in the house, the
disinfected discharges may be buried at least 100 feet from any well
or stream. Typhoid fever is only derived from the germs escaping in
the urine, and in the bowel, nose, or mouth discharges of typhoid
patients.
=MUMPS.=--Mumps is a contagious disease characterized by inflammation
of the parotid glands, situated below and in front of the ears, and
sometimes of the other salivary glands below the jaw, and rarely of
the testicles in males and the breasts in females.
Swelling and inflammation of the parotid gland also occur from injury;
and as a complication of other diseases, as scarlet fever, typhoid
fever, etc.; but such conditions are wholly distinct from the disease
under discussion. Mumps is more or less constantly prevalent in most
large cities, more often in the spring and fall, and is often
epidemic, attacking ninety per cent of young persons who have not
previously had the disease. It is more common in males, affecting
children and youths, but rarely infants or those past middle age. One
attack usually protects against another.
=Development.=--A period of from one to three weeks elapses, after
exposure to the disease, before the first signs develop. The germ has
not yet been discovered, and the means of communication are unknown.
The breath has been thought to spread the germs of the disease, and
mumps can be conveyed from the sick to the well, by nurses and others
who themselves escape.
=Symptoms.=--Sometimes there is some preliminary discomfort before the
apparent onset. Thus, in children, restlessness, peevishness, languor,
nausea, loss of appetite, chilliness, fever, and convulsions may usher
in an attack. Mumps begins with pain and swelling below the ear on one
side. Within forty-eight hours a large, firm, sensitive lump forms
under the ear and extends forward on the face, and downward and
backward in the neck. The swelling is not generally very painful, but
gives a feeling of tightness and disfigures the patient. It makes
speaking and swallowing difficult; the patient refuses food, and talks
in a husky voice; chewing causes severe pain. After a period of two to
four days the other gland usually becomes similarly inflamed, but
occasionally only one gland is attacked. There is always fever from
the beginning. At first the temperature is about 101 deg. F., rarely much
higher than 103 deg. or 104 deg.. The fever continues four or five days and
then gradually declines. The swelling reaches its height in from two
to five days, and then after forty-eight hours slowly subsides, and
disappears entirely within ten to fourteen days. The patient may
communicate the disease for ten days after the fever is past, and
needs to be isolated for that period. Earache and noises in the ear
frequently accompany mumps, and rarely abscess of the ear and deafness
result. The most common complication occurs in males past puberty,
when, during recovery or a week or ten days later, one or both
testicles become painful and swollen, and this continues for as long a
time as the original mumps. Less often the breasts and sexual organs
of females are similarly affected.
=Complications and Sequels.=--Recovery without mishap is the usual
result in mumps, with the exception of involvement of the testicles.
Rarely there are high fever, delirium, and great prostration.
Sometimes after inflammation of both testicles in the young the organs
cease to develop, and remain so, but sexual vigor is usually retained.
Sometimes abscess and gangrene of the inflamed parotid gland occur.
Recurring swelling and inflammation of the gland may occur, and
permanent swelling and hardness remain. Meningitis, nervous and joint
complications are among the rarer sequels.
=Treatment.=--The patient should remain in bed while the fever lasts.
A liquid diet is advisable during this time. Fever may be allayed by
frequent sponging of the naked body with tepid water. High fever and
delirium demand the constant use, on the head, of the ice cap (a
rubber bag, made to fit the head, containing ice). The relief of pain
in the swollen gland is secured by the frequent application of a thick
layer of sheet cotton, large enough to cover the whole side of the
neck, wrung out of hot water and covered with oil-silk or rubber
sheeting, with a bandage to retain it in place.
Paregoric may be given for the same purpose--a tablespoonful for
adults; a teaspoonful for a child of eight to ten, well diluted with
water, and not repeated inside of two hours, and not then unless the
pain continues unabated. Inflammation of the testicles demands rest in
bed, elevation of the testicle on a pillow after wrapping it in a
thick layer of absorbent cotton, or applying hot compresses, as
recommended for the neck. After the first few days of this treatment,
adjust a suspensory bandage, which can be procured at any apothecary
shop, and apply daily the following ointment: guiacol, sixty grains;
lard, one-half ounce, over the swollen testicle.
=WHOOPING COUGH.=--A contagious disease characterized by fits of
coughing, during which a whooping or crowing sound is made following a
long-drawn breath. Whooping cough is generally taken through direct
contact with the sick, rarely through exposure to the sick room, or to
persons or clothing used by the sick. The germ which causes the
disease is probably in the mucus of the nose and throat. Whooping
cough is usually more or less prevalent in all thickly settled
civilized communities, at times is epidemic, and often follows
epidemics of measles. It occurs chiefly in children from six months to
six years of age. Girls and all weak and delicate subjects are
slightly more susceptible to the disease. Some children are naturally
immune to whooping cough. One attack usually protects against another.
=Development.=--A variable period elapses between the time of exposure
to whooping cough and the appearance of the first symptoms. This may
be from two days to two weeks; usually seven to ten days.
=Symptoms.=--Whooping cough begins like an ordinary cold in the head,
with cough, worse at night, which persists. The coughing fits increase
and the child gets red in the face, has difficulty in getting its
breath during them, and sometimes vomits when the attack is over.
After a variable period, from a few days to two weeks from the
beginning of the cough, the peculiar feature of the disease appears.
The child gives fifteen or twenty short coughs without drawing breath,
the face swells and grows blue, the eyeballs protrude, the veins stand
out, and the patient appears to be suffocating, when at last he draws
in a long breath with a crowing or whooping sound, which gives rise to
the name of the disease. Several such fits of coughing may follow one
another and are often succeeded by vomiting and the expulsion of a
large amount of phlegm or mucus, which is sometimes streaked with
blood. In mild cases there may be six to twelve attacks in twenty-four
hours; in severe cases from forty to eighty. The attacks last from a
few seconds to one or two minutes. Occasionally the whoop comes before
the coughing fit, and sometimes there may be no whooping at all, only
fits of coughing with vomiting. Between the attacks, puffiness of the
face and eyes and blueness of the tongue persist. The coughing fits
and whooping last usually from three to six weeks, but the duration of
the disease is very variable. Occasionally it lasts many months,
especially when it occurs in winter. The contagiousness of whooping
cough continues about two months, or ceases before that time with the
cessation of the cough. Oftentimes there may be occasional whooping
for months; or, after ceasing altogether for some days, it may begin
again. In neither of these conditions is the disease considered still
contagious after two months. When an attack of whooping is coming on,
the child often seems to have some warning, as he seems terrified and
suddenly sits up in bed, or, if playing, grasps hold of something, or
runs to his mother or nurse. Coughing fits are favored by emotion or
excitement, by crying, singing, eating, drinking, sudden change of
temperature, and by bad air.
=Complications and Sequels.=--These are many and make whooping cough a
critical disease for very young children. Bronchitis and pneumonia
often complicate whooping cough in winter, and diarrhea frequently
occurs with it in summer. Convulsions not infrequently follow the
coughing fits in infants, and, owing to the amount of blood forced to
the head during the attacks, nosebleed and dark spots on the forehead
and surface of the eyes appear from breaking of small blood vessels in
these places. Severe vomiting and diarrhea occasionally aggravate the
case, and pleurisy and consumption may occur. The violent coughing may
permanently damage the heart. Rupture of the lung tissue happens from
the same cause, and paralysis sometimes follows breaking of a blood
vessel in the brain. But in the vast majority of cases in children
over two years old no dangerous sequel need be feared.
=Outlook.=--Owing to the numerous complications, whooping cough must
be looked upon as a very serious disease, especially in infants under
two years, and in weak, delicate children. It causes one-fourth of all
deaths among children, the death rate varying from three to fifteen
per cent in different times and under different circumstances. For
this reason a physician's services should always be secured when
possible.
=Treatment.=--A host of remedies is used for whooping cough, but no
single one is always the best. It is often necessary to try different
medicines till we find one which excels. Fresh air is of greatest
importance. Patients should be strictly isolated in rooms by
themselves, and it is wise to send away children who have not been
exposed. Morally, parents are criminally negligent who allow their
children with whooping cough to associate with healthy children. If
the coughing fits are severe or there is fever, children should be
kept in bed. Usually there is not much fever; perhaps an elevation of
a degree or two at first, and at times during the disease. Otherwise,
children may be outdoors in warm weather, and in winter on warm, quiet
days. Sea air is especially good for them. It is best that the sick
should have two rooms, going from one to the other, so that the
windows in the room last occupied may be opened and well ventilated.
Fresh air at night is especially needful, and the patient should sleep
in a room which has been freshly aired. The temperature should be kept
at an even 70 deg. F., and the child should not be exposed to draughts.
Vaporizing antiseptics in the sick room has proved beneficial. A two
per cent solution of carbolic acid in water is useful for this
purpose, or a substance called vapo-cresoline, with which is sold a
vaporizing lamp and directions for use. A one per cent solution of
resorcin, or of hydrogen dioxide, diluted with four parts of water,
used in an atomizer for spraying the throat, every two hours, has
given good results. In the beginning of the disease, before the
whooping has begun, a mixture of paregoric and syrup of ipecac will
relieve the cough, ten drops of the former with five of the latter,
for a child of two years, given together in water every three hours.
The bromide of sodium, five grains in water, every three hours during
the day, for a child of two, is serviceable in relieving the fits of
coughing in the day; while at night, two grains of chloral, not
repeated, may be given in water at bedtime to secure sleep, in a child
of two. The tincture of belladonna, in doses of two drops in water,
three times daily, for a child of two, is also often efficacious.
Quinine, given in the dose of one-sixth grain for each month of the
child's age under a year; or in one and one-half grain doses for each
year of age under five, is one of the older and more valuable
remedies. It should be given three times daily in pill with jelly, or
solution in water. Bromoform in doses of two drops for a child of two,
and increasing to five drops for a child of six, may be given in syrup
three times daily with benefit. Most of these drugs should be employed
only with a doctor's advice, when this is possible. To sum up, use the
vapo-cresoline every day. When no physician is available, begin with
belladonna during the day, using bromide of sodium at night. If this
fails to modify the whooping after five days' trial, use bromide and
chloral. In severe cases use bromoform. During a fit of coughing and
whooping, it is well to support the child's head, and if he ceases to
breathe, he should be slapped over the face and chest with a towel wet
with cold water. Interference with sleep caused by coughing, and loss
of proper nourishment through vomiting, lead to wasting and debility.
Teaspoonful doses of emulsion of cod-liver oil three times daily,
after eating, are often useful in convalescence, and great care must
be taken at this time to prevent exposure and pneumonia. Change of air
and place will frequently hasten recovery remarkably in the later
stages of the disease.
=ERYSIPELAS.=--Erysipelas is a disease caused by germs which gain
entrance through some wound or abrasion in the skin or mucous
membranes. Even where no wound is evident it may be taken for granted
that there has been some slight abrasion of the surface, although
invisible. Erysipelas cannot be communicated any distance through the
air, but it is contagious in that the germs which cause it may be
carried from the sick to the well by nurses, furniture, bedding,
dressings, clothing, and other objects. Thus, patients with wounds,
women in childbirth, and the newborn may become affected, but modern
methods of surgical cleanliness have largely eliminated these forms of
erysipelas, especially in hospitals, where it used to be common.
Erysipelas attacks people of all ages, some persons being very
susceptible and suffering frequent recurrences. The form which arises
without any visible wound is seen usually on the face, and occurs most
frequently in the spring. The period of development, from the time the
germs enter the body until the appearance of the disease, lasts from
three to seven days.
Erysipelas begins with usually a severe chill (or convulsion in a
baby) and fever. Vomiting, headache, and general lassitude are often
present. A patch of red appears on the cheeks, bridge of nose, or
about the eye or nostril, and spreads over the face. The margins of
the eruption are sharply defined. Within twenty-four hours the disease
is fully developed; the skin is tense, smooth, and shiny, scarlet and
swollen, and feels hot, and is often covered with small blisters. The
pain is more or less intense, burning or itching occurs, and there is
a sensation of great tightness or tension. On the face the swelling
closes the eye and may interfere with breathing through the nose. The
lips, ears, and scalp are swollen, and the person may become
unrecognizable in a couple of days. Erysipelas tends to spread like a
drop of oil, and the borders of the inflammatory patch are well
marked. It rarely spreads from the face to the chest and body, and but
occasionally attacks the throat. During the height of the inflammation
the temperature reaches 104 deg. F, or over. After four or five days, in
most cases, erysipelas begins to subside, together with the pain and
temperature, and recovery occurs with some scaling of the skin. The
death rate is said to average about ten per cent in hospitals, four
per cent in private practice. Headache, delirium, and stupor are
common when erysipelas attacks the scalp. The appearance of the
disease in other locations is similar to that described. Relapses are
not uncommon, but are not so severe as the original attack. Spreading
may extend over a large area, and the deeper parts may become
affected, with the formation of deep abscesses and great destruction
of tissue. Certain internal organs, heart, lungs, spleen, and kidneys,
are occasionally involved with serious consequences. The old, the
diseased, and the alcoholic are more apt to succumb, also the newborn.
It is a curious fact that cure of malignant growths (sarcoma), chronic
skin diseases, and old ulcers sometimes follows attacks of erysipelas.
=Treatment.=--The duration of erysipelas is usually from a few days to
about two weeks, according to its extent. It tends to run a definite
course and to recovery in most cases without treatment. The patient
must be isolated in a room with good ventilation and sunlight.
Dressings and objects coming in contact with him must be burned or
boiled. The diet should be liquid, such as milk, beef tea, soups, and
gruels. The use of cloths wet constantly with cold water, or with a
cold solution of one-half teaspoonful of pure carbolic acid to the
pint of hot water, or with a poisonous solution of sugar of lead, four
grains to the pint, should be kept over small inflamed areas. Fever is
reduced by sponging the whole naked body with cold water at frequent
intervals. A tablespoonful of whisky or brandy in water may be given
every two hours to adults if the pulse is weak. Painting the borders
of the inflamed patch with contractile collodion may prevent its
spreading. The patient must be quarantined until all scaling ceases,
usually for two weeks.
CHAPTER III
=Malaria and Yellow Fever=
_The Malarial Parasite--Mosquitoes the Means of Infection--Different
Forms of Malaria--Symptoms and Treatment--No Specific for Yellow
Fever._
=MALARIA; CHILLS AND FEVER; AGUE; FEVER AND AGUE; SWAMP OR MARSH
FEVER; INTERMITTENT OR REMITTENT FEVER; BILIOUS FEVER.=--Malaria is a
communicable disease characterized by attacks of fever occurring at
certain intervals, and due to a minute animal parasite which inhabits
the body of the mosquito, and is communicated to the blood of man by
the bites of this insect.
In accordance with this definition malaria is not a contagious disease
in the sense that it is acquired by contact with the sick, which is
not the case, but it is derived from contact with certain kinds of
mosquitoes, and can be contracted in no other way, despite the many
popular notions to the contrary. Mosquitoes, in their turn, acquire
the malarial parasite by biting human beings suffering from malaria.
It thus becomes possible for one malarial patient, coming to a region
hitherto free from the disease, to infect the whole district with
malaria through the medium of mosquitoes.
=Causes.=--While the parasite infesting mosquitoes is the only direct
cause of malaria, yet certain circumstances are requisite for the life
and growth of the mosquitoes. These are moisture and proper
temperature, which should average not less than 60 deg. F. Damp soil,
marshes, or bodies of water have always been recognized as favoring
malaria.
Malaria is common in temperate climates--in the summer and autumn
months particularly, less often in spring, and very rarely in winter,
while it is prevalent in the tropics and subtropics all the year
round, but more commonly in the spring and fall of these regions. The
older ideas, that malaria was caused by something arising in vapors
from wet grounds or water, or by contamination of the drinking water,
or by night air, or was due to sleeping outdoors or on the ground
floors of dwellings, are only true in so far as these favor the growth
of the peculiar kind of mosquitoes infected by the malarial parasites.
Two essentials are requisite for the existence of malaria in a region:
the presence of the particular mosquito, and the actual infection of
the mosquito with the malarial parasite. The kind of mosquito acting
as host to the malarial parasite is the genus _Anopheles_, of which
there are several species. The more common house mosquito of the
United States is the _Culex_. The _Anopheles_ can usually be
distinguished from the latter by its mottled wings, and, when on a
wall or ceiling, it sits with the body protruding at an angle of 45 deg.
from the surface, with its hind legs hanging down or drawn against the
wall. In the case of the _Culex_, the body is held parallel with the
wall, the wings are usually not mottled, and the hind legs are carried
up over the back.
When a mosquito infected with the malarial parasite bites man, the
parasite enters his blood along with the saliva that anoints the
lancet of the mosquito. The parasite is one of the simplest forms of
animal life, consisting of a microscopical mass of living, motile
matter which enters the red-blood cell of man, and there grows,
undergoes changes, and, after a variable time, multiplies by dividing
into a number of still smaller bodies which represent a new generation
of young parasites. This completes the whole period of their
existence. It is at that stage in the development of the parasite in
the human body when it multiplies by dividing that the chills and
fever in malaria appear. What causes the malarial attack at this point
is unknown, unless it be that the parasites give rise to a poison at
the time of their division. Between the attacks of chills and fever in
malaria there is usually an interval of freedom of a few hours, which
corresponds to the period intervening in the life of the parasite in
the human body, between the birth of the young parasites and their
growth and final division, in turn, into new individuals. This
interval varies with the kind of parasite. The common form of malaria
is caused by a parasite requiring forty-eight hours for its
development. The malarial attacks caused by this parasite then occur
every other day, when the parasite undergoes reproduction by division.
However, an attack may occur every day when there are two separate
groups of these parasites in the blood, the time of birth of one set
of parasites, with an accompanying malarial attack, happening one day;
that of the other group coming on the next, so that between the two
there is a daily birth of parasites and a daily attack of malaria. In
cases of malaria caused by one group of parasites the attacks appear
at about the same time of day, but when the attacks are caused by
different groups of parasites the times of attack may vary on
different days. In the worst types of malaria the parasites do not all
go through the same stages of development at the same time, as is
commonly the case in the milder forms prevalent in temperate regions,
so that the fever--corresponding to the stage of reproduction of the
parasites--occurs at irregular intervals.
In a not uncommon type of malaria the attacks occur every third day,
with two days of intermission or freedom from fever. Different groups
of parasites causing this form of malaria, and having different times
of reproduction, may inhabit the same patient and give rise to
variation in the times of attack. Thus, an attack may occur on two
successive days with a day of intermission.
The reproduction of the parasite in the human blood is not a sexual
reproduction; that takes place in the body of the mosquito.
When a healthy mosquito bites a malarial patient, the parasite enters
the body of the mosquito with the blood of the patient bitten. It
enters its stomach, where certain differing forms of the parasite,
taking the part of male and female individuals, unite and form a new
parasite, which, entering the stomach wall of the mosquito, gives
birth in the course of a week to innumerable small bodies as their
progeny. These find their way into the salivary glands which secrete
the poison of the mosquito bite, and escape, when the mosquito bites a
human being, into the blood of the latter and give him malaria.
=Distribution.=--Malaria is very widely distributed, and is much more
severe in tropical countries and the warmer parts of temperate
regions. In the United States malaria is prevalent in some parts of
New England, as in the Connecticut Valley, and in the course of the
Charles River, in the country near Boston. It is common in the
vicinity of the cities of Philadelphia, New York, and Baltimore, but
here is less frequent than formerly, and is of a comparatively mild
type. More severe forms prevail along the Gulf of Mexico and the
shores of the Mississippi and its branches, especially in Mississippi,
Texas, Louisiana, and Arkansas, but even here it is less fatal and
widespread than formerly. In Alaska, the Northwest, and on the Pacific
Coast of the United States malaria is almost unknown, while it is but
slightly prevalent in the region of the Great Lakes, as about Lakes
Erie and St. Clair.
=Development.=--Usually a week or two elapses after the entrance of
the malarial parasite into the blood before symptoms occur; rarely
this period is as short as twenty-four hours, and occasionally may
extend to several months. It often happens that the parasite remains
quiescent in the system without being completely exterminated after
recovery from an attack, only to grow and occasion a fresh attack, a
month or two after the first, unless treatment has been thoroughly
prosecuted for a sufficient time.
=Symptoms.=--Certain symptoms give warning of an attack, as headache,
lassitude, yawning, restlessness, discomfort in the region of the
stomach, and nausea or vomiting. The attack begins with a chilliness
or creeping feeling, and there may be so severe a chill that the
patient is violently shaken from head to foot and the teeth chatter.
Chills are not generally seen in children under six, but an attack
begins with uneasiness, the face is pinched, the eyes sunken, the lips
and tips of the fingers and toes are blue, and there is dullness and
often nausea and vomiting. Then, instead of a chill, the eyelids and
limbs begin to twitch, and the child goes into a convulsion. While the
surface of the skin is cold and blue during a chill, yet the
temperature, taken with the thermometer in the mouth or bowel, reaches
102 deg., 105 deg., or 106 deg. F., often. The chill lasts from a few minutes to
an hour, and as it passes away the face becomes flushed and the skin
hot. There is often a throbbing headache, thirst, and sometimes mild
delirium. The temperature at this time, when the patient feels
intensely feverish, is very little higher than during the chill. The
fever lasts during three or four hours, in most cases, and gradually
declines, as well as the headache and general distressing symptoms
with the onset of sweating, to disappear in an hour or two, when the
patient often sinks into a refreshing sleep. Such attacks more
commonly occur every day, every other day, or after intermissions of
two days. Rarely do attacks come on with intervals of four, five, six,
or more days. The attacks are apt to recur at the same time of day as
in the first attack. In severe cases the intervals may grow shorter,
in mild cases, longer. In the interval between the attacks the patient
usually feels well unless the disease is of exceptional severity.
There is also entire freedom from fever in the intervals except in the
grave types common to hot climates. Frequently the chill is absent,
and after a preliminary stage of dullness there is fever followed by
sweating. This variety is known as "dumb ague."
=Irregular and Severe Form--Chronic Malaria.=--This occurs in those
who have lived long in malarial regions and have suffered repeated
attacks of fever, or in those who have not received proper treatment.
It is characterized by a generally enfeebled state, the patient having
a sallow complexion, cold hands and feet, and temperature below
normal, except occasionally, when there may be slight fever. When the
condition is marked, there are breathlessness on slight exertion,
swelling of the feet and ankles, and "ague cake," that is, enlargement
of the spleen, shown by a lump felt in the abdomen extending downward
from beneath the ribs on the left side.
Among unusual forms of malaria are: periodic attacks of drowsiness
without chills, but accompanied by slight fever (100 deg. to 101 deg. F.);
periodic attacks of neuralgia, as of the face, chest, or in the form
of sciatica; periodic "sick headaches." These may take the place of
ordinary malarial attacks in malarial regions, and are cured by
ordinary malarial treatment.
=Remittent Form (unfortunately termed "bilious").=--This severe type
of malaria occurs sometimes in late summer and autumn, in temperate
climates, but is seen much more commonly in the Southern United States
and in the tropics. It begins often with lassitude, headache, loss of
appetite and pains in the limbs and back, a bad taste, and nausea for
a day or two, followed by a chill, and fever ranging from 101 deg. to 103 deg.
F., or more. The chill is not usually repeated, but the fever is
continuous, often suggesting typhoid fever. With the fever, there are
flushed face, occasional delirium, and vomiting of bile, but more
often a drowsy state. After twelve to forty-eight hours the fever
abates, but the temperature does not usually fall below 100 deg. F., and
the patient feels better, but not entirely well, as in the ordinary
form of malaria, where the fever disappears entirely between the
attacks. After an interval varying from three to thirty-six hours the
temperature rises again and the more severe symptoms reappear, and so
the disease continues, there never being complete freedom from fever,
the temperature sometimes rising as high as 105 deg. or 106 deg. F. In some
cases there are nosebleed, cracked tongue, and brownish deposit on the
teeth, and a delirious or stupid state, as in typhoid fever, but the
distention of the belly, diarrhea, and rose spots are absent. The skin
and whites of the eyes often take on the yellowish hue of jaundice.
This fever has been called typhomalarial fever, under the supposition
that it was a hybrid of the two. This is not the case, although it is
possible that the two diseases may occur in the same individual at the
same time. This, indeed, frequently happened as stated, in our
soldiers coming from the West Indies during the Spanish-American
War--but is an extremely uncommon event in the United States.
=Pernicious Malaria.=--This is a very grave form of the disease. It
rarely is seen in temperate regions, but often occurs in the tropics
and subtropics. It may follow an ordinary attack of chills and fever,
or come on very suddenly. After a chill the hot stage appears, and the
patient falls into a deep stupor or unconscious state, with flushed
face, noisy breathing, and high fever (104 deg. to 105 deg. F.). Wild delirium
or convulsions afflict the patient in some cases. The attack may last
for six to twenty-four hours, from which the patient may recover, only
to suffer another like seizure, or he may die in the first. In another
form of this pernicious malaria the symptoms resemble true cholera,
and is peculiar to the tropics. In this there are violent vomiting,
watery diarrhea, cramps in the legs, cold hands and feet, and
collapse. Sometimes the attack begins with a chill, but fever, if any,
is slight, although the patient complains of great thirst and inward
heat. The pulse is feeble and the breathing shallow, but the intellect
remains clear.
Death often occurs in this, as in the former type of pernicious
malaria, yet vigorous treatment with quinine, iron, and nitre will
frequently prove curative in either form.
=Black Water Fever.=--Rarely in temperate climates, but frequently in
the Southern United States and in the tropics, especially Africa;
after a few days of fever, or after chilliness and slight fever, the
urine becomes very dark, owing to blood escaping in it. This sometimes
appears only periodically, and is often relieved by quinine. It is
apparently a malarial fever with an added infection from another
cause.
=Chagres Fever.=--A severe form of malarial fever acquired on the
Isthmus of Panama, apparently a hemorrhagic form of the pernicious
variety, and so treated.
=Detection.=--To the well-educated physician is now open an exact
method of determining the existence of malaria, and of distinguishing
it from all similar diseases, by the examination of the patient's
blood for the malarial parasite--its presence or absence deciding the
presence or absence of the disease. For the layman the following
points are offered: intermittency of chills and fever, or of fever
alone, should suggest malaria, particularly in a patient living in or
coming from a malarial region, or in a previous sufferer from the
disease. In such a case treatment with quinine will solve the doubt in
most cases, and will do no harm even if the disease be not malaria.
Malaria is one of the few diseases which can be cured with certainty
by a drug; failure to stop the symptoms by proper amounts of quinine
means, in the vast majority of cases, that they are not due to
malaria. There are many other diseases in which chills, fever, and
sweating occur at intervals, as in poisoning from the presence of
suppuration or formation of pus anywhere in the body, but the layman's
ignorance will not permit him to recognize these in many instances.
The quinine test is the best for him.
=Prevention.=--Since the French surgeon, Laveran, discovered the
parasite of malaria in 1880, and Manson, in 1896, emphasized the fact
that the mosquito is the medium of its communication to man, the way
for the extermination of the disease has been plain. "Mosquito
engineering" has attained a recognized place. This consists in
destroying the abodes of mosquitoes (marshes, ponds, and pools) by
drainage and filling, also in the application of petroleum on their
surface to destroy the immature mosquitoes. Such work has already led
to wonderful results.[11] Open water barrels and water tanks prove a
fruitful breeding place for these insects, and should be abolished.
The protection of the person from mosquito bites is obtained by proper
screening of habitations and the avoidance of unscreened open air, at
or after nightfall, when the pests are most in evidence. Dwellings on
high grounds are less liable to mosquitoes. Persons entering a
malarial region should take from two to three grains of quinine three
times a day to kill any malarial parasites which may invade their
blood, and should screen doors and windows. Patients after recovery
from malaria must prolong the treatment as advised, and renew it each
spring and fall for several years thereafter. A malarial patient is a
direct menace to his entire neighborhood, if mosquitoes enter.
=Treatment.=--The treatment of malaria practically means the use of
quinine given in the proper way and in the proper form and dose.
Despite popular prejudices against it, quinine is capable of little
harm, unless used in large doses for months, and no other remedy has
yet succeeded in rivaling it in any way. Quinine is frequently useless
from adulteration; this may be avoided by getting it of a reliable
drug house and paying a fair price for the best to be had. Neither
pills nor tablets of quinine are suitable, as they sometimes pass
through the bowels undissolved. The drug should be taken dissolved in
water, or, more pleasantly, in starch wafers or gelatin capsules. When
the drug is vomited it may be given (in double the dose) dissolved in
half a pint of water, as an injection into the bowels, three times
daily. Infants of a few months may be treated by rubbing an ointment
(containing thirty grains of quinine sulphate mixed with an ounce and
a half of lard) well into the skin of the armpits and groins, night
and morning. Children under the age of two can be best treated by
quinine made into suppositories--little conical bodies of cocoa butter
containing two grains each--one being introduced into the bowel, night
and morning.
During an attack of malaria the discomfort of the chill and fever may
be relieved to considerable extent by thirty grains of sodium bromide
(adult dose) in water. Hot drinks and hot-water bottles with warm
covering may be used during the chill, while cold sponging of the
whole naked body will afford comfort during the hot stage. In the
pernicious form, attended with unconsciousness, sponging with very
cold water, or the use of the cold bath with vigorous friction of the
whole body and cold to the head are valuable. The effect of quinine is
greatest during the time of birth of a new generation of young
parasites in the blood, which corresponds with the time of the
malarial attack. But in order that the quinine shall have time to
permeate the blood, it must be given two to four hours before the
expected chill, and then will probably prevent the next attack but
one. A dose of ten grains of quinine sulphate taken three times daily
for the first three days of treatment; then a dose of three grains,
three times daily for two weeks; and finally two grains, three times
daily for the rest of the month of treatment will, in many cases,
complete a cure. If the quinine cause much ringing in the ears and
deafness, it will be found that sodium bromide taken with the quinine
(in twice the dose) dissolved in water, will correct this trouble. If
the patient is constipated and the bowel discharges are light colored,
a few one-quarter grain doses of calomel may be taken every two hours,
and followed in twelve hours by a dose of Epsom salts, on the first
day of treatment, with quinine. It is no use to take quinine by the
mouth later than two hours before an attack, and if the patient cannot
secure treatment before this time, he should take a single dose of
twenty grains of quinine.
To children may be given a daily amount of quinine equal to one grain
for each year of their age. In the severe forms of remittent and
pernicious types of malaria it may be necessary for the patient to
take as much as thirty grains of quinine every three days or so to cut
short the attack. But, unfortunately, the digestion may be so poor
that absorption of the drug does not occur, and in such an event the
use of quinine in the form of the bisulphate in thirty-grain doses,
with five grains of tartaric acid, will in some cases prove effective.
Chronic malaria is best treated with small doses of quinine, together
with arsenic and iron. A capsule containing two grains of quinine
sulphate, one-thirtieth grain of arsenious acid, and two grains of
reduced iron should be taken three times daily for several weeks.
=YELLOW FEVER.=--This is a disease of tropical and subtropical
countries characterized by fever, jaundice, and vomiting (in severe
cases vomiting of blood), caused by a special germ or parasite which
is communicated to man solely through the agency of the bites of a
special mosquito, _Stegomyia fasciata_.
=Distribution.=--Yellow fever has always been present in Havana, Rio,
Vera Cruz, and other Spanish-American seaports; also on the west coast
of Africa. It is frequently epidemic in the tropical ports of the
Atlantic in America and Africa, and there have been numerous epidemics
in the southern and occasional ones in the northern seacoast cities of
the United States. The last epidemic occurred in the South in 1899.
Rarely has the disease been introduced into Europe, and it has never
spread there except in Spanish ports. The disease is one requiring
warm weather, for a temperature under 75 deg. F. is unsuitable to the
growth of the special mosquito harboring the yellow-fever parasite. It
spreads in the crowded and unsanitary parts of seacoast cities, to
which it is brought on vessels by contaminated mosquitoes or
yellow-fever patients from the tropics. Havana has heretofore been the
source of infection for the United States, but since the disease has
been eradicated by the American army of occupation, that danger has
been removed. Yellow fever is not at all contagious in the sense that
a healthy person can contract the disease by contact with a
yellow-fever patient, or with his discharges from the stomach, bowels,
or elsewhere, and is probably only communicated to man by the bite of
a particular kind of mosquito harboring the yellow-fever organism in
its body. Both these facts have been incontestably proved,[12] in part
by brave volunteers from the United States Army who submitted to sleep
for twenty-one days on clothes soiled with discharges from patients
dying of yellow fever, and escaped the disease; and by others living
in uncontaminated surroundings who permitted themselves to be bitten
by infected mosquitoes and promptly developed yellow fever.
=Development.=--After a person has been bitten by an infected
mosquito, from fourteen hours to five days and seventeen hours elapse
before the development of the first symptoms--usually this period
lasts from three to four days. With the appearance of a single case in
a region, a period of two weeks must elapse before the development of
another case arising from the first one. This follows because a
mosquito, after biting a patient, cannot communicate the germ to
another person for twelve days, and two days more must elapse before
the disease appears in the latter.
=Symptoms.=--During the night or morning the patient has a chill (or
feels chilly) and experiences discomfort in the stomach, with
sometimes nausea and vomiting. There is pain through the forehead and
eyes, in the back and thighs, and often in the calves. The face is
flushed and slightly swollen--particularly the upper lip--and the eyes
are bloodshot, and gradually, in the course of thirty-six hours, the
whites become yellowish. This is one of the most distinguishing
features of the fever, but is often absent in children. The tongue is
coated, there are loss of appetite, lassitude, sore throat, and
constipation. In the beginning the temperature ranges from 101 deg. to
103 deg. F., or in severe cases as high as 105 deg. or 106 deg. F., and the pulse
from 110 to 120 beats a minute. The fever continues for several
days--except in mild cases--but the pulse usually falls before the
temperature does. For example, the temperature may rise a degree
during the third day to 103 deg. F., while the pulse falls ten or more
beats at the same time and may not be over 70 or 80, while the
temperature is still elevated. This is another peculiar feature of the
disease. Vomiting often increases on the second or third day, and the
dreaded "black vomit" may then occur. This presents the appearance of
coffee grounds or tarry matter and, while a dangerous symptom, does
not by any means presage a fatal ending. The black color is due to
altered blood from the stomach, and bleeding sometimes takes place
from the nose, throat, gums, and bowels, with black discharges from
the latter. The action of the kidneys is usually interfered with,
causing diminution in the amount of urine. It is extremely important
to pay regard to this feature, because failure of the patient to pass
a proper amount of urine calls for prompt action to avert fatal
poisoning from retained waste matters in the blood. The normal amount
of urine passed in twenty-four hours in health is over three pints,
and while not more than two-thirds of this amount could be expected to
be passed by a fever patient, yet in yellow fever the passage of urine
may be almost or wholly suppressed. The course of the disease varies
greatly. In children--especially of the Creoles--it is frequently so
mild as to pass unnoticed. In adults the fever may only last a few
hours, or two or three days, with gradual recovery from the various
symptoms, and yellowness of the skin lasting for some time. This is
not seen readily during the stage of fever when the surface is
reddened, but at that time may be detected by pressure on the skin for
a minute, when the skin will present a yellow hue on removing the
finger before the blood returns to the pressure spot. With fall of
fever, and abatement of symptoms after two or three days, the patient,
instead of going on to recovery may, after a few hours or a day or
two, again become very feverish and have vomiting--perhaps of blood or
black vomit--yellow skin, feeble pulse, failure of kidney action with
suppression of urine, delirium, convulsions, stupor, and death; or may
begin to again recover after a few days. Mild fever, slight jaundice,
and absence of bleeding are favorable signs; black vomit, high fever,
and passage of little urine are unfavorable signs. The death rate is
very variable in different epidemics and among different classes;
anywhere from fifteen to eighty-five per cent. Among the better
classes it is often not greater than ten per cent in private practice.
Heavy drinkers and those living in unfavorable surroundings are apt to
succumb.
=Prevention.=--Yellow fever, like malaria, is a preventable disease,
and will one day be only a matter of historic interest. Dr. W. C.
Gorgas, U. S. A., during 1901, by ridding Havana of the mosquito
carrying the yellow-fever organism through screening barrels and
receptacles holding water, and by treating drains, cesspools, etc.,
with kerosene, succeeded in also eradicating yellow fever from that
city, so that in the following year there was not one death from this
disease; whereas, before this time, the average yearly mortality had
been 751 deaths in Havana. Spread of the disease is controlled by
preventing access of mosquitoes to the bodies of living or dead
yellow-fever patients; while personal freedom from yellow fever may be
secured by avoiding mosquito bites, through protection by screens
indoors, and covering exposed parts of the face, hands, and ankles
with oil of pennyroyal or spirit of camphor, while outdoors.
=Treatment.=--There is unfortunately no special cure known for yellow
fever such as we possess in malaria. The patient should be well
covered and surrounded with hot-water bags during chill. It is
advisable to give a couple of compound cathartic pills or a
tablespoonful of castor oil at the start. Two, or at most three,
ten-grain doses of phenacetin at three hours intervals will relieve
the pain during the early stage. Cracked ice given frequently by the
mouth and the application of a mustard paper or paste (one part
mustard, three parts flour, mixed with warm water and applied between
two layers of thin cotton) over the stomach will serve to allay
vomiting. Cold sponging (see Typhoid Fever, p. 232) is the best
treatment for fever. The black vomit may be arrested by one-quarter
teaspoonful doses of tincture of the chloride of iron, given in four
tablespoonfuls of water, every hour after vomiting. The bowels should
be moved daily by injection of warm soapsuds. The patient should not
rise from his bed, but should use a bedpan or other receptacle. In
addition, a pint of warm water, containing one-half teaspoonful of
salt, should be injected into the bowel night and morning and, if
possible, retained by the patient. The object of the latter is by its
absorption to stimulate the action of the kidneys. The diet should
consist of milk, diluted with an equal amount of water, broths,
gruels, etc., and only soft food should be given for ten days after
recovery. Iced champagne in tablespoonful doses at frequent intervals,
or two teaspoonful doses of whisky in a little ice water, given every
half hour, relieves vomiting and supports the strength.
FOOTNOTES:
[11] See Volume V, p. 76, for detailed methods.--EDITOR.
[12] See Frontispiece, Vol. V.
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| TRANSCRIBER'S NOTE. |
| =================== |
| |
| The following change was made: |
| |
| Part II, Chapter II, Typhoid Fever, Symptoms (p. 225) |
| |
| Original text: |
| |
| "... flushed face, pulse 100 deg., gradually increasing as |
| described." |
| |
| Changed to: |
| |
| "... flushed face, pulse 100, gradually increasing as |
| described." |
| |
| "Pulse 100" was preferred over "temperature 100 deg.". |
| |
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