\ j ; i « ( i SIM 650452261�5� 82603997573�52791995 WY 153 W749f 1919 54410110R »7 5\1 MUi1 T ;w-^ /7\1 NLM Q5Eflbfl34 5 NATIONAL LIBRARY OF MEDICINE J ' ^ * ^^ "X * NUIOIW JO A « • I IVNOIIVN JNOIQJW JO ABVURIl IVNOIIVN 1NI3IQ1W JO A 1V•R II IVN NI3IQ3W JO AIVIII1 IVNOIIVN 1NI3I03W JO A » V « B I 1 1VNOUVN INDIOiW JO A I V 11 II IVN 1 ^v/1 NLM052868342 ^3, 6 *" P LIPPINCOTT'S NURSING MANUALS FEVER-NURSING DESIGNED FOR THE USE OF PROFESSIONAL AND OTHER NURSES AND ESPECIALLY AS A TEXT-BOOK FOR NURSES IN TRAINING BY J. C. WILSON, A.M., M.D. AUTHOR OF "A TREATISE ON CONTINUED FEVERS" AND "A HANDBOOK ON MEDICAL DIAGNOSIS" LIPPINCOTT'S NURSING MANUALS NURSING TECHNIC By MARY C. WHEELER, R.N., Superintendent of Illinois Training School for Nurses, Chicago, 111. 265 pages. 32 illustrations, fi.sonet. „m . ~„ „^ ■ ^^ Second Edition, STATE BOARD Raised and Reset QUESTIONS AND ANSWERS FOR NURSES Compiled and Edited by JOHN FOOTE, M.D., Georgetown Uni- versity, Washington, D.C. 398 pages. $2.50 net. Ninth Edition Revised COOKE'S HANDBOOK OF OBSTETRICS Revised by CAROLYN E. GRAY and MARY ALBERTA BAKER, of City Hospital, New York. 49s pages. 20s illustrations. J2.60 net. 4 colored full page inserts. CARE AND FEEDING OF INFANTS AND CHILDREN A TEXT-BOOK FOR TRAINED NURSES By WALTER REEVE RAMSEY, M.D., of University of Minnesota. 290 pages. 123 illustrations. $2.00 net. PRIVATE DUTY NURSING 5'e^T™' By KATHERINE DeWITT, R.N., Assistant Editor of American Journal of Nursing. 254 pages. $1.75 net. SURGICAL AND GYNAECOLOGICAL NURSING By EDWARD MASON PARKER, M.D., and SCOTT DUDLEY BRECKINRIDGE, M.D., of Providence Hospital, Washington, D.C, 425 pages. 134 illustrations. $ 2.50 net. ESSENTIALS OF MEDICINE Third Edition By CHARLES PHILLIPS EMERSON, M.D., of University of Indiana. 401 pages. 49 illustrations. $2.50 net. Second Edition Revised PHYSICS AND CHEMISTRY FOR NURSES By A. R. BLISS, M.D., Grady Hospital, Atlanta, Ga. and A. H OLIVE, A.B., Ph.D. Hillman Hospital, Birmingham. 239 pages. 49 illustrations. $1.75 net. Third Edition Rtvised MATERIA MEDICA AND THERAPEUTICS By JOHN FOOTE, M.D.,of Providence Hospital, Washington, D. C 310 pages. $1.75 net. ESSENTIALS OF SURGERY By ARCHIBALD L. McDONALD, M.D., St. Luke's Hospital, Duluth, Minn. 254 pages. 46 illustrations. I2.00 net. PRACTICAL BANDAGING By ELDRIDGE L. ELIASON. M.D.. University of Pennsylvania Hospital. 124 pages. 155 illustrations. $1.50 net. NURSING AND CARE Third Edition OF THE NERVOUS AND THE INSANE By CHAS. K. MILLS, M.D., and N. S. YAWGER M D 142 pages. 12 illustrations. $1.50 net. HOW TO COOK Fifth Edition RF°R THE SICK AND CONVALESCENT By HELENA V. SACHSE. 337 pages. $i.Sonet. LIPPINCOTT'S NURSING MANUALS FEVER-NURSING DESIGNED FOR THE USE OF PROFESSIONAL AND OTHER NURSES \ND ESPECIALLY AS A TEXT-BOOK FOR NURSES IN TRAINING / BY J. C. ^ILSON, A.M., M.D. Author of "A Treatise on the Continued Fevers" and "A Handbook on Medical Diagnosis" EMERITUS PHYSICIAN TO THE PENNSYLVANIA HOSPITAL, PHYSICIAN-IN-CHIEF TO THE LANKENAU HOSPITAL, PHILADELPHIA; EMERITUS PROFESSOR OF THE PRACTICE OF MEDICINE AND OF CLINICAL MEDICINE IN THE JEFFERSON MEDICAL COLLEGE; CONSULTING PHYSICIAN TO THE RUSH HOSPITAL FOR CONSUMPTIVES, THE JEWISH HOSPITAL, THE BRYN MAWR HOSPITAL, THE PHILADELPHIA LYING-IN CHARITY, FORMERLY PRESIDENT OF THE COLLEGE OF PHYSICIANS OF PHILADELPHIA; MEMBER AND FORMER PRESIDENT OF THE ASSOCIATION OF AMERICAN PHYSICIANS, ETC., ETC., FORMERLY VISITING PHYSI- CIAN TO THE PHILADELPHIA HOSPITAL AND ST. AGNES' HOSPITAL, ETC., ETC. NINTH EDITION. REVISED AND ENLARGED PHILADELPHIA AND LONDON J. B. LIPPINCOTT COMPANY %3GZ6fi LIBRARY wy 153 v/,„ /-•'/'- ih'-y jh^ >■• Copyright, 1887, 1899,1904, 1907, 1910, 1912, 1915, 1919, by J. B. Lippincott Company / 001 13 1313 PRINTED BY J. B. LIPPINCOTT COMPANY AT THE WASHINGTON SQUARE PRESS PHILADELPHIA, U. S. A. ©CI.A53 52 75 1 *V PREFACE TO THE NINTH EDITION. Several printings of the " Fever-Nursing" have been made in response to a very steady demand since the last revision. The present editing, however, has become necessary in order to bring the book fully up to date. Among the items of new matter are included the following subjects: Multiple and In- tercurrent Relapse and the Cause of Relapse in Acute Febrile Diseases; Blood-Pressure Estimation; the Paratyphoid Infections and the Use of Mixed Triple Vaccines in Prophylactic Inoculations; Sporadic Ty- phus Fevers—so-called Brill's Disease; the Schick Test and Toxin-Antitoxin Inoculations in Diphtheria Immunity. Two movements of our time have en- larged the requirements of the training of the nurse and greatly widened her field of usefulness—waT and social service. The first, waged upon a scale and with a ferocity that seems to shake the foundations of civilization, may prove, as many hope, to be the termi- nal crisis of a long historical era of military misrule and mark the birth of the history of international justice and peace on earth. The second marks the establish- ment of good will to men upon practical and efficient grounds. In both of these movements Medicine and its hand-maid, the Profession of Nursing, find a widened opportunity for help and usefulness. That the pages of this little book may be of service to those in search of the technical knowledge that is necessary to high efficiency in the care of the sick and the prevention of disease is the earnest wish of the writer. 1509 Walnut Street, Philadelphia. March, 1919. \ i PREFACE TO THE FIRST EDITION. The following pages embody the substance of a Course of Lectures on Fever-Nursing, originally de- livered before the Nurse Class at the Philadelphia Hospital. I have sought to treat the subject in plain words and from the stand-point of the physician; to teach not only how fever patients are to be cared for, but also why they must be cared for in particular ways. The directions and descriptions are intended to meet the needs both of the professional nurse and of others who may be called upon to minister to fever cases, and to enable each of these classes of attendants to under- stand the principles of treatment upon which the direc- tions of the physician are based. My thanks are due to Miss Dalziel and Miss Moulder for copying the charts. If this little book prove useful to a wider circle of workers than that of the Hospital Amphitheatre, its purpose will have been fully achieved. 1437 Walnut Street, Philadelphia. 5 CONTENTS. i. ON FEVER-NURSING IN GENERAL. PAGE Fever—Pyrexia, Apyrexia, Hyperpyrexia—Essential Fevers and Symptomatic Fever—Qualifications of the Nurse— Ventilation—Removal of Furniture—Avoidance of Un- necessary Contact—Contagion—Infection—Disinfection— Transmission of Disease—Isolation—Order and Method in the Sick-room—Medical Thermometry—Thermometers and Their Use—Temperature of the Body in Health, in Disease —Unstable Temperature of Convalescence—Temperature Charts—Temperature Curves—Types of Fever—Continued, Remittent, Intermittent Fevers—Inverse Type—Deferves- cence—Lysis—Crisis—Recrudescence—Relapse......11 II. fever-nursing in general—Continued. Essential Fevers Infectious Diseases—Classification of Fevers: I. Continued, II. Periodical, III. Eruptive, IV. Fevers with marked Local Manifestations—All Fevers Really Symptomatic—Causation of Symptoms—Symptoms Com- mon to the Fevers—The Nervous System—Organs of Special Sense—The Digestive System—The Circulatory System—'Blood-Pressure Estimation—The Respiratory System—The Skin—The Urine—Different Plans of Treatment: I. The Symptomatic, II. The Expectant, III. The Rational, IV. The Specific...........57 7 g CONTENTS. III. fever-nursing in general—Concluded. PAOI Duties of the Nurse in regard to Various Symptoms—The Patient's Bed, Clothing, Room, Toilet—The Fever—Ex- ternal Antipyretics: Sponging, Compresses, Ice, the Cold Pack, Cold Baths, Cold Affusions, Iced-Water Injections— Nurse Management of the Nervous Symptoms—Of Symp- toms relating to the Organs of Special Sense ; to the Diges- tive Organs—Drinks, Fever Foods, Alcohol—Pulse-Taking —The Respiration—Cough—The Urine . . . .82 IV. the continued fevers. Enteric, or Typhoid Fever—Paratyphoid—Typhus Fever —Relapsing Fever—Influenza—Yellow Fever—Dengue 117 V. THE PERIODICAL FEVERS. Intermittent Fever—Remittent Fever—Pernicious Malarial Fever...........182 VI. THE ERUPTIVE FEVERS. Scarlet Fever—Measles—Rotheln, or German Measles—Vari- ola, or Small-pox—Varioloid—Varicella, or Chicken-Pox . 189 VII. FEVERS WITH MARKED LOCAL MANIFESTATIONS. Rheumatic Fever—Pneumonia—Cerebro-Spina-1 Fever— Diphtheria—The Bubonic, or Oriental Plague . . . 217 CHARTS AND LIST OF ILLUSTRATIONS. FlO. PAGS 1. Schering's formalin lamp..............28 2. Hyperpyrexia...................48 3. Clinical chart...................48 4. Intermittent fever; double tertian infection.....54 5. Temperature of inverse type............54 6. Temperature curve in enteric fever; recrudescence and relapse...................54 7. Fever of irregular periodicity............54 8. Pneumonia. Defervescence by crisis........54 9. Pneumonia. Interrupted crisis...........54 10. Temperature range in enteric fever.........122 11. Sudden fall of temperature.............123 12. Typhus fever...................166 13. Relapsing fever..................166 14. Tertian fever...................184 15. Double tertian fever................184 16. Quartan fever...................184 17. Estivo-autumnal fever...............185 18. Scarlet fever...................192 19. Desquamation after scarlet fever..........194 20. Measles......................202 21. Discrete small-pox: chart.............210 22. Eruption of discrete small-pox...........210 23. Confluent small-pox................210 24. Small-pox in unvaccinated girl...........212 25 Small-pox—varioloid—in sister of girl depicted in Fig. 24, who was successfully vaccinated in infancy . . 212 26. Croupous pneumonia...............224 27. Croupous pneumonia: chart showing pseudo-crisis and crisis......................225 28. Epidemic cerebro-spinal fever...........230 29 Petechial eruption; cerebro-spinal fever.......230 I ^ i i FEVER-NURSING. i. ON FEVER-NURSING IN GENERAL. Fever—Pyrexia, Apyrexia, Hyperpyrexia—Essential Fevers and Symptomatic Fever—Qualifications of the Nurse—Ventilation —Removal of Furniture—Avoidance of Unnecessary Contact —Disinfection—Transmission of Disease—Isolation—Order and Method in the Sick-room—Medical Thermometry—Thermom- eters and Their Use—Temperature of the Body in Health, in Disease—Unstable Temperature of Convalescence—Temperature Charts—Temperature Curves—Types of Fever—Continued, Remittent, Intermittent Fevers—Inverse Type—Defervescence— Lysis—Crisis—Recrudescence—Relapse. Fever is the term used in ordinary parlance to designate any considerable rise in the temperature of the body, which lasts for a time. This morbid condi- tion is found upon investigation to be invariably associ- ated with wasting or increased tissue-change and more or less disturbance of the functions of the body. Pyrexia is the term used to designate abnormal ele- vation of the temperature of the body. Pyrexia and fever are not the same. The former is merely a sin- gle factor in the association of symptoms, or symptom- complex, which constitutes the latter. Apyrexia is the absence of abnormal elevation of temperature. Hyper- pyrexia is excessive elevation of temperature. Fever is a prominent symptom in the greater number of acute 11 12 FEVER-NURSING. and in many chronic constitutional diseases. It also occurs in certain local diseases and in the absence of proper treatment after wounds and injuries. Fever is the controlling symptom in a large group of acute ill- nesses, and then becomes so important as to constitute the essential characteristic of the sickness. Such sick- nesses are classed together as The Fevers or the Essen- tial Fevers, and the fever which occurs as a mere symptom in the course of other diseases is known as Symptomatic Fever. Thus typhoid and scarlet fever are essential fevers, while hectic and the irritative fever which accompanies a neglected wound are symptomatic. When we come to consider the causes of fever we will find that the distinction between essential and sympto- matic fevers is rather apparent than real. While the consideration of fever necessarily forms a large part of the training of every nurse and at almost every stage of her preparation, the importance of the subject renders special instruction necessary. To this purpose the following pages are devoted. I do not consider it necessary to occupy much space with the qualifications of the nurse. It is assumed that she should be in good health, of at least moderate physical strength, scrupulously neat in person and attire; that she be quiet, watchful, orderly, of moderate speech both in kind and quantity, gentle always, firm when needs be; that she be well trained in her work and love it for its own sake as well as a means of support; and that she have enough of the spirit of science in her to be ab- solutely truthful and direct in reporting the facts of the case and in carrying out the directions of the physicians. The more tact and common sense she has the better. ON FEVER-NURSING IN GENERAL. 13 These are the requirements of the nurse in all sickness. In nursing fevers they are needed in large measure. Health and strength are especially needful, and as febrile illnesses are often protracted and involve serious strains upon the endurance of the nurse, her duty to her self de- mands the careful observanceof hygienic measures neces- sary to the preservation of her own health. Many of the fevers are contagious. It is therefore expedient that such cases should be attended only by nurses who have themselves previously experienced an attack of the disease from which the patient is suffering. It is true that there are exceptions to the rule that the contagious fevers are self-protective; thatis, that persons who have passed through an attack are im- mune, in other words, not likely to contract the disease again. But the exceptions are sufficiently rare to war- rant the hope that an attack in the past will confer im- munity in the future. It is a great hardship for the nurse to contract a fever from her patient, and often a very serious matter for the patient himself and his friends. Nevertheless, cases occasionally occur in which it ap- pears absolutely necessary for an unprotected nurse to undertake the care of a person suffering from a contagi- ous disease. The danger of contracting the disease will then be diminished by unremitting attention to rules, which are derived from the fact that the cause of the fevers is in every case an actual substance, capable of transmission in various ways from person to person, and of producing the disease only when it has reached the interior of the body; that, though too minute to be de- tected except by staining and the aid of powerful micro- scopes, it has been proved to be in many of the fevers 14 FE VER-NURSING. a plant-germ or bacterium (plural bacteria), endowed with the capacity of rapid growth and enormous multi- plication, and that the vitality of these minute vegetable organisms is destroyed by the action of certain chemical agents known as germicides or disinfectants. Among the more important of these rules to be observed in all cases of fever are the following: Ventilate the sick-room thoroughly and continuously. Direct draughts and extreme reductions of tempera- ture of the room are to be avoided, but fever patients are little liable to "take cold." The local congestions and inflammations to which they are prone are due to other causes, and constitute in most instances incidents of the sickness which arise independently of any such exposure as is involved in efficient ventilation. The free access of pure air is not only desirable in itself, but it also means the expulsion of the foul air of the room, together with innumerable particles of dust to which adhere disease-germs thrown off from the body of the patient. Remove from the sick-room all unnecessary furniture. This rule includes all hangings, pictures, and orna- ments. Even the carpet must be taken up when we are dealing with such diseases as small pox or scarlet- fever. In that case a strip of old carpet or a mat beside the bed will add much to the comfort of the nurse, and may be destroyed when the sickness is over. If the carpet be not removed it must be covered with linen, which is to be frequently sprinkled with some efficient disinfectant. For this use old sheets may be tacked down. The bareness of a well-managed hos- pital ward is a safeguard against the spread of disease. ON FEVER-NURSING IN GENERAL. 15 Avoid in so far as possible close or prolonged contact with the patient and his bed. Contagion means contact. But this is not the whole truth of the matter. The infecting principle of differ- ent contagious diseases shows great variation in its mode of transmission. Thus the poison of scarlet fever is tenacious, and clings closely and for a long time to the patient and his belongings. It is but little blown about in the air, but may be conveyed to great distances in articles of clothing, toys, and the like. Of course, very small or light articles saturated with it, as the scales or particles of skin shed towards the close of the attack, may be carried in the air and transmit the disease. On the other hand, the infecting principle of measles and that of whooping-cough are light and easily wafted about in the air. The nearer the patient the greater the concentration of the poison and the dan- ger of infection. Minute material particles are more lia- ble to attach themselves to rough and woolly than to smooth, hard-surfaced fabrics. The nurse's gown must be of plain, smooth stuff, capable of being washed and very simply made. Her apron, sleeves, and cap must be white. The cap, when properly made and of sufficient size, serves a useful purpose in protecting the hair. There is much confusion regarding the terms " con- tagion " and " infection." Contagion means primarily conveyance of disease by actual contact; but contagion is often, as we have seen, indirect and by means of various intervening articles, or even by the persons of those who, themselves immune, may transfer the mi- croscopical organisms which constitute the exciting cause of disease from the sick to the well even at a 16 FE VER-NURSING. distance. For these reasons it is suggested that " trans- missible " be used instead of " contagious." Infection is essentially different from contagion. Bacteriology has enabled us to frame a new definition for the infectious diseases. An infectious disease arises when a pathogenic or disease-producing germ, having gained access to the interior of the body, grows and multiplies, evolving poisonous chemical substances or toxines which are soluble in the fluids of the body and produce characteristic effects. Constitutional infections by pus-producing organisms are described under the term Sepsis. Pycemia is the term used to designate the form of sepsis in which pus-col- lections occur in various parts of the body ; Septicemia Bacteremia, that form in which circumscribed purulent collections are absent but there is invasion of the tissues and blood by bacteria, with the manifestations of pro- found disorder of the whole body, and Septicopycemia, that form in which bactersemia and pyaemia are present at the same time. Saprozmia is the condition caused by the absorption into the blood of the products of putre- faction. All these conditions are associated with fever of irregular type and duration. By far the greater num- ber of micro-organisms or germs which cause disease are specific, that is, the particular germ always causes the same disease. But many are merely pyogenic or pus- producing and introduction into the body gives rise to morbid conditions which are not specific in the sense of being definite diseases, but which may be either local, as an abscess or ulcer, or constitutional, and vary according to the intensity of the process from a trifling and tran- sient ailment to an overwhelming and fatal malady. ON FEVER-NURSING IN GENERAL. 17 Use disinfectants thoroughly and systematically. There is wide-spread misapprehension in regard to the subject of disinfection. Chlorinated lime and car- bolic acid as ordinarily used are useless for this pur- pose. Certainly the odors of these substances, how- ever strong, are wholly without effect in purifying the atmosphere of the sick-room. No volatile substance diffused in the air to any extent tbat does not interfere with its being breathed by human beings is an efficient disinfectant. The disinfectants are chemical substances which have the power of destroying the activity of infectious material, and the object of disinfection is to prevent the extension of infectious diseases by destroying the specific disease-producing organisms which give rise to them. In popular language, the term disinfection is used in a much wider sense. Chemical agents which destroy or mask bad odors — deodorizers,— or which arrest putrefactive decomposition — antiseptics,— are spoken of as disinfectants. And such substances have been confidently recommended and extensively used for the destruction of the germs of disease in cholera, typhoid fever, etc. The dangers that attend such mis- apprehension and misuse of the word disinfection be- come apparent when we consider the fact that it has within recent years been positively shown that many of the efficient deodorizers and antiseptics are wholly without value for the destruction of disease-germs. Bad odors in the sick-room and about the dwelling serve a useful purpose in calling attention to the fact that there is something wrong, even if it be simple uncleanliness. Though often associated with sub- stances which constitute the infecting principle of dis- 18 FE VER-NURSING. ease they do not necessarily belong to it, and to get rid of them is by no means to disinfect. In fact, so far as is known, the actual causes of the infectious diseases— pathogenic germs—are unattended by recognizable odors. The heavy, ill-smelling atmosphere which sur- rounds fever patients is due rather to deranged secre- tions than to anything in the infecting principle itself. Those agents which are disinfectants by virtue of their property of acting upon germs so as to destroy their vital- ity, and thus prevent their growth and reproduction, are called germicides; that is, germ-destroyers. While science has not yet shown that every kind of infectious material owes its specific disease-producing power to the presence of minute organisms or germs, ithas been proved that the best disinfectants are potent germicides. The room, articles of clothing, the person of the pa- tient and of the attendant, discharges from the bowels, and other discharges, the bed-pans, urinals, and other utensils used, particularly in the wards of hospitals, and finally water-closets, privy-vaults, etc., require disinfec- tion. The extent to which disinfection is to be used inany particular case, the agents employed, and the method of their application will be determined by the physician, and will vary according to the nature of the fever. All body linen and bed-clothing, towels, napkins, dressings, and bandages must be disinfected in the room or ward. Not only discharges from the patient must be disinfected, but also utensils into which they are received must be thoroughly disinfected before they are again used. This is especially important in hos- pital wards, and when several patients are treated in the same room or house, since it has been shown that ON FEVER-NURSING IN GENERAL. 19 secondary infections may be conveyed by such articles. This rule applies also to dishes, feeding-cups and spoons, and other similar objects. Insects are very important conveyors of the germs of disease. The sick-room or ward in the case of trans- missible diseases must be effectually screened, and flies, mosquitoes, and other insects destroyed. Recent investigations have demonstrated the fact that many diseases are transmitted by insects. These creatures act in two ways; first as mere carriers of disease-producing germs, as the house-fly in the cases of enteric fever; and second as intermediate hosts in which pathogenic micro-organisms undergo a phase of their life history, as in the case of the genus of mos- quito which is responsible for the causation and spread of malaria. As will be seen in the sections upon cau- sation in the descriptions of particular diseases in sub- sequent pages of this work, species of mosquitoes dis- seminate among human beings malaria in its various types and yellow fever; the bed-bug plays an active part in spreading relapsing fever, and the species of flea which infests rats and other rodents is the active agent in the transmission of the bubonic plague. Furthermore, the tropical disease known as filariasis is conveyed by a mosquito, Rocky Mountain fever by a tick, several diseases by bed-bugs, the African sleep- ing sickness by the tsetse fly and a number of severe diseases of domestic animals by insects. But in our climate and in the prolonged season of its activity there is no insect which plays a more active part in the dissemination of diseases than the ordinary house-fly. So common is this insect that Professor Howard, Chief 20 FE VER-NURSING. of the U. S. Bureau of Entomology, has shown that nearly 99 per cent, of all the insects captured in houses throughout the whole country were Musca domestica, or the ordinary house-fly, and so important is this fact in the spread of diseases, the causative germs of which are voided with the stools, as was shown in the terrible epidemics of enteric fever among our recruits in the practice camps at the time of the Spanish-American war, that the same authority has suggested that instead of the " house-fly," it should be called the " typhoid-fly." This insect also spreads intestinal diseases, children's complaints, and pulmonary tuberculosis. It has been demonstrated that there is a close correspondence be- tween the period of greatest abundance of flies and the highest mortality from intestinal diseases, namely, the weeks ending July 27 and August 3 (New York, 1907). In fact there is scarcely a disease attended with dis- charges containing specific germs which may not be trans- mitted by this insect and many obscure facts concerning the spread of diseases through the air and in the direction of prevailing winds and for limited distances have become perfectly plain in the light of our present knowledge. Among the more important of the diseases thus trans- mitted, in addition to tbose mentioned above, are scar- let fever, measles, diphtheria, cholera and smallpox. The house-fly breeds chiefly in horse manure—95 per cent.—and to some extent in privies, receptacles of kitchen offal and animal and vegetable substances un- dergoing putrefaction, especially if exposed to air and sunlight. They swarm over food substances and every sort of excrement and discharge, both physiological and pathological. Upon these they feed, carrying the germs ON FEVER-NURSING IN GENERAL. 21 of disease to be discharged upon articles of food in their excrement and at the same time other germs upon their feet. From every point of view as regards sanitation and prophylaxis it is important to get rid of this pes- tiferous insect. How is this to be done ? In the first place it is necessary to reduce the breed- ing places to a minimum by disposing of horse and other manure in such a manner that the flies cannot gain ac- cess to it and so protecting it by screens that those which are hatched cannot find egress from the recep- tacles. Putrefying animal and vegetable substances must be gotten rid of in a similar way. All morbid discharges in sickness must be at once disinfected and protected in such a manner as to be absolutely inac- cessible to flies. Articles of food and drink of every description must be effectively guarded against flies. The open latrine and the unscreened mess table in the military camps of a former period have their counter- parts upon a small scale in mismanaged houses. The decimation of an army is a national calamity ; the loss of a child a household tragedy. Make it impossible for flies to come and go by screening the house. Flies that are in or come in may be destroyed one by one by the wire whisks and bats sold for the purpose in the shops, or caught with fly-paper or fly-traps; those that are outside are kept there. To clear a room of many flies the following substances are available:— 1. Carbolic Acid.—Drop 30 drops upon a hot shovel. The vapor is promptly poisonous to flies. 2. Potassium Bichromate.—Dissolve one dram in two ounces of water; add a little sugar. Set about the room in shallow plates. This will prove most efficient. 22 FEVER-NURSING. 3. Formalin.—Solution of formaldehyde 40 per cent. A tablespoonful to a gill of water, exposed in shallow vessels is very fatal to flies. 4. Pyrethrum Powder.—Burn small quantities in *n iron ladle. The flies become stupefied and may be swept up and burned. To sum up :—Prevent breeding by destroying breed- ing places or rendering them inaccessible; destroy flies that are within and prevent those without from coming in—in other words cleanliness and screening. The nurse cannot do all these things but she can do many of them and she can make it clear to persons who have never realized it that the common house-fly is a very disgusting and dangerous insect. Visitors are frequently conveyors of disease in two ways. This is true of hospitals and other similar in- stitutions. They may bring it in, as is done in diph- theria ; or they may carry it out, as happens in small- pox or scarlet fever. Considerations of sentiment must often be disregarded in the matter of visitors. One of the more important duties of the physician is to prevent any particular case under his care from be- coming a focus or centre of infection, and this is only to be accomplished by the isolation of the patient and the proper use of disinfectants. A realizing sense of her power to avert suffering will be a great help to the nurse in en- deavoring to assist the physician in achieving this result. The following list includes the disinfectants available for general purposes: Dry and moist heat. Fumes of sulphur (sulphur dioxide). Lime. ON FEVER-NURSING IN GENERAL. 23 Chloride of lime (calcium hypochlorite). Labarraque's solution (solution of chlorinated soda). Corrosive sublimate (mercuric chloride). Sulphate of copper (cupric sulphate). Carbolic acid. Formaldehyde. Disinfection of the Sick-Room.—In the sick-room no disinfection can take the place of thorough ventilation and cleanliness. Complete disinfection of a room while it is occupied is impracticable. Much, however, can be done by washing the floor, window-ledges, and other surfaces with a solution of corrosive sublimate of the strength of one part in one thousand (1 :1000), or a solution of carbolic acid, two parts in one hundred (2 :100), or of chloride of lime, one part in one hun- dred (1 :100), of sulphate of copper, one part in one hundred (1 : 100). Compressed tablets are sold in the shops for the purpose of making the corrosive subli- mate disinfectant solution. Each tablet contains seven and three-tenths grains, and the solution formed by dissolving one tablet in a pint of water is of about the strength of one part in one thousand (1 : 1000).1 These tablets are extremely dangerous and have fre- quently caused death by being mistaken for tablets of soda mint, sodium bicarbonate, etc. They must under all circumstances be labelled " Poison " and kept by themselves, away from the "medicine closet." Corrosive sublimate (mercuric chloride) is a valuable disinfectant. Its advantages are that it is destructive to all forms of germ life including their spores, freely soluble in alcohol, moderately so (1 to 16) in cold water i As suggested by the late Dr. C. M. Wilson. 24 FEVER-NURSING. and readily (1 to 3) in hot water and that it is cheap. Its disadvantages are that it exerts a highly corrosive action upon metals, that it is intensely poisonous and that it enters into chemical combination with albuminous matter, forming inert and insoluble substances, which greatly impair its value as a sick-room disinfectant. Commercial preparations sold under various names for household and sick-room disinfection, being of un- known and probably of inconstant composition and unduly expensive, should never be employed. The nurse must bear constantly in mind that nearly all efficient chemical disinfectants are poisonous, most of them intensely so. Care must, therefore, be taken to keep them in large bottles or demijohns suitably and conspicuously labelled and marked "Poison," and in a place entirely apart and away from all medicines, food, and beverages. At the close of the sickness the room may be effec- tually disinfected. For this purpose the reliable gaseous disinfectants are the fumes of sulphur (sulphur dioxide) in the presence of moisture, chlorine, and formaldehyde. The agent first named is very commonly used. The fire-place, windows, and doors are to be closed, the cracks being packed with paper, or covered with paper pasted on, or strips of adhesive plaster. The walls and floor are to be freely sprinkled with water and dripping sheets or towels hung up on lines stretched across the room. Roll sulphur broken fine or the flowers of sul- phur (sulphur sublimatum) may be used. A little fine sawdust mixed with the latter causes it to burn more freely. The sulphur may be placed in a shallow iron vessel or an earthenware pie-dish, which, to avoid the ON FEVER-NURSING IN GENERAL. 25 danger of fire, should be set inside upon the bottom of a high tin wash-kettle or on tongs laid across a tub of water. It is ignited by a live coal or by first pouring over it a little alcohol. Three pounds of sulphur is required for every thousand cubic feet. A room fifteen feet long by twelve wide, with a ceiling ten feet high, contains eighteen hundred cubic feet(15 X 12 X 10 = 1800). It must be borne in mind that the inadequate use of the most effectual disinfectant is as bad as none at all, and that in all cases the disinfectant must be used far in excess of the quantity indicated by rule. As the fumes cannot be breathed even in diluted form, the doors must be immediately and tightly closed. The following day all windows are widely opened, and allowed to remain so for twenty-four hours. Sulphur dioxide has the advantage of being cheap and easily procurable, an effective surface disinfectant, very destructive to forms of animal as well as of vege- table life and therefore available in the case of disease germs carried by rats, mice, flies, fleas, mosquitoes and other vermin. The objections to it are that it bleaches fabrics colored with vegetable or some of the analine dyes, it rots cotton and linen fabrics and corrodes metals. These effects are due to sulphurous and sul- phuric acid developed in the presence of the necessary moisture. Metal utensils must be taken from the room and metal fixtures smeared with vaseline or oil. Chlorine is not employed as a gaseous disinfectant. Its suffocating and disagreeable odor, even in dilute mixture with the atmosphere, and its bleaching prop- erties render it unavailable for use in sick-room, house- hold or hospital disinfection ordinarily. 26 FE VER-NURSING. Formaldehyde, as generated from formalin (para- form) pastils by the Schering lamp or by the perman- ganate method, constitutes the most efficient gaseous disinfectant available for household use. It has the advantages of a high degree of effectiveness as a germ- icide, some power of penetration, and of being at the same time neither poisonous nor destructive to fabrics or metals. It is a very energetic deodorizer, not mask- ing foul odors, but destroying them by the formation of new chemical combinations. It does not destroy insects. The commercial substance known as Formalin is a 40 per cent, solution of formaldehyde. The following, extracted from the " Circular of In- formation," is the method of formaldehyde disinfec- tion used by the Chicago Department of Health: " The room to be disinfected is sealed and prepared as usual for sulphur disinfection, by pasting strips of paper over cracks of doors and windows. All its sur- faces are exposed as much as possible; closet doors are opened and their contents, together with the contents of drawers, are removed, scattered about and the drawers left open ; mattresses are set on end; pillows, bedding, clothing, etc., are suspended from lines stretched across the room or spread out on chairs and other objects so as to expose all sides; books are opened and the leaves spread—in short, the room and its contents are so dis- posed as to secure free access of the gas to all parts as fully as possible. " For every 1,000 cubic feet of space in the room, sus- pend, by one edge, an ordinary bed-sheet (2 by 2J yards) from a line stretched across the middle of the room. ON FEVER-NURSING IN GENERAL. 27 Properly sprinkled this will carry, without dripping, 8 ounces of liquor formaldehyde—the 40 per cent, solu- tion of formaldehyde gas—which is sufficient to disin- fect 1,000 cubic feet of space. As many sheets as necessary are used, hung at equal distances apart. The ordinary rather coarse cotton sheet should be used in order to secure rapid evaporation. The house should remain sealed not less than eight hours. " A rosehead sprinkler used by florists can be used for sprinkling the sheets. " After the disinfection soak all sheets, pillow slips, towels and other washable articles in the sick-room in the strong disinfectant and remove them while wet to the laundry, to be boiled at least thirty minutes. Sprinkle thoroughly all the surfaces of pillows and of the mattresses with the strong disinfectant and then carry into the open air, to be exposed to sunshine for at least six hours—frequently turning the articles. Mattresses a id pillows should be burned or sterilized by heat if soiled by discharges from the patient. Consult the physician on this point." Directions for the Use of Schering's Formalin Lamp. The lamp should be placed upon a table or on the floor in the middle of the room, the doors, windows, and other openings being closed. The cup e should be removed, as it is used only for deodorization and inhalation, then the glass chimney a with the globular container r is taken off from the lamp b, and the con- tainer r filled with Schering formalin pastils. For the destruction of the less resistant disease organisms, such 28 FEVER-NURSING. as the bacilli of diphtheria, typhoid fever, and tuber- culosis, forty one-gramme pastils will suffice in a medium-sized room, two thousand cubic feet. Then the reservoir of the lamp b is about half filled with alcohol; the wick is lighted and so regulated that it projects about one-twelfth to one- eighth inch above the tube. If wood alcohol is used as a fuel the wick should be about even with the tube (burner), as a too large flame will pro- duce more heat than is required. More than two ounces wood alcohol should not be placed in the reservoir, which holds four ounces. The chim- ney a, with the filled container r, is then replaced upon the lamp. No one should remain in the room, and the doors should be tightly closed, since the large amount of formalin vapor that is developed is very penetrating, and may be unpleasant, in that it causes lachrymation in the occupants of adjoining rooms. Nevertheless, it is ex- pressly to be remarked that the inhalation of formalin vapors is in no way injurious to health. The apparatus once started, it may be left entirely to itself. The light need not be extinguished, since the lamp burns out with perfect safety. According to the flame, two ounces of alcohol or wood alcohol will burn from four to eight hours. After twelve to twenty-four hours the room should be aired, and the formalin vapors will quickly disappear. If the room is to be thoroughly disinfected, and the most resistant spores ON FEVER-NURSING IN GENERAL. 29 killed,—a procedure that is not necessary under ordi- nary circumstances,—two lamps should be employed, or a larger apparatus can be used. Various other formaldehyde disinfectors are in use. Some of them, as Lister's, may be placed in the room, or the vapor may be led in by way of the key hole; others may be used in both of these ways. Formaldehyde fumigators are sold in the shops ahd are more convenient and economical. They consist of solidified formaldehyde in the form of a candle which burns from the bottom upward with a limited supply of air. The fumigator is placed in a shallow dish of earthenware and left to itself in the sealed room. It does not splutter and is free from the danger of setting fire to the room. About ten ounces of formalin are required for every 1000 cubic feet of air space. The Permanganate Method.—Formalin is poured upon the needle shaped crystals of potassium perman- ganate in a suitable container, such as a large ordinary dishpan. For the disinfection of 1000 cubic feet of room space use sixteen and a half ounces of perman- ganate and twenty ounces of formalin. The solution should be poured quickly and the room which has been previously sealed should be immediately closed. A violent chemical reaction occurs with the development of great heat. Spraying. Formalin is sprayed upon the objects to be disinfected and upon sheets hung in the room. The gas is slowly liberated by evaporation and per- meates the atmosphere. This method is available only for small apartments. Ten ounces are required for 30 FE VER-N URSING. every 1000 feet and the room should remain closed for at least twenty-four hours. After the room has been exposed some days to the air and sunshine, the walls must be scraped and re- papered or painted. Disinfection of Clothing.—Boiling for half an hour will destroy the vitality of all known disease-germs. Clothing may be disinfected by immersion for two hours in a solution of corrosive sublimate of the strength of 1:1000; or of sulphate of copper, 1:100; or of carbolic acid, 1: 50; or of chloride of lime, 1:100. The bleach- ing properties of chloride of lime must not be over- looked. The clothing of the sick-room should not be al- lowed to accumulate, but should go to the laundry as promptly as can be arranged. As an additional measure, and to lessen the risks of the laundry-women, it should be at once freely sprinkled with one of the above solu- tions by the nurse. Articles of clothing that would be injured by boiling or by immersion in a disinfectant solution may be disinfected by formalin or by exposure to dry heat in a properly constructed " oven," such as are arranged in the hospitals of our large cities, and which may be used by the public. The separate ar- ticles must be freely spread out, as the penetrating power of dry heat is feeble. A temperature of 230° to 284° F. and an exposure of three hours are neces- sary. This heat is injurious to woollen fabrics. Steam under pressure in specially constructed apparatus is employed for the same purpose in institutions. Finally, ON FEVER-NURSING IN GENERAL. 21 we must not forget the purifying effect of fire. Arti- cles not readily disinfected by ordinary measures can be destroyed by burning. Disinfection of the Person.—The hands of those who nurse persons sick of infectious diseases should be occasionally washed in a solution of corrosive subli- mate, 1 : 2000; or of carbolic acid, 1 : 50; or of Labar- raque's solution, 1 : 10. This should invariably be done before taking food. If a solution of corrosive sublimate be employed, the hands must be afterwards rinsed with fresh water running from the spigot or sterilized by recent boiling as a safeguard against mer- curial poisoning. The above solutions are to be employed for washing instruments and utensils that are exposed in the sick- room, except those used for eating and drinking purposes, which should be washed in very hot water, and may, if necessary, be also rinsed with alcohol. Carbolic Acid.—Phenol is a useful disinfectant. It occurs in commerce as a whitish crystalline mass which gradually acquires a red color and upon exposure to air undergoes liquefaction. It has a peculiar, penetrating odor, a burning taste and is a corrosive poison. It is soluble in water at ordinary temperature (1 to 15 parts) and is used 2 to 5 per cent, solutions. Except in strong solutions and upon prolonged exposure it does not destroy spores and is therefore not available for disinfection in cases of tetanus, anthrax, malignant edema and other infections caused by spore-producing bacteria. 32 FEVER-NURSING. The advantages of carbolic acid as a disinfectant are effectiveness in destroying bacteria which do not contain spores; the very slight formation of insoluble enveloping coverings in albuminous substances; the absence of destructive action upon metals, fabrics, colors and wood in ordinary solutions (2 to 5 per cent.) and the ease with which it can be obtained. Among its disadvantages are. failure to destroy the spores of certain disease-producing bacteria, its intensity as a poison and its relatively high cost. The Cresols. These substances are closely related to carbolic acid chemically and like it are derived from coal tar. They enter into the so-called crude carbolic acid of commerce and contribute largely to its dis- infecting power. They are not readily soluble in cold water and should be dissolved in hot water and a com- plete solution made before using. The following com- mercial preparations of cresols are available and effi- cient in the strengths recommended in the directions which accompany the vials in which they are dis- pensed ; tricresol, compound solution of cresol, creolin, lysol, saprol, solveol and solutol. The advantages of this group of disinfectants con- sist in their greater cheapness than carbolic acid, a 2 per cent, solution of cresol being as effective as a 5 per cent, solution of carbolic acid; their efficiency being not diminished in the presence of albuminous sub- stances ; their harmlessness to metals, fabrics and colors in ordinary solutions (2 per cent.) and their destructive action upon the spore-bearing bacteria such as those of anthrax and tetanus. ON FEVER-NURSING IN GENERAL. 33 Their chief disadvantage is a lower degree of sol- ubility in water and the consequent danger of a solu- tion weaker than required unless great care is taken to see that complete solution is effected. For bathing the patient's body weaker solutions must be employed,—corrosive sublimate, 1 : 5000; car- bolic acid, 1 :250 ; Labarraque's solution, 1:30. As a rule, however, pure water or water with alcohol added in the proportion of one to five or six is prefer- able for this purpose. The bodies of the dead should be wrapped in a sheet wet with a strong disinfectant solution,—corrosive sublimate, 1: 500; carbolic acid, 1:20; or of chloride of lime, 1: 25. Disinfection of the Stools.—Lime is a very valuable disinfectant for the discharges from the bowels, espe- cially in privies. In one or another of the following forms it must be thoroughly mixed with the mass: Quicklime is a very caustic substance highly de- structive to organic matter and especially to the germs of disease. Slaked lime (calcium hydrate) may be made by the addition of one pint of water to two pints of lime. This preparation must always be prepared immediately before use. Whitewash is prepared by the addition of an excess of water to slaked lime. It is used for brightening the walls of cellars and outhouses and the destruction of moulds and disease germs which are lodged upon such surfaces. Milk of lime consists of freshly slaked lime incor- porated with about four times its bulk of water and 3 34 FE VER-NURSING. is of the consistency of cream. It must be freshly prepared and shaken in the vessel before using. Unslacked lime has been used from early times as a disinfectant for the bodies of those dead of virulent infectious diseases. Chlorinated lime (chloride of lime; bleaching pow- der) when freshly prepared has about the same value as a germicide and disinfectant as unslaked lime. The preparations of lime have the advantages of be- ing efficient and cheap; the disadvantages of being very uncertain in disinfecting power, rapid deteriora- tion upon keeping and exposure to the air and destruc- tiveness to metals and fabrics. Dissolve chloride of lime in water in the proportion of six ounces to the gallon; use one quart of this solu- tion for the disinfection of each liquid stool in typhoid fever or cholera. Jf the discharge be very copious it is advisable to use even a larger amount. For the dis- infection of solid fecal matter the above solution should be of double the strength. The matter to be disinfected must be exposed to the action of the solution for four hours, and solid masses are to be broken up by agita- tion of the vessel. Solutions of carbolic acid, 1: 20; or of sulphate of copper, 1:25; or freshly slaked quicklime, may also be used for this purpose. Corrosive sublimate is not available for the disinfec- tion of fecal matter because of its combining with al- buminous substances and forming an inert, insoluble covering to the masses which may subsequently undergo disintegretion and liberate active pathogenic organisms. Formalin may be used for the disinfection of fecal ON FEVER-NURSING IN GENERAL. 35 discharges in one-to-three-per-cent. solution in water, a sufficient quantity of the dilute mixture being poured over the stool and allowed to stand one hour. Disinfection of the Urine.—Drop one of the cor- rosive sublimate tablets, mentioned on page 24, into the urine and allow it to stand an hour before emptying; or add one-fourth the volume of a mercuric-chloride solution 1:500. This solution must, for safety against accidental poisoning, be colored by the addition of potassium permanganate and conspicuously labelled. Disinfection of Bed-pans, Urinals, etc.—Place the utensil, after it has been carefully washed, in a bath of corrosive sublimate solution, 1:1000, and allow it to stand until again required for use. It must then be rinsed in warm water. It may be placed in an especially made sterilizer, and subjected to boiling for half an hour. Disinfection of Water-Closets, Privy-Vaults, etc.— No stool from a case of typhoid fever, cholera, or dysentery should be thrown into a closet without having been previously disinfected as above. Great care must be taken to prevent the contact of the discharges with the woodwork of the seat. The closet is to be thor- oughly flushed several times a day, and in the intervals of its use a quantity of carbolic acid or chloride of lime solution should be allowed to remain in the hopper. A privy-vault requiring disinfection may be treated with fresh, unslaked lime in dry powder, or milk of lime in liberal quantities slowly poured into the vault. During an epidemic of enteric fever, cholera, or dysen- tery, chloride of lime should be freely sprinkled over the surface of the contents of the vault every day. 36 FE VER-N URSING. Fever patients should, as a rule to which there are few exceptions, receive no visitors until convalescence is fairly established. This is a rule the observance of which is conducive alike to the welfare of the patient and of his friends. On the one hand, visitors excluded from the sick-room escape the risks of contracting the fever and the danger of conveying it, without them- selves contracting it, to others outside. On the other hand, the patient is delivered from disturbance and ex- citement, which, whether it be pleasurable or otherwise, is almost certain to act injuriously upon him, and for which in any case he is in no condition. Visits to persons very sick of a fever, except such as are abso- lutely necessary, are an infringement of the discipline of the sick-room, and ought to be discountenanced by those in authority. Practical regulations for an efficient quarantine of cases -j /. High febrile temperature . . f 102°—104° F., a.m. ~ (Severe pyrexia).....I 104°—-105.8° F., p.m. g a. Intense febrile temperature. . f £ y ,tt ■ s 1 105 8°—110° F. ^ I (Hyperpyrexia)......I The range of deviation from the normal within the limits of which life can be well maintained is comprised between 92° F. and 110° F. A temperature of 95° on the one hand or of 106° F. on the other, already indi- cates great danger, especially if it be prolonged, and beyond these limits in both directions the danger to life speedily becomes extreme. a. Temperature of Collapse, or Shock.—A consider- able and rapid fall of temperature attends the collapse which sometimes occurs during or towards the close of some of the essential fevers. In enteric fever this condition may be produced by hemorrhage from the bowels, or by sudden peritonitis due to perforation of ON FEVER-NURSING IN GENERAL. 47 the wall of the bowel at some point of ulceration, or in consequence of sudden failure of the heart. The last of these accidents is liable to occur in any verv grave case of fever, and occasionally follows the critical fall of temperature which occurs in pneumonia, re- lapsing fever, and more rarely in other febrile diseases. Very low axillary temperatures are met with in the stage of collapse in the algid or cold stage of cholera, the internal temperature as indicated by the vagina or rectum remaining extremely high. Great depression of the general temperature occurs in the collapse pro- duced by various poisons, and especially by large quan- tities of alcohol. The temperature is apt to fall con- siderably below the normal in ordinary deep alcoholic intoxication, especially if the patients have been ex- posed to cold and wet. b. Subnormal Temperature.—This condition attends considerable losses of blood ; starvation from any cause; the wasting of certain of the chronic diseases, such as cancer of various organs; some diseases of the brain and spinal cord and the later stages of chronic diseases of the lungs and heart, especially when attended by dropsy. The temperature is very apt to reach subnormal ranges in the morning for a few days at the termination of febrile disorders. c. Normal Temperature.—If in the course of a con- tinued fever, as enteric, the temperature, which has been elevated two or three degrees or more, suddenly falls to normal or near it, though not below, this in itself is significant of something wrong, and may even 48 FE VER-N URSING. acquire the importance of the "temperature of col- lapse," as indicating internal hemorrhage, perforation, or failure of the heart. d. Subfebrile Temperature.—Slight elevations of tem- perature often accompany trifling and transient dis- turbances of the general health, especially in children. They are also observed at the beginning of gradually developing fevers, as enteric, and at the close of slowly subsiding febrile conditions. In obscure chronic cases they are of importance as indicating the existence of actual disease which may not manifest its ordinary symptoms. e. Moderate Febrile Temperature.—When the morn- ing temperature reaches 101°—102° F. and the evening shows a further increase of one or two degrees, we have to do with actual fever, the nature of which must be investigated by the physician, and which, whether it be symptomatic or essential, calls for treatment. So long, however, as the temperature does not exceed these limits there is no serious dauger from the fever process itself. f. High Febrile Temperature.—When the tempera- ture in the morning is above 102°—104° F. and in the evening reaches or ranges higher than 104.5°, the case becomes serious from the intensity of the fever alone, and active treatment becomes imperative. High fever is unattended by immediate danger to life if it be transient, but when prolonged it is ominous. A tem- perature of 105° or even 107° in the hot stage of an ague, when the whole attack lasts but a few hours, is much less dangerous than the same temperature occur- Fig. 2.—Cerebral hemorrhage. Hyperpyrexia. Pre-agonistic rise of temperature. • DIAGNOSIS Notes of Cost. M E M E M E M E MIE M E M E M E M E M E M E M E M E M E M E M E M E M E M E M E M E c. -42° -41* -40° -36° •38° -37° -36° -35° »<>.'Z?i' ''":: 107° 4= 106° 1 IOS" -t— i i -j— Hr — ~ Z>att of admission,.....................—--Trnlmttt 1 104° 103" 102° r 101° 100° »e° I 8S° * 07° rkiiitj/Dts Pulst. Date. ^ =i= ™ E " 1 - \- 4= H- ■- —j— -j- [ 1 —(- -1— q= -±- - H- - =E - — " ~ " -j— — _J__ -i— ~r y ,■' .••' ,-' .-' y v'hun, il.D. PuUi.i'4 fcv J. B. Lippincott Company, Fh>'uIdPhui. P* Fig. y.—clinical churt. Actual size 28 x 21 cm. ON FEVER-NURSING IN GENERAL. 49 ring, even for a short time, in the course of one of the continued fevers, when the patient's powers of resistance are called upon to withstand some degree of fever for several days or weeks. g. Hyperpyrexia, or Intense Febrile Temperature.— The temperature reaches 105.8° and continues to rise, or at all events does not fall. The condition is one of extreme and imminent danger to life. The resources of the art of medicine are put to their severest test. Hyperpyrexia often supervenes with great suddenness Not a moment is to be lost. The most prompt and radical measures to reduce the temperature of the body too often fail to avert the fatal result. This condition has been encountered after injuries to the brain and to the upper part of the spinal cord; in lockjaw; in sunstroke, and very often in the infectious diseases, especially scarlet fever and pneumonia. It sometimes occurs in rheumatic fever, especially after the intensity of the symptoms has begun to subside, or even when the patient is apparently almost well. Hyperpyrexia is often one of the indications of approaching death. Hence, in certain cases the futility of treatment. In such cases a temperature of 110° to 112° is sometimes seen. The temperature sometimes continues to slowly rise for an hour or two after death. The thermometer may be made to indicate a tempera- ture much higher than that of the patient's body, by friction, or by being slipped against a poultice, or hot- water bag, or into a cup of tea, when the attention of the nurse is given to other duties. Very high read- ings of the thermometer may be caused by envelop- ing the bulb in the folds of a handkerchief or napkin 4 50 FEVER-NURSING. and placing it in the mouth for a few minutes. These tricks are sometimes played by hysterical girls. They are readily detected by repeated observations under the eye of the attendant. A number of cases have been recorded in the medical journals in which excessively high temperatures—120°, 150°, even 170° F.—have been noted and apparently verified by repeated and most careful observations. Many of the patients have subsequently been found to be very clever pretenders and tricksters, but the method by which the high temperatures have been recorded has not been explained. In such cases the temperature should be taken in several different regions, axilla, mouth, rectum, etc., at the same time, and the tempera- ture of the urine when voided. The temperature of a fever patient may be some- what affected by excitement, fatigue, or exposure. Hence hospital patients often show for a few hours after admission a temperature higher than subsequently, or, if they have been exposed to cold, lower than really corresponds to their condition. It is a peculiarity of the state of convalescence from the acute fevers that the temperature, though normal, is disturbed by trifling causes, and may be made to rise two or three degrees by the first visit of a friend, the first solid food, or even by sitting up. Such rises are usually very brief, the temperature quickly falling again to normal. They occasion uneasiness lest they be the beginning of a relapse. On the other hand it occasionally happens that, though all the other symp- toms have disappeared and the patient is almost well, the temperature remains subfebrile, and the patient is ON FEVER-NURSING IN GENERAL. 51 for that reason alone kept in bed—the so-called " Bed Fever." In many such cases I have seen all traces of fever vanish upon cautiously allowing the patient to sit up an hour or so each day. The temperature must be recorded at once. At the same time a record of the pulse-beats and movements of respiration per minute is to be made. They are to be carefully counted while the thermometer is in position. Ruled sheets, called " Temperature Charts," or "Clini- cal Charts," are sold in the shops for this purpose. The form here shown will be found very convenient.1 It may be so kept with little trouble as to preserve in a compact form all the important facts of an acute case, and is equally useful in hospital and in private prac- tice. Reference to the charts further on in this book, which are records of actual cases, will show the reader how simple the process of case-recording may be made. The space on the left is arranged for the number of the case, for instance, in a series; the diagnosis, with the opportunity of revising it, if necessary; the name of the patient; his sex, the letter M or F being, as the case may be, crossed by a stroke of the pen; his age and social state, whether single S, married M, or widowed W, the two letters not needed being crossed by the pen ; his nativity ; his occupation ; his residence, post-office address, in case it should be desirable to trace his subsequent medical history; the date of his coming under observation ; the diet in a general way, 1 J. C. Wilson's Clinical Charts. Published by J. B. Lippin- cott Company, Philadelphia. I 52 FEVER-NURSING. space being left for general changes, which may be dated; the treatment, with an allowance of space for the same purpose, and finally, the result, " Recovery," with date of leaving the hospital, or last visit, or " Death," with the date. The ruled space is arranged for twenty-one days by vertical lines, the weeks being divided by heavy lines. The space for each day is again subdivided for the morning and evening record, as indicated by th6 M and E. At the left margin the purposes of the spaces formed by the transverse rulings are indicated. At the top the number of movements of the bowels; imme- diately below the quantity of urine passed, which may be recorded in fluidounces or cubic centimetres; then the scale of Fahrenheit, with the equivalent Centigrade opposite on the right margin. The coarse horizontal line at 98.4° F. indicates approximately the normal. At the bottom are, first, spaces for each day of the disease, then similar spaces divided by a diagonal line for morning (upper, left triangle) and for the evening (lower, right) pulse rate ;.below these again correspond- ing spaces for the respiration-rate, and at the bottom of the chart spaces for the date or day of the month. Important clinical facts, as " hemorrhage," " convul- sions," " suppression of urine," etc., may be noted at the time of their occurrence between the vertical lines on the right or upper side of the chart in the position indicated by the arrows, under the words "Clinical Memoranda." While changes in treatment, and in particular such temporary changes as are made neces- sary by accidents, like hemorrhage, convulsions, or ON FEVER-NURSING IN GENERAL. 53 suppression of urine, may be noted at the left or lower side under the words " Details of Treatment," as shown by the arrows. The previous history and the condition of the patient when first seen may be written on the back of the chart. The spaces corresponding to a degree of the Fahren- heit scale are divided into fifths. The temperature, as observed, is designated by a dot in the appropriate position. These dots joined by ruled lines form a zigzag line, called the temperature curve. It is usual to form the general curve of the case by means of the regular morning and evening temperatures, and to in- dicate the result of observations made at other hours by dots in the appropriate positions, with figures and letters showing the hour at which they were made; thus, 12 noon, 3 p.m., or 6 a.m. It is now customary to join the general curve or range by lines drawn with black ink; the hourly or three-hour observations by lines drawn with red ink. If the fever be prolonged beyond three weeks two or more charts may be pasted together. These charts thus kept are not only of value for preservation. They are also of immediate use as showing at a glance and with precision the facts of the case at every period from its coming under observa- tion, the course it is running by a comparison of the symptoms day by day, and in a general way the effects of treatment, the changes of which are fully presented. Those only who have used them can understand their value. 54 FEVER-NURSING. Especially are they valuable in fevers in enabling us to watch the course of the temperature, which is an important part of the natural history of the disease and conforms in most of the acute infections to a type not only in its daily fluctations but also in its duration. The attack of fever may begin suddenly, as in pneu- monia, in which the temperature often rises rapidly and continuously to 104° F., or more. Such diseases frequently begin with a more or less violent rigor or chill. Or the access of fever may be gradual, as in typhoid fever, in which the temperature rises little by little from the normal until the fourth or fifth day, when it attains about the height which, in the absence of complications, will be characteristic of the attack, 103°—105° F. The fever having attained its height, remissions or falls of temperature follow. If these be not more than one or two degrees in extent, conforming to the diurnal variation in health, but at a higher range, the temperature is said to be continuous, or, more properly, subcontinuous, and the fever is a Continued Fever; if, however, the decline is greater than in health, the re- missions being marked as compared with the rises or exacerbations, the fever is said to be of Remittent Type; and, thirdly, when the remissions reach the normal or fall below it, we speak of the fever as being of the Intermittent Type. Remittent and Intermittent Fevers are grouped with the Periodical Fevers. When acute they are usually of malarial origin. The symptomatic fever which accompanies chronic inflammatory diseases, especially t g Details a/iTtatment hib5<« - — -5S«-*5. 1 O , & .=:---------- S ' : 2 ir *» T -=--------------" *'~~3' m rT <.'"' Z :±:::::;:::::::::::::::::::::: rn r* ± *: S "±::"_:::»:::::::.::.:_____ m tf «•'.'« 5 i "i~ m 1 < ) o o o 0 4 o o e • u ■<■ *■ ^P © 5 TS •» • • v • Yiq. 4.—Intermittent malarial fever, quotidian type; double tertian infection.. Man, aged twenty-nine. ._ J? *«lail» of Treatment b h> 7 5 - m -° 2 S- *. .OilO O O O p Clinical Memoranda o 5,5 o i o f. CI o o o+o o + 3 P \ s m \ £ n \ S m \ \ S m \ \ S m s m \ \ S 4= - m I ( \ < J i o .» *• *P Fis. 5.—Temperature of inverse type. memTme" ■TmemIemEuJemJeEem 'u"u'MEMEUCUEUEU[lEMpMEMtM(UEUfVEu"k r.------- ----T 1 11- -iiii---i------i-------: ------±------------a*. ri!!!!l! J'^EEEEEEE EEEEEEEzEEEEEEEEEEEEEEEEEEE ■*•• *—1111111 103* :::-::; 1|^|P|J|=||||||e|||||||||||1|||||| EEEEEE: EEEEEEEEEEE: EEEEEEEE ■*** EEEEEE: EEzJe^ESE^EE EEEEEEEE «•• I00. EJ^zEE: EEEEEEjSEEEEEEEzEz:S=EJEEEE *» •»* T~------ 2EcaErEEEEEEEEEEEE:EEEES;ZE ^^ 1 -t-=F- z = zzz±3zzizzzzzzE izb z£z-;E5z5 ---±-t I.:::::::::::::;;::;:::::*: * -E^EJEEEE EEEEEE: EEEE±EEEEE: EEEEEEEE eii ----Egmiaq 44- -j- 1 'rHn'M^TTTIJ J 1 1 H .1 1 1 1 111 1 1 1 1 ,----------------------LUiEilEL ^^ v j- t 7 r f /o / / /j /i /✓ /j- /* // /t /r " */ si iij^j/.dn/i f 1. J/ 32 aj ^C jr « j/j| jf K. v/ x X -■' ■■' / X X' ' X .--' X .' X XX .' •' -^ x . .•• x X - X X •■• •'* x x -•■' .•* - ' •* X X' x' x x' ■■' /' x x" x * -" X X ,x x X x' x X ■' ^^ .•-' X x 1'^ x - .' x x "> l«' JW*. _ -- - 1 Fig. 6.—Temperature curve in enteric fever, with recrudescence and relapse. § Details of Treatment Clinical Memoranda 11 1 1' j 5 i 8 8 8 2 8 8 I j a 8 J §_?» 3* 3 ■ £ "s ~ "if — " m S m S m 1 S jl m | .J. £ | ^ " 1 m £ p i (J U J •» * 4 Fig. 7.—Fever of irregular periodicity j? .Details of Treatment ^ 3 g- f ^ |-j jo o o - CWnt'calJtfemorando j o o Si© ° 9 ^ ?2 " to JJlci •? i "J ' s* \J 5* x~- <: ot - - ------- ------ ";~=»- m \J § _--" = r^ _"\s m----------------- '-■ p-, =5J4 < ___ °°--------_-----+ ____ 1 r- # ___ «----------------- £ r. ^= -----, ----------------------- 2 „-----±----------- + T n- \ ^ --- ------- g ^—\------::;____ m \ ^, ----, ___ s to---- ______ m \ _J\< > — z: 3 Cu ----. m i 0 A o i> g ^ p " 'i *■ iP 9 V "J M Fig. 8.—Croupous pneumonia in a child three years old. Defervescence by crisis on the evening of the sixth day. l^ y M fc Details of Sfreatmait CUiu£nJ.Adi*wronriti. IIS'Se «C.«0 «3 5 g © O O O © , C> 1 ' f. 1 ^ 1 » <2 o K «» tj ^13 11 I "o k lie \ >« i j 1 s r 1 n \ \ Co 1 i _|_ 1 S 1 ! m \ ■f. _j. 3 ! 1 ■ ~C I 1 m \ *» _!_ . ; 3 -T" ! 1 1 m \ «\ i^. „ 11' 2 1 1 : 1 1 m M i 1 : 1 Jj 3 1 1 1 n \ 1 1 i j 2 UC| 1 I n N> 1 3 1 i m \ ,1 2 J n * 'i 1 S 1 1 i m Fig. 9.—Pneumonia. Early defervescence; interrupted crisis. ON FEVER-NURSING IN GENERAL. 55 those of a tuberculous character, as pulmonary con- sumption, is of well-marked remittent or of intermit- tent type. The daily exacerbations or increase of fever occurs, as a rule to which there are very few exceptions, in the afternoon or evening; the remissions or falls in the morning. In rare cases of general tuberculosis and still less frequently in typhoid fever this order is re- versed, the rise occurring in the morning and the decline in the evening. The fever is then said to be of " Inverse Type." The range of the temperature after it has reached its height is called the Fastigium. The decline of the fever is known as the deferves- cence. It is usually gradual, the remissions between the evening and morning exceeding the evening ex- acerbations until the normal is again established. This form of defervescence constitutes lysis. On the other hand, the decline of the temperature is sometimes abrupt, the temperature falling in the course of a single night or in a few hours from a considerable height to the normal or below it. This is known as a critical defervescence, or crisis. It is very often attended by some critical discharge, as of sweat or diarrhoea, and is sometimes followed by collapse. Marked irregularity of the temperature curve of a fever usually indicates some disturbance or complica- tion. A gradual fall of temperature often precedes death; in some cases of fever, however, the temperature rises as death draws near (preagonistic rise), and it may 56 FEVER-NURSING. even continue to rise for a short time after dissolution has taken place. A transient rise in temperature after defervescence has taken place is called recrudescence; a recurrence of fever with the other symptoms of the original at- tack, lasting several days or weeks, constitutes a relapse. Kecrudescences are due to accidental causes; relapses to reinfection: the former are usually of trifling importance; the latter always serious, some- times fatal. In order to at once detect these occasional recurrences of fever the temperature ought to be system- atically taken for at least a week after it has fallen to the normal range. Instances of two or more relapses—multiple relapse —are of occasional occurrence. That form of relapse which begins before the defervescence from the primary attack is completed is known as intercurrent relapse. The reinfection which causes relapse may be from out- side the patient's body or from within. In both cases the infecting germ becomes active before immunity is established. II. FEVER-NURSING IN GENERAL—Continued. Essential Fevers Infectious Diseases—Classification of Fevers: I. Continued, II. Periodical, III. Eruptive, IV. Fevers with marked Local Manifestations—All Fevers Really Sympto- matic;—Causation of Symptoms—Symptoms Common to the Fevers—The Nervous System—Organs of Special Sense— The Digestive System—The Circulatory System—Blood- Pressure Estimation—The Respiratory System—The Skin— The Urine—Different Plans of Treatment: I. The Sympto- matic, II. The Expectant, III. The Rational, IV. The Specific. The Essential Fevers are acute general infectious diseases. The original cause or infecting principle of most, if not all, of them is a specific minute organism or germ, different in character in the different fevers. That such a germ is the cause of most of the fevers has been demonstrated, and it may be assumed to be the case in regard to the others. Upon no other theory is our accumulated knowledge concerning the fevers to be explained. These germs, which are de- rived either directly or indirectly from a previous case of the same kind of fever in the continued and erup- tive fevers, and from a previous case by means of a variety of the mosquito called Anopheles, which by its bite transfers the specific blood parasites in the malarial fevers, and from a previous case in yellow fever by the bite of another mosquito, Stegomyia fasciata, find their way either by inhalation, or, as 57 58 FEVER-NURSING. is more probable, along with the food or drink or by the inoculation by insect bites into our bodies. There finding the conditions of warmth, moisture, and nutriment suitable, they undergo rapid and enormous multiplication, invading the tissues of the organism far and wide, and either by their presence directly, or by the action of subtile chemical principles called toxins produced by their presence and growth, they induce wide-spread disturbances of the functions of the body manifested by symptoms which, taken together, consti- tute the disease. These symptoms show themselves in a progressive series, and though differing in different cases, particularly in intensity, obviously conform more or less closely to a common type. Among them, that which is almost invariably present and characteristic is fever. Upon close investigation we are impressed with the large part played by disturbances of the nervous system in the production of the symptoms. Not less striking is the fact that these diseases are self-limited; that is, that they tend to come to an end within a definite time; or that they are self-protective; that is, that a person once having suffered from a particular fever becomes immune, that is to say, is not likely to be attacked by it again. The malarial fevers are neither self-limited nor self-protective. Certain of the fevers, differing in themselves, possess prominent features in common. They are, therefore, arranged together in groups. Thus we have I. The Continued Fevers, characterized by the sub- continuous range of the temperature, as Typhoid or Enteric Fever; ON FEVER-NURSING IN GENERAL. 59 II. The Periodical Fevers, characterized by the completeness and long duration of the remissions or intermissions, as the Agues; III. The Eruptive Fevers, characterized by a well- marked eruption on the skin, as Scarlet Fever, Measles, Small-pox; and IV. Fevers with marked local manifestations, as Rheumatic Fever and Pneumonia. This classification is not scientific. Enteric or typhoid fever is looked upon as the very type of a continued fever. Yet it presents an eruption which though slight is very often seen, and when present is very significant. Typhus, another of the continued fevers, is accompanied by a very marked eruption. Cerebro-spinal fever, which I have classed among the fevers with marked local manifestations, is sometimes grouped with the continued fevers and sometimes with the eruptive fevers, as "spotted fever." The difficulty in classifying the fevers arises from the fact that there is no common principle of division applicable to them all. The classification above given is convenient, and in many respects the best at present available. Certain diseases, as small-pox, measles, and typhus, are wholly contagious; that is, they are only caused by material derived from the bodies of those suffering from them. It is not to be understood that direct contact of person with person is necessary, though this is a very frequent method by which transmission is effected. Transmission takes place by indirect con- tact in a thousand different ways, and the corpses of those dead of such diseases may become a source of contagion to the living. 60 FEVER-NURSING. The articles of clothing and other innumerable sub- stances by which contagion may be conveyed are spoken of as fomites, or carriers of the infecting principle. Other diseases, of which the malarial fevers, yellow fever, and vaccinia or cow-pox are examples, are only inoculable. They are not transmitted from the sick to the well by the ordinary means of contagion, but by the insertion of the virus by the lancet of the operator in vaccination or by the sting of the mos- quito in malaria and yellow fever. A third group of diseases, which includes enteric or typhoid fever, cholera, and dysentery, are neither directly communicable from person to person by ordinary contact on the one hand, nor are they propa- gated by inoculation on the other hand. In these diseases the infecting principle is eliminated from the body by the bowels and urine, retains its power of in- fection, and under favorable circumstances even may undergo an increase for a longer or shorter time outside of the body. To the accidental contami- nation of drinking-water or of food by the evacua- tions of the patient is to be attributed the spread of such diseases, the germs which occasion them having a continued existence, sometimes within the bodies of the victims of the disease, sometimes outside of them, in drains, sewers, cesspools, dung-heaps, and the adja- cent moist soil into which their contents may have leaked, and in wells, cisterns, or even running-streams, accidentally contaminated, as well as in mattresses, bed- clothing, and apparel that have been soiled by the evacuations of the patient and not subsequently sub- jected to effectual disinfection. ON FEVER-NURSING IN GENERAL. 61 For these reasons this group of diseases is sometimes spoken of as " water-borne" diseases. This term is misleading because it falls far short of the truth. They very often are " milk-borne and food-borne" and borne by dirty hands and by " house flies," in and upon which the germs of cholera and of enteric fever have been discovered during recent epidemics of these diseases. The results of modern antiseptic surgery and of anti- septic midwifery show that when foreign matters, and in particular the disease-causing germs which abound in and around our dwellings, can be excluded by strict surgical cleanliness and disinfection, serious wounds and lacerations of the tissues heal with- out fever. The so-called surgical or septic fevers which otherwise occur are symptomatic fevers. But we have seen that the fevers spoken of as essential are made up of the symptoms produced by the presence and working of certain germs. As a matter of fact, the division of fever into essential and symptomatic is an artificial one, the distinction between them from the stand-point of causation being rather apparent than real. The attendant upon the sick, who understands the nature of contagion and the mode of communication of the different diseases, will not regard the details by which the spread of such diseases is prevented as irk- some, nor discharge her duties in this respect in a half- hearted and time-serving manner. On the contrary, these will be among the most satisfactory of her labors, and their thorough performance will find its reward in the knowledge that in it lies the prevention of untold 62 FEVER-NURSING. suffering and sorrow. The importance of effectual isolation and disinfection in cases of those infectious diseases in which the infecting principle is developed only in the bodies of the sick and communicated by direct or indirect contagion, becomes evident when we reflect that in theory it would be possible by the uni- versal application of these measures to utterly " stamp out" such scourges to the human race as small-pox, scarlet fever, and enteric fever. The art of prevent- ing diseases is not only more certain in its working, but it is also vastly more beneficent in its results than the art of curing diseases. Whether or not prevent- ive medicine will ever in its practical workings realize the theoretical possibility of wholly stamping out any contagious disease, remains for the future of our civili- zation to show.' When such a possibility is universally understood, and when it is regarded as an attainable goal towards which public and private efforts are to be steadfastly directed, then and not till then will its realization be near. The symptoms of a fever are not all due to the direct action of the infecting principle upon the organ- ism. Certain, perhaps many, of them are the result of the febrile process itself. Others are the result of derangement of the nutritive processes, caused in part by the infective matters, in part by the fever. Yet others are caused by the absorption of disordered and decomposing secretions, which produce a secondary in- fection or blood-poisoning quite different from that proper to the original cause of the disease, but serious in itself and often sufficient, in the already enfeebled state of the patient, to turn the scale and bring about ON FEVER-NURSING IN GENERAL. 63 the fatal result. Thus, for example, the sore throat, the chill, and vomiting at the beginning, and the sudden rise in temperature in scarlet fever are due to the direct ac- tion of the germs or infecting principle of the disease, or the poisons—toxins—which they produce; the pallor, which is so striking after the rash has faded, the rapid loss of flesh, and extreme weakness are due to the de- rangement of the functions of the body by which its nourishment is carried on, and are, in fact, the result of the action of the infecting principle on the blood and tissues, and in part the result of the derangement by the fever of the glandular apparatus by which the fluids necessary to digestion are secreted. Finally, in certain cases of scarlet fever there is retention, then decompo- sition, of the morbid secretions of the throat and nose, and, as a consequence, secondary blood-poisoning, or sep- ticaemia, with prolongation of the fever, the formation of abscesses, and still greater wasting and prostration. It is not always possible for us to say what symptoms are due to one, what to another, of these causes, but it is the duty of the physician to investigate each symp- tom closely, and to diligently seek out the cause of every unusual or excessive symptom. It is the part of the nurse to observe and report to the physican at his visits changes in the symptoms of the case and the recurrence of new symptoms. Habits of close observa- tion and a little experience will enable her to recognize the symptoms which are characteristic of the disease and those which are unusual, and to distinguish between those which are important and those which are trivial. The following are among the symptoms of the fevers 64 FEVER-NURSING. which are important. They are arranged in groups which refer to the physiological systems, as the nervous system, digestive system, and so on, but it is not to be forgotten that these bodies of ours are marvellously complex organizations, and that arrangements of topics and divisions of subjects that are convenient for de- scription and the purposes of teaching are largely arti- ficial. At the bedside, it is not always possible to tell at once what system or organ is at fault in caus- ing a given symptom. For example, vomiting may be either caused by a fault in diet or by medicine or by some condition of the stomach itself, or it may be the result of disease of the brain or of the kidneys, or indeed of other organs; or retention of urine may be caused by spasm of the neck of the bladder or by paralysis of its walls, or simply by such a dulness of the whole nervous system that it fails to appreciate the ordinary sensation of a full bladder and to act upon the suggestion. The fever itself has already been sufficiently con- sidered. THE NERVOUS SYSTEM. Headache is one of the earlier and more constant symptoms of fever. It is most severe in the early days of the attack, and often abates or disappears en- tirely upon the advent of delirium. The seat of the pain is usually in the forehead and temples; sometimes it is general; less frequently it is most severe in the back of the head. The character of the pain is described by patients as being dull, heavy, binding, throbbing, or ' ON FEVER-NURSING IN GENERAL. 65 bursting. It varies in degree from slight heaviness or dulness to an indescribable agony. Vertigo, or Giddiness, is very often associated with headache in the early days of fever. It is aggravated by sitting up. Giddiness may also occur in attempting to sit up at the close of an attack. It is then due to weakness and anaemia. Pains in the Back and Limbs are present in the early days of many fevers. They are sometimes very severe, and are likened to the soreness of bruises or to cramps. They sometimes recur during convales- cence. Chills, or Rigors, are common at the onset. They are accompanied by a rise of internal temperature and marked, often distressing, coldness of the surface and extremities; by sensations resembling streams of cold water running down the back, by shivering, chattering of the teeth, pallor of the countenance, bluencss of the lips and finger-tips, and feelings of distress. A chill may occur during the course of a fever in consequence of some sudden change or complication. It is an important, sometimes a serious symptom, and should at once be reported to the physician. Impairment of the Mental Faculties is a usual accom- paniment of the fevers. It varies in intensity from mere indifference or dulness to maniacal delirium or stupor from which the patient cannot be aroused. The nature of the mental disturbance is much influenced by the habits and character of the patients. Persons of refinement and cultivation, brain-workers, those who have been subjected to mental anxiety or fatigue, and 5 66 FEVER-NURSING. the intemperate are especially liable to early and severe mental disturbances. The character of the fever and the severity of the attack also exert an influence in determining the severity of this group of symptoms. Other things being the same, the severity of the men- tal disturbance is a measure of the gravity of the sickness. Mental impairment is sometimes rapidly de- veloped : as a rule, however, it comes on slowly, and reaches its height at the height of the attack. Delirium is among the more frequent of the mental symptoms. It is sometimes among the first manifesta- tions of an attack of fever, and it has happened that patients ill of fever have, from the early appearance of delirium, been supposed to be insane. More commonly it is developed in the course of the disease, and in the low fevers, as typhus and enteric, delirium comes on at the end of the first or the beginning of the second week. The general derangement of consciousness, with incohe- rence of thought and action, which constitutes delirium, is manifested in many ways. Three forms are in general described : a. Low, Muttering, or Wandering Delirium. The patient lies motionless, or simply moves his hands or fingers, fumbling at the bedclothes, taking little or no notice of the objects around him, and muttering or mumbling in a low voice, for the most part unintelligi- bly and always incoherently. He is not difficult of restraint, but is liable to start up suddenly or even to leave his bed in obedience to a momentary influence. It is not to be forgotten by the nurse that occasionally violent maniacal delirium is suddenly developed in the midst of this form. b. Wild or Raving Delirium. The ON FEVER-NURSING IN GENERAL. 67 patient is maniacal. His utterances are noisy and in- coherent ; his actions violent and fantastic; both are determined, not by external impressions, but by the fleeting and purposeless phantasies of a disordered brain. Yet both speech and action may for a moment be made subservient to a clear design, as when in the delirium of fever the attendant has been asked to go out of the room on some plausible pretext, and the patient has in her absence jumped headlong from the window or cut his throat with a razor. The patient is often violent in demeanor and restrained with difficulty, c. Delirium Tremens. This form is encountered in alcoholism. It is also seen in fevers which have attacked persons ad- dicted to alcoholic excesses, but it may occur in fever patients who have led temperate or even abstemious lives. The patient is restless and agitated; the hands, arms, and lips tremble incessantly, a symptom which is increased by movement; hallucinations of sight and hearing of a terrifying and loathsome character occur ; and the whispered, muttered, and often startled ravings betray the fears and terrors by which the patient is possessed. It is very rare that in this form of delirium the phantasies of the patient assume, even momentarily, a pleasing or agreeable shape. When delirium first appears it is transient, occurring at intervals during the night, or it may last throughout the night, ceasing in the morning, to return again at night. Persons quite rational during the day are often very delirious at night. In the course of a day or so the delirium becomes continuous, but as a rule it is worse at night; or the patient may be wakeful and 68 FE VER-N URSING. delirious at night, stupid and drowsy during the day. Active delirium may pass into stupor, or into the low muttering form, and it gradually passes away as the patient's general condition improves. Somnolence.—The patient lies upon his back with the eyes closed, quiet and motionless; if spoken to, he opens his eyes, sometimes utters a laconic reply, more fre- quently none at all, and quickly relapses into his former lethargy. This condition is usually preceded by and alternates with delirium. Stupor is the term applied to the state of uncon- sciousness from which the patient may be aroused, but with difficulty. Coma.—A condition of profound insensibility. In fever cases coma may be followed by death in some hours or days. Patients, however, occasionally re- cover after having been for several days in a condition of insensibility from which it is impossible to rouse them. Coma-Vigil.—A peculiar condition, in which the patient lies with his eyes wide open, gazing at nothing; his mouth partly open, his face pale and expression- less. He is evidently awake, but absolutely insensible to all that is going on about him. At the same time there are all the evidences of profound depression of all the forces of life. This condition almost always ends in death. Prostration.—Loss of strength is a prominent symp- tom in the fevers. It is often early shown, almost always as the fever passes off. The patients suffer from sensations of feebleness and lassitude. The mus- ON FEVER-NURSING IN GENERAL. 69 cular weakness may be masked by the activity of de- lirium. It is a sign of this weakness that the patient lies motionless upon the back with the hands crossed over his body and the head sunk into the pillow, and that the whole body gravitates towards the foot of the bed. Tremor.—Trembling of the hands and tongue is often observed in the low fevers. This symptom always indi- cates great prostration. It is apt to occur in aged or previously infirm persons and in those habitually given to the abuse of spirits. Other movements that occur in conditions of great depression and are of grave import are spasmodic twitchings of the muscles, picking and fumbling at the bed-clothes, and obstinate hiccough. The twitchings affect especially the face and wrists, and are called subsultus tendinum; the fumbling or corphologia— literally the picking of chaff—is sometimes associated with curious grasping motions at the empty air, and the hiccough, which is produced by spasmodic move- ments of the diaphragm, or midriff, may continue, despite treatment, for hours or days. Convulsions.—General convulsions may occur during an attack of fever, and are very common at the begin- ning of the eruptive diseases of childhood. In adults they occur late in the course of the disease, and are usually either hysterical or uraemic in character. In very rare instances they are clue to disease or inflam- mation of the brain or its membranes. Uraemic convulsions are associated with failure of the kidneys to perform their functions properly. They are of unfavorable import, and require prompt atten- 70 FEVER-NURSING. tion. Suppression of urine often precedes uraemic con- vulsions. A specimen of urine must be submitted for examination. It may be necessary to procure it by the use of the catheter. THE ORGANS OF SPECIAL SENSE. The Eyes are apt to be bright and moist at first, dull and dry at the edges of the lids later. There is often intolerance of bright light—photophobia. The condition of the pupil varies. Ringing and other Noises in the Ears are common in the early stages of fever, and again in convales- cence. Deafness is not uncommon, especially in enteric fever. Inflammation of the middle ear is a frequent complication in the fevers of childhood. In such cases there is apt to be a discharge from the affected ear, at first of a watery fluid tinged or not with blood, as the case may be; later of pus. If neglected, these dis- charges soon become offensive. They are attended with the danger of the development of mastoid disease. Bleeding of the Nose occurs in enteric fever with great frequency. It may occur spontaneously or it may be. brought on by the patient picking his nose. It is sometimes copious, oftener scanty. It occurs also with more or less frequency in other fevers. The Sense of Taste is almost always perverted in fevers, sometimes it is for a time wholly lost. Nearly everything tastes bad. Sweets are especially unpleas- ant, acids are preferred; cold water is always relished. THE DIGESTIVE SYSTEM. The Tongue.—This organ denotes the disturbance of the organs of digestion. It is at first coated with a ON FEVER-NURSING IN GENERAL. 71 whitish or yellowish, sometimes pasty, fur or it may be of a brighter red than normal. Afterwards it usually grows dry, and may become hard and leathery. It is sometimes in severe cases contracted into a ball and cannot be protruded. It is then usually covered with a dry, dark-brown or black cracked crust. With conva- lescence the tongue becomes clean and moist at the tip and edges, and gradually cleans off. Sordes.—Collections of brown or black material, con- sisting of accumulated debris from the epithelial layer of the mucous membrane of the mouth, darkened by drying or by admixture with blood which oozes from the edges of the gums, form upon the teeth and lips at the height of severe cases of fever. Thirst is constant and often extreme. Loss of Appetite is one of the earliest and constant symptoms of fever, and usually lasts till the disease takes a favorable turn. A demand for food may gen- erally be regarded as a favorable sign, although no improvement may yet have taken place in the other symptoms. Nausea and Vomiting are not common in the fevers. Scarlatina often begins with vomiting in the night. Persistent vomiting is an unfavorable sign. It may occur in enteric fever as a symptom of peritonitis, and is frequently associated with complications involving the kidneys. Tympanites.—Distention of the abdomen is common in enteric fever and in grave cases of pneumonia. Constipation is the rule in fevers; diarrhoea the ex- ception. In enteric fever and measles, diarrhoea is a common symptom. 72 FEVER-NURSING. THE CIRCULATORY SYSTEM. The Pulse varies in frequency and force. It may be in enteric fever even slower than in health. As a rule, it is much more rapid, varying from 100 to 120 in the adult, and running up to 180 in children. Its frequency increases with the severity of the general symptoms. A pulse exceeding 120 in the adult is an indication that the case is severe. A gradual fall in frequency is a favorable sign. The pulse sometimes, like the temperature, falls below the norm in early convalescence. A decided increase in frequency after a fall denotes the advent of some com- plication. The pulse is much accelerated by movement, and especially upon the patient first resuming the up- right or sitting posture. In taking the pulse-frequency, therefore, it is important that the patient be in the recumbent posture and have for some time lain quiet. The pulse is in some fevers full and bounding in the early days of the attack; in others soft and compres- sible from the beginning. Later in the course it is usually soft in all. In the second week of typhus it is often undulatory or irregular in force or actually in- termits—arrhythmia. Both very rapid pulse and very slow pulse occasionally occur after severe febrile ill- nesses in nervous persons. Blood-Pressure Estimation.—This procedure be- comes necessary in certain cases of the acute infectious febrile diseases. The instrument used is called the sphygmomanometer—measurer of the pulse. There are many varieties constructed upon two essentially different principles. As observations at fixed inter- ON FEVER-NURSING IN GENERAL. 73 vals may be required, the nurse should have a knowledge of the mode of application and the readings. In enteric fever hypotension or low systolic pressure occurs with great constancy—120 to 100 or below. A gradually progressive fall indicates increasing failure of vaso- motor tonus; a sudden fall actual collapse or hemor- rhage. A sharp rise of pressure attends the occurrence of perforation. In the peritonitis that follows, the pres- sure falls and as death approaches hypotension be- comes extreme. In pneumonia subnormal pressures are common; in severe cases they are the rule. A rapid fall may precede collapse or the fatal issue. When arterial pressure expressed in millimetres of mercury does not fall below the pulse-rate expressed in beats per minute, the fact may be taken as of excel- lent augury, while the converse is equally true (Gibson). THE RESPIRATORY SYSTEM. The Respiration is often hurried, especially in com- plications which implicate the lungs. Cough is usually present in cases complicated by bronchitis or congestion of the lungs. In severe cases of the low fevers grave pulmonary disease may develop without the occurrence of special symptoms. THE CUTANEOUS SYSTEM. The Skin is, as a rule, hot and dry; in rheumatic fever, it is often bathed more or less copiously in perspiration. 74 FE VER-N URSING. General Hyperemia of the Skin.—There is often in the fevers, and especially in children and others whose skin is naturally soft and actively supplied with blood, a general redness or flushing of the surface, quite in- dependent of any rash or eruption. This redness, which disappears on pressure with the finger, leaving a white streak, which remains for some minutes, usually shows itself early in the attack, and lasts but a short time. A similar redness often precedes the appearance of the rash in the eruptive diseases. Sudamina.—Little clear water blisters, resembling minute pearls, often crop out in great numbers over the surface of the body, and particularly over the belly, in the sweating stage of the fevers. They are unattended by inflammation and have no significance whatever. Desquamation, or Peeling.—The outer layer of the skin is apt to scale off in minute particles or shreds after the fevers, especially after those attended by eruptions. This process is very complete after scarlet fever. The various eruptions will be described in the proper place in connection with the descriptions of the dif- ferent fevers. THE URINARY SYSTEM. The Urine in fever undergoes important changes. The Quantity varies with the amount of fluid taken into the body and the quantity gotten rid of by way of other channels, such as liquid discharges from the bowels and perspiration. During the first week of the continued fevers and ON FEVER-NURSING IN GENERAL. 75 the early days of the fevers of shorter duration, the quantity of urine is usually less than the normal by as much as one-third or one-half, notwithstanding the large quantity of water which the patient takes and the absence of perspiration. The quantity of urine voided is usually increased in the later stages of the attack, but occasionally there is suppression. During con- valescence the quantity is almost always greater than normal. The Color is usually dark during the early stages of the attack, and especially while the amount is small. Later, or whenever the quantity is increased, the color becomes lighter and clearer. The urine in fever, though clear when passed, is apt to deposit on cooling a cloudy sediment, varying from a light dust color to brick-red. This sediment consists of urates, and is one of the re- sults of the excessive waste of the tissues of the body. The urine presents other very important alterations in its physical and chemical properties during fever, which require its systematic examination by the physician. THE TREATMENT OF FEVERS. Although the nurse is in no way concerned in de- termining or arranging the treatment, it may not be without value in rendering her work more intelligible to her to explain the different plans by which the fevers are treated by physicians. No one of these plans is usually strictly adhered to throughout. Modifications may become necessary in any case, and must then be unhesitatingly adopted. But the wise physician has a plan, and although he may not explain it in so many 76 FE VER-NURSING. words to the nurse, it quickly becomes evident from his directions. The better the plan is the more obvious it will always be, and usually the more simple. Notwithstanding the great number of methods and the innumerable drugs employed in the treatment of the fevers, they may all be referred to one or another of five general plans: I. The Symptomatic. II. The Expectant. III. The Rational or Expectant-Symptomatic. IV. Hydrotherapy. V. The specific, including the therapeutic use of se- rums, bacterins, phylacogens, tuberculins, glandular ex- tracts, toxins, cultures, antigens.and other agents of a simi- lar nature, all of which are the outcome of animal experi- mentation and are prepared in biological laboratories. I. The Symptomatic Plan.—In the early days of knowledge of diseases and among those imperfectly in- formed concerning their causes and natural history, the treatment of symptoms is the only reasonable method. If the patient be chilly, to warm him ; if he have fever and thirst, to cool his burning temples and place water to his parched lips is not only humane, but is the one course open to the physician who can no longer place dependence upon supernatural methods. To relieve constipation by purgatives; to control diarrhoea by ap- propriate remedies, and so on throughout the series of symptoms which taken together constitute the fever, is to act in accordance with this plan. But even in the absence of exact knowledge concern- ing the causes and nature of diseases, the symptomatic plan does not work well. To be sure, the control of a ON FEVER-NURSING IN GENERAL. 77 symptom may be absolutely necessary to save life, as when the heat of the body reaches that intensity which of it- self speedily kills, or when hemorrhage threatens to prove fatal, or diarrhoea is reducing the patient's strength beyond the limits where recovery can take place. But the ordinary symptoms are not easily controlled. If checked for a time, they return, or other symptoms assert themselves with renewed violence, and when all is done by this plan, the patient remains as sick as be- fore until the fever runs its course. When this came to be fully understood, a new plan arose. II. The Expectant Plan.—The fevers being self- limited and running a definite course, which is little or not at all modified by treatment directed against symp- toms, and the tendency being to recovery in all uncom- plicated cases in which the patient's strength holds out long enough, it is evident that a proportion of the cases will recover if well nursed, properly fed, and protected from unfavorable influences. This is the expectant or waiting plan. Under this treatment a majority of the cases of all fevers would probably recover, the propor- tion being determined by the virulence of the in lection, the powers of resistance of individual patients, their proneness to complicating diseases of particular organs, the presence or absence of previous chronic diseases, and the efficiency with which the hygiene of the sick- room, the feeding and the nursing in general, may be carried out. But we have already seen that certain symp- toms must be treated at times because they threaten life. Moreover, those who have most closely studied the fevers know that in large numbers of cases a 78 FEVER-NURSING. majority will recover under the expectant plan, a few will die under any plan, and a considerable number that would certainly die under the expectant plan may be saved by the prompt and judicious treatment of symptoms. To adopt the expectant plan in all cases would be simply to fold our hands and let a certain number of patients who might be saved die. Further- more, by the proper treatment of certain symptoms it is in our power not only to occasionally save life, but also to very often mitigate suffering. III. The Rational Plan.—This consists in a combi- nation of the symptomatic and the expectant plans. It is based upon a recognition at once of the value and the defects of both, and is the plan at present in vogue. We know that a fever will run its course. Therefore we take the best possible care of the sick man till his sickness has spent itself. At the same time we are on the alert for unfavorable symptoms. If he is restless, we soothe him ; if the fever runs too high, we cool him off; if his heart flags, we give stimulants; if excessive diarrhoea is present, we seek to check it. But we do not place much reliance upon the mere treatment of symptoms, and we know that in doing so we cannot cure the fever or even shorten its duration. So long as the ordinary symptoms of his fever are of moderate intensity we let them alone. IV. Hydrotherapy.—As fever is the chief symptom, a plan of treatment at first energetically directed against the fever, and really capable of modifying that symp- tom, would appear to have much in its favor. Hence the employment of cold water both internally and ex- ON FEVER-NURSING IN GENERAL. 79 ternally, according to the rules formulated below. But it has been found that the judicious use of water in the treatment of these diseases produced favorable effects other than the temporary reduction of the temperature, and hydrotherapy has now assumed an important place in the management of fever cases. The method of treat- ing enteric fever cases by systematic cold bathing, origi- nally formulated by Ernest Brand, of Stettin, in Ger- many, is now in use in many of the larger hospitals in this and other countries. V. The Specific Plan.—The tendency of modern thought in medicine is to pay increasing hted to the causation of disease. Out of this tendency has grown up the whole subject of Preventive Medicine. From the study of diseases we have gone on to the study of their causes. The medical profession has cast off super- stition. No longer is the anger of the gods, or the possession of demons, or an offended Providence in- voked in explanation of a pestilence. We know that the causes of the fevers, whether oc- curring in single cases scattered among the people,— sporadically, as the doctors say ; or here a few, there a few, throughout a community,—that is, endemically ; or in great numbers at once so as to constitute epidemics,— the causes of fevers are actual substances; and we fur- ther know that in many of the fevers these substances are minute organisms or germs, and this leads us to suspect, with very good reason, that germs of a similar kind produce them all. As these germs multiply enormously in the body of the sick man, each case of fever becomes directly or indirectly a focus or centre of 80 FEVER-NURSING. infection, and the cases thus caused become in their turn centres of infection. In this way the disease spreads. But the germs cast off from the bodies of the sick lose their vitality under unfavorable conditions and become incapable of causing sickness. Among the conditions unfavorable to them are cleanliness, fresh air, and sunshine. They are, as we have seen, at once destroyed by disinfection. By such measures is the spread of disease arrested. It has been thought that what Preventive medicine does outside the body, Cura- tive medicine might do, to some extent at least, after the germs have found their way into the body and commenced to do their evil work there. The disinfect- ants and germicides are poisonous. It is obviously impossible to destroy the germs of disease in the body without causing at the same time the death of the body itself; that is, by our ordinary means of disinfection. But our experience with quinine in the malarial fevers and arsenic in the form of salvarsan in syphilis war- rants the hope that remedies may yet be found that will act in a like specific manner upon other fever- producing organisms inside the body itself. It is quite reasonable to hope that the means may yet be brought to light by which, without risk to the human organism, its fluids may be rendered less favorable to the nurture and growth of particular disease-germs. This is constantly done in regard to small-pox by vaccination. Like results have been worked out in diphtheria, in hydrophobia and the plague. These achievements belong to Preventive Medicine. Curative medicine is seeking the specific means by which the fevers, even when they ON FEVER-NURSING IN GENERAL. 81 cannot be cut short, may be rendered less severe and fatal than at present. Treatment having this end in view is known as the Specific Plan. Its most brilliant results have been accomplished in the use of the blood- serum of animals artificially rendered immune to par- ticular diseases. They are both curative and prevent- ive. The property by which curative serums destroy the organisms which cause disease is spoken of as bactericidal; that by which they counteract the poisons produced by bacteria, as antitoxic. This method is comprehensively known as Serum- therapy. It is directed not against the symp- toms, but against their cause. It does all that is done by the expectant plan; it stands ready to do all that the symptomatic plan can possibly do. It is more rational than the rational plan, because its efforts are directed at causes rather than at effects. Allied methods are Preventive and Curative Vaccinations, which have proven especially valuable in enteric fever, influenza, whooping-cough, pneumonia, rabies, some forms of septic infection, and other febrile and afebrile affections; and Organo-Therapy, which has shown re- markable resultsin diseases arising in consequenceof dis- order of the functions of certain glands which produce an internal secretion, as, for example, the thyroid gland, deficiency of absence of its internal secretion giving rise in the infant to a form of idiocy—cretinism, and in the adult to myxcedema. In this connection we do not for an instant overlook the fact that it is the sick man, not the disease, who is to be treated, and that under no circumstances is actual harm to be done in the hope of doing possible good. 6 III. fever-nursing in general—Concluded. Duties of the Nurse in regard to Various Symptoms—The Pa- tient's Bed, Clothing, Room, Toilet—The Fever—External Antipyretics : Sponging, Compresses, Ice, the Cold Pack, Cold Baths, Cold Affusions, Iced-Water Injections—Nurse Manage- ment of the Nervous Symptoms—Of Symptoms relating to the Organs of Special Sense; to the Digestive Organs—Drinks, Fever Foods, Alcohol — Pulse-Taking—The Respiration — Cough—The Urine. The duties of the nurse in the sick-room now de- mand our attention. The physician determines the general plan of treat- ment and arranges the details. The nurse reports to him the course of the case during the intervals of his visits, especially any changes that may have taken place, and carries out his directions. Their work is mutually interdependent; their responsibility separate and dis- tinct. No amount of skill or experience will warrant the nurse in assuming a responsibility which does not belong to her. The best nurses are among those who recognize most fully the line which separates their duty from that of the doctor. The doctor who protects the nurse in this respect by telling her beforehand what to do in possible emergencies is wise. But the unlooked for happens at every turn. In what follows I speak of things that every nurse must know. It is 82 ON FEVER-NURSING IN GENERAL. 83 knowledge that trenches in no way upon the province of the doctor. How far the nurse may go in interrupt- ing a prescribed plan, or in acting, without previous explicit directions, upon the occurrence of an emergency against which no provision has been made in the doc- tor's instructions, the nurse herself must decide. The welfare of the patient is immeasurably above all other considerations. To know how, without knowing when to do, is a poor kind of blundering knowledge. GENERAL CONSIDERATIONS. The fever patient should lie upon a moderately firm but elastic mattress, which is protected against invol- untary discharges by a strip of oiled-cloth or mackin- tosh and a draw-sheet across the middle. The head should be rather low than high, a single large pillow or bolster being more convenient than two. In severe or prolonged cases a single bed is more desirable than a wide bedstead, and a well-made iron hospital bed bet- ter than any other. The covering should be light and often renewed, except in highly contagious fevers, such as scarlet fever, small-pox, and typhus, when infre- quent changes lessen the danger of disseminating in- fection. The patient may wear his ordinary night- dress, unless he has been accustomed to wear drawers or pajamas, in which case he should have a long night- shirt slit down at the back. This kind of garment should also be provided for children instead of night- drawers. In changing the clothing and bedding, the precau- tion of having the fresh articles well aired and warmed 84 FE VER-NURSING. must be observed, and where the condition of the pa- tient requires it, the night-dress may be slit up in front and secured with tapes, and the bed may be made up one side at a time, and the patient lifted over, as in obstetrical cases. The room should be large, airy, and well lighted. It ought to have little or no furniture in it except that required by the patient and the nurse. Hangings, pictures, and ornaments must, in contagious diseases, be removed. An open fire-place, in which even in warm weather a stick or two may be occasionally burned, promotes ventilation. Much trouble is saved if there be a bath-room and water-closet near at hand. The medicines, writh the cups, spoons, and other utensils of the sick-room, must be neatly arranged in proper and convenient places; the disinfectants' in a place by themselves; everything must be washed and restored to its proper place as soon as possible after having been used. No dirty dishes or soiled vessels of any kind are to be allowed to stand about the sick- room. Ice should be cracked before being brought into the room ; it is best kept in the hollow of a flan- nel, tied over the mouth of a deep bowl or large mug, so that the water drips away as it melts. Convenient jars, with covers, for keeping ice in the sick-room are sold in the shops. Disagreeable odors are gotten rid of by cleanliness, ventilation, and sprays of Labarraque's solution or the formalin lamp. Direct disinfection of the patient's person may be necessary. Cologne-water is only to be used when it is grateful to the patient. It is often ON FEVER-NURSING IN GENERAL. 85 objectionable. All discharges are to be at once disin- fected and removed. The patient's toilet should be made morning and evening. His face and hands are to be washed; his mouth rinsed or washed : the tooth-brush used if he desires it; his hair gently brushed. The long hair of women should be plaited and laid up over the pillow. Severe cases of fever are usually followed by loss of hair. It is often desirable to cut it off during the sickness; occasionally it is necessary to do so. As a rule, the hair lost after an acute sick- ness grows in again. A sponge-bath once a day with tepid water, to which may be added a little alcohol or bay rum, or Labar- raque's solution, is always useful and usually grateful to the patient. The feet should be regularly bathed. If the patient be permitted to rise, the commode should be brought to the side of the bed. Due pre- cautions against taking cold must be taken. Patients weak enough to require support ought to use the bed- pan. Most persons at first object to using this vessel; many declare that it is impossible for them to use it. There are very few who cannot use it if they will. The urinal ought to be regularly used. It saves much wearisome getting up and down. The person and the bed must be kept dry. THE FEVER. In mild cases the fever as a symptom demands very little attention on the part of the nurse. A tempera- ture range not exceeding in the morning 102° F., or 86 FEVER-NURSING. 103.5° F. in the evening, in an acute case, may well take its course. When higher temperatures occur, the fever itself, as a symptom, may call for action. Treat- ment directed against fever is called antipyretic treat- ment; the means employed are called antipyretics. Among them are a number of drugs which possess the property of lowering febrile temperatures with great promptness. WThen drugs are used for this purpose the nurse is usually informed of it beforehand. Her duty is to closely observe and record the effects of the medicine. The temperature should be taken at inter- vals of an hour after the drug is given, or sooner if required. The fall is usually rapid; its extent varies from two or three to several degrees. It is associated with free sweating, and occasionally with a tendency to collapse. The drenching sweat may be dried by slipping the hand wrapped in a towel under the night- dress and thus mopping the surface. Dry towels can be slipped up in the same way and removed when wret. The prostration at times calls for restoratives, such as brandy, ammonia, hot bottles, hot blankets, and fric- tions. After a time the temperature rises again. External antipyretics consist in the use of cold water and ice for the purpose of reducing high temperatures. This mode of treatment is carried out by the attendant in accordance with the orders of the physician, who selects the special application. External antipyretics (measures to reduce fever),— a. Cold Sponging. b. Cold Compresses. c. The Application of Ice. ON FEVER-NURSING IN GENERAL. 87 d. The Cold Pack. e. The Cold or Gradually Cooled Bath. /. Cold Affusion. g. Iced-Water Enemas. a. Cold Sponging.—The water may be of the tem- perature of the room or cooled with ice. A little alco- hol or vinegar may be added to it, or Labarraque's solution. A sponge or wash-cloth may be used, fully charged with water and more or less moderate friction, according to the sensations of the patient. In all use of water great care must be taken to protect the bed. Every part of the body is in turn bared, washed, dried, and again covered. The spongings may be re- peated at intervals of two or three hours. In the hands of a skilful nurse they not only add greatly to the comfort of the patient, but also exert a favorable influence upon the nervous system and circulation of the blood, by causing it to flow more freely in the ves- sels directly under the skin. They lower the temper- ature only slightly, unless the water be very cold and the spongings frequently repeated. b. Cold Compresses.—For this purpose three or four thicknesses of old table linen or towelling, which is sufficiently loose woven to hold a good deal of water, is most useful. The compress is wrung out of water of the required temperature and reapplied as it be- comes warm; or two compresses may be used alter- nately, each being cooled in turn by placing it on a block of ice in a basin or pan at the bedside. Cold compresses are often used for the head, and are com- monly very acceptable to patients. They are without 88 FEVER-NURSING. appreciable effect upon the general temperature. Very large cold compresses extending over the entire thorax and abdomen and frequently renewed exert a decided effect upon the internal fever. The compresses are sometimes allowed to remain continuously in position, a small quantity of cold water being from time to time sprinkled over them to replace that lost by evaporation. The flexible coils of pipe sold in the shops, known as Leiter's coils and made of lead-pipe or rubber, which may be fitted to the head, applied over the heart, or to other regions of the body in such a manner as to re- duce local temperature by means of cold water flowing through them from a reservoir over the bed, exert an analagous but not exactly the same influence as the cold compress. c. The Application of Ice.—Ice may be applied di- rectly to the surface of the body, being rubbed gently over the skin. This is sometimes done in case of in- tense hyperpyrexia. Ice is more commonly applied by means of a bladder or gum ice-bag. It must be cracked into pieces the size of a walnut and introduced into the bag with a little water, the bag being about half or two-thirds full. The air is then squeezed out and the stopper adjusted. If the bag be filled, or air enough left in it to distend it, it will not conform itself to the part to which it is applied. A much more effec- tual method of applying ice to the abdomen or over the heart consists in spreading a thick layer of finely cracked ice between the folds of a coarse towel, which is then placed directly over the skin. This method requires constant watching, and is almost sure to wet ON FEVER-NURSING IN GENERAL. 89 the bedding unless proper precautions are taken. It is not available for prolonged use. d. The Cold Pack.—A blanket is spread evenly over a couch or cot, protected by a rubber sheet or mackintosh; over this blanket is laid a coarse sheet wrung lightly out of water of the prescribed tempera- ture and folded once. The patient is lifted upon the bed thus prepared and quickly wrapped in the wet sheet by the attendant in such a manner that it lies as smoothly as possible over every part of the body except the head. If the extremities feel cold before the packing, they must be warmed by friction, or else not included in the packing. So soon as the damp linen is everywhere in contact with the body, the attendant folds the blanket over the patient in the same way, first drawing over and tucking one side smoothly under and then the other, seeing that the chin is free and that the blanket is folded evenly, but without tension at the neck. Finally, the long end is drawn down and folded smoothly under the feet. Three or even four thicknesses of wet sheets spread first upon the blanket are necessary to effectively reduce the temperature. The reduction of temperature from a single pack is usually transient, and repeated packings, even to the number of five or six, are often administered, the rise of temperature being slower after each. When the temperature does not rise above normal, or when shiv- ering takes place, the packing must not again be re- newed. When repeated packings are necessary, two 90 FEVER-NURSING. beds or cots are used side by side, and the patient is lifted directly from one pack on to the other. The same effect is produced, but less completely, by unfolding the blanket and sprinkling the sheet afresh with cold water. The patient is allowed to remain in the last pack from three-quarters of an hour to an hour and a half; at the expiration of this time the skin generally be- comes pleasantly warm, and in many cases outbreaks of perspiration take place. During the packing the pulse is felt at the carotid or temporal artery and the temperature taken in the mouth. e. The Cold or Gradually Cooled Bath.—The use of baths in the treatment of fevers is extensively practised by the physicians of Germany, a majority of whom regard it as the most effectual plan yet devised. It is an old treatment, but was for a long time forgotten, and has been recently revived. It has not, however, been generally adopted in England or America. It is very extensively practised in Philadelphia, and as it is re- garded with favor by many competent physicians, and as systematic cold baths may become necessary as the only means of saving life in cases of hyperpyrexia, a knowledge of this treatment is essential to the skilful fever-nurse. The gradually cooled bath is generally employed. The quantity of water used should be suf- ficient to wholly immerse the body of the patient. The tub must stand if possible at the bedside. In hos- pitals it is better to roll the patient's bed into the bath- room. Patients who are severely ill should be lifted into the bath and there held and supported. During ON FEVER-NURSING IN GENERAL. 91 the bath the skin should be gently rubbed. The tem- perature of the water should be about 90° F., or even higher than this, at the first bath, and also for elderly, sensitive, and timid persons. As the patient becomes accustomed to the bath it is gradually cooled by the addition of cold water to 80° F., or lower. Under no circumstances should it be cooled below 65° F. It is rarely advantageous to reduce the temperature of the bath below 70° F. The average duration of the bath is ten minutes. But if shivering or great uneasiness occur, the patient is at once lifted into bed, placed upon a sheet previously made ready, and wiped dry, with brisk rubbing of the extremities and back. The moist sheet is then removed. The patient is covered up, and some hot soup or wine, or brandy and water, adminis- tered. The temperature is not always immediately reduced, but—as measured in the rectum—usually falls within an hour from one and a half to four or five degrees. In the course of some hours it rises again, and the bath is then repeated. If cold baths are not well borne, good results in lowering the temperature often follow prolonged lukewarm baths. Sometimes it becomes necessary to repeat the bath four or five times in the course of twenty-four hours. A patient who is quietly sleeping, even if his temperature be high, should not be immediately placed in the bath upon being aroused. When young children are treated by this method, the temperature of the bath at the beginning should be warm, and a blanket spread over the tub, in which the little patient is gradually lowered into the water. 92 FE VER-N URSING. Not only is the temperature lowered by this means, but also a very favorable influence is exerted upon the state of the nervous system. In enteric fever the intellect clears up, the dulness diminishes. Under this treatment bed-sores are less frequent. Instead of the bath gradually cooled down, a cold bath of 65° F. to 80° F. is sometimes employed. In cases of hyperpyrexia, such as are sometimes seen in rheumatic fever, a still bolder use of this method of cold-water treatment is necessary to save life. The baths must be then colder, more prolonged, and re- peated at shorter intervals. f. Cold Affusions.—While the patient is in the tub, cold water—60° F.—is thrown from a pail, or by means of an ordinary garden-sprinkler, over his head, face, neck, shoulders, and chest. This is repeated once or twice just before he is removed from the bath. It is done rather for the sake of its good effects upon the nervous system in cases of great stupor and other evi- dences of serious nervous derangement than merely as a means of reducing high temperature. In severe cases of croupous pneumonia, with a tendency to coma, cold affusions are often practised with good result. g. Iced- Water Enemas.—Copious rectal injections of iced-water are sometimes followed by a prompt fall of temperature. They are, when carefully administered, rather grateful than otherwise to patients. They are best given by means of the fountain syringe, the water being introduced into the bowel slowly, and the flow stopped for a few minutes by pressure upon the tube without withdrawing the nozzle, whenever a sense of ON FEVER-NURSING IN GENERAL. 93 pain or of desire to evacuate the bowel is experienced. In this way a large quantity of fluid may be injected. It is not often necessary to exceed three pints. This method of applying cold constitutes a useful addition to those in ordinary use, and may be advantageously employed in connection with them under suitable cir- cumstances. The patient's head and face must always be well bathed with cold water just before and during applica- tions of cold to the general surface of the body. The occurrence of chill or rigor may be delayed by more or less vigorous rubbing or chafing of the body. Sudden spontaneous falls of several degrees in the course of a fever are commonly significant of danger. The physician should be at once notified. Meanwhile, especially if the pulse be feeble and there be evident faintness, the patient's head is to be placed low, the foot of the bed slightly elevated by blocks, hot-water bags put at the patient's feet, hot blankets over him, and twenty to forty drops of aromatic spirit of am- monia or a little brandy or whiskey administered. If signs of collapse continue, the legs and arms should be chafed in the direction of the body and sinapisms (mus- tard-plasters) of full strength applied over the pit of the stomach and the region of the heart. Such spontaneous sudden falls of temperature at the close of certain fevers, although sometimes attended by the same symptoms and demanding similar prompt treatment, are usually critical, and therefore rather favorable than otherwise. When there is any indication of a crisis about the time of the expected defervescence, 94 FEVER-NURSING. as, for example, in relapsing fever or pneumonia, the nurse must be upon her guard lest a tendency to col- lapse occur, and prepared to combat it with appro- priate treatment. The fall may extend scarcely to the normal, or much below it; its extent is, however, less important than the symptoms of depression which attend it. The occurrence of hyperpyrexia must be met by prompt measures to reduce temperature, and the physi- cian must be summoned without delay. When the temperature suddenly mounts up to 105.8° F. and con- tinues to rise, the nurse should proceed to use cold compresses, cold sponging, or even to administer an iced-water enema, while waiting for the arrival of the physician, and may make ready a full bath in case its use should be considered necessary. Whenever sudden unlooked-for rises or falls of sev- eral degrees occur in the course of a fever, the nurse must carefully repeat the observation in order to be quite sure she is right before taking action upon it. THE NERVOUS SYMPTOMS. Much can be done by the nurse to allay the minor nervous symptoms of the fever patient. Quiet and order in the sick-room, a light touch, a low voice, a gentle manner, even the fine art of letting the patient alone at times, go far towards saving him from worry, excitement, and headache. To turn his pillow and smooth his bed at the right time for him, to regulate the light without asking, to guard successfully against things that annoy him, to step noiselessly, to see every- thing and say little, and that little well and to the point, ON FEVER-NURSING IN GENERAL. 95 to cheer, encourage, and to calm by one's very presence, are the gifts of the fortunate among you. To those who have such gifts it is useless to speak of them; to those who lack them they cannot be taught. They are of the largess of nature, not of the learning of schools. Headache is often soothed by cold applications, some- times by hot. That temperature should be selected which is found to do good. Patients who suffer from vertigo ought to keep the recumbent posture. They must not be allowed to stand up without assistance lest they fall and injure themselves. This precaution is especially to be heeded on first rising after a long sick- ness. It is a good plan to allow the patient to sit up in the bed once or twice for an hour; then to move him into an easy chair at the bedside without letting him stand up; after a day or so he may walk a few steps. Pains in the back and limbs are relieved by gentle frictions or massage, and by the application of anodyne liniments. Persistent gentle chafing is very useful. Shivering, chills, or rigors call for extra covering, hot dry applications to the feet, hot spirits and water, chafing the limbs under the covers with hot dry flan- nels. When reaction occurs and the patient becomes warm again, the extra coverings must be removed. Delirium demands the closest attention of the nurse. The delirious patient should never be left alone. It is important that this rule should be literally un 1 'T "Mt^-^* 1 1 1 1 1 1 i ^~ ^3 v Mil 3 M i 1 ! i nn u....... -!■!■!rrfrtrRiJ-- ! !'■!! 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IS. & ^M"—-T- —-, 5 feS^zqiiiiiiiTiitt^f m >-* $ --jJ*r--J-l----+-J- l S 8 ni ■r0 —i?ii 1 t 1__jl " m >-*\ $ -i?3":::::":"!: i~~~ I _£__ J I?.4«-I...........I—— m I ^_..m!sm:- i 5 _s:r________"+ n £• L'"5 fcf. ^ ^.. 1 J * ~-S» 1 n Vi S\ .1-1-*—.....' 3 **! ' m & it 1 ------*--g J» S •* ___U4-J— m T V* 1 —■ —• : T T L_____________________________________ Fl C/l s i nu m i | i irrrriv| 11 i j 11111 i i i > i > u °1 S! $ "3 S 1 11 1 1 1 1 111 ; 1 n m 111 n 1 11 itti 4- fe d painless. The pulse is increased in frequency; it soon reaches the neighborhood of 110 in the morning and runs up to 120-130, or even higher in the evening, with a much higher rate in children. It is full at first, but compres- sible,—rarely firm or tense; it soon grows feeble. As a rule, the temperature rises rapidly, attaining 103°-104° F. by the morning of the third or fourth day, and 104°-105.8° F. the same evening, and re- maining nearly stationary at these points until some time in the second week. A decided difference between the morning and evening temperature is more favorable, even when the evening increase is considerable, than a continuously high temperature range in which the morning remission fails. On the fourth or fifth day, as a rule, less often at the end of the first week, the characteristic eruption appears. It consists of numerous roseola-like spots of irregular outline and varying in measurement from a line to three or four lines across, scattered singly, like the spots of enteric fever, or, as is by far more common, arranged in irregular groups. At first these spots are of a dirty rose-color, very slightly raised above the sur- face of the surrounding skin, and upon pressure they momentarily disappear. Within the course of a day or two they become darker from the escape of the 162 FEVER-NURSING. coloring-matter of the blood into the tissues; they are no longer elevated, but appear as faint, dirty brown stains, without defined margin, and fading, not dis- appearing, upon pressure. They closely resemble the rose-rash of enteric fever, differing principally in their numbers and grouping, and in the fact that they appear once for all, and not in successive crops. Their course is typical. They fade during the first half of the second week, and disappear with or without desquamation to- wards its close. True petechia? appear about the time the typical rash begins to fade,—that is to say, about the eighth or tenth day. A faintly reddish, ill-defined mottling or marbling of the skin between the spots or groups of spots, which form the characteristic rash, also occurs to a greater or less extent. It is this that has been described, from its appearing to lie beneath the surface, as the " subcuticular" eruption of typhus. The appearance of the rash varies greatly, and the variation is determined by the general abundance of the two eruptions, by the relative preponderance of one or the other, and, in certain cases, by the extent of the petechia?, which are, however, frequently absent altogether. The distribution of the typhus eruption is irregular: appearing usually first at the sides of chest or abdomen, it spreads in a brief time to the chest, abdomen, back, and limbs. It rarely appears upon the neck or face, and in these regions is usually faint when present. It has in some instances been observed to appear first upon the backs of the hands. In some cases the roseola- like rash is absent altogether, the faint, subcuticular THE CONTINUED FEVERS. 163 mottling alone being present. An entire absence of eruption is very rare. About the end of the first week the depression be- comes profound, headache passes into delirium, and the impairment of the mental powers is extreme. The patient is dull of hearing; he answers questions very slowly and vaguely; drowsiness and stupor are marked, and in severe cases there is a tendency to coma. The character of the delirium is variable. It is commonly low, wandering, muttering; occasionally it is at first acute, severe, boisterous. This excitement usually soon passes away, leaving the patient in a state of the most profound exhaustion, or it gradually subsides into dul- ness with muttering. With both forms of delirium there is sleeplessness. The tongue is now dry, fissured, and crusted; sordes collect upon the teeth and lips; the conjunctivae are deeply injected; the flushing of the face gives place to a dusky pallor, most marked about the nostrils and lips, and emaciation progresses. The breath and the skin exhale a peculiar fcetor, and there is annoying cough with mucous expectoration. The heart-sounds and the impulse are faint and indistinct. The state of the bowels varies from constipation to irregular, scanty dejections, or a moderate intestinal catarrh; the urine is scanty, opaque, high-colored, and very frequently contains albumen. In severe cases the discharges are passed involuntarily, or there is reten- tion of urine. The symptoms deepen. The patient utters no com- plaint. Neither pain nor headache is felt. Appetite is completely lost; thirst no longer distresses him, 164 FEVER-NURSING. although he swallows with difficulty, owing to the dry- ness of his throat. He lies upon his back, stupid, lost, utterly indifferent to everything around him, sometimes moaning or muttering incoherently, sometimes quiet. The eyelids are partly closed, the pupils contracted. Deafness is often present. When spoken to loudly he stares vacantly, without attempting a reply. If asked to put out his tongue, he opens his mouth, and leaves it open till reminded to close it. He is unable to raise himself, or even to turn from side to side; from mus- cular weakness he is continually sliding down in the bed; his hands tremble; he picks at the bedclothes, and feebly grasps at unseen objects in the air; there is subsultus. The pulse is small and weak, often diffi- cult to count, less commonly irregular or intermittent. It ranges from 112 to 140 or over. The portions of the skin subjected to pressure show a tendency to slough. The surface now becomes cooler, and is often moist. If petechia? are present they become more numerous. Death may take place at any time after a condition such as has been described becomes fully developed. In very severe cases it may occur in the course of a few days or before the end of the first week. More commonly the fatal termination takes place between the tenth and the seventeenth days. Death at a later period is uncommon, except as a consequence of com- plications. The mode of death is by coma, or by as- phyxia in consequence of sudden pulmonary engorge- ment, or by failure of the heart, the pulse becoming imperceptible, the surfaces cold, livid, and bathed in sweat. THE CONTINUED FEVERS. 165 In abortive cases a favorable termination may take place by critical defervescence at the end of the first or the beginning of the second week. In average cases the fever comes to an end about the fourteenth day, sometimes as early as the tenth day, sometimes as late as the middle of the third week. The improvement is more or less sudden. The tem- perature, which in many cases shows a little abatement for some days before the crisis, falls in a single night, or, in the course of twenty-four or forty-eight hours, to the normal, or even a little below it; the pulse becomes much slower and its character improves; the stupor and coma immediately disappear after a prolonged, re- freshing sleep, out of which the patient awakes as from an oppressive dream, conscious, but at first bewildered and confused. The eruption fades and gradually dis- appears; the tongue cleans and becomes moist at its edges; the appetite returns. The crisis is often at- tended by moderate sweating or diarrhoea, or both, and by an increase in the amount of urine, with the copious deposit of urates and the disappearance of albumin. In the course of a few days the tongue is moist, the appetite eager, strength begins to return, and the con- valescence progresses rapidly, so that many patients are able to resume their work within a month from the beginning of the attack. Temporary loss of hair not infrequently occurs dur- ing convalescence, and in many cases a considerable length of time ensues before the body-weight and the original vigor of mind are regained. The deafness in almost all cases gradually passes away. 166 FEVER-NURSING. Relapses occur, but they are much less common in typhus than in enteric fever. The mean duration of typhus fever is about four- teen days. Mild cases may end in permanent improve- ment at the close of the first or beginning of the second week. The duration of average cases is from thirteen to fifteen days. Uncomplicated cases rarely exceed twenty days. If the defervescence be postponed to the end of the third week, it is in consequence of some local complication. Improvement in the sanitary condition of localities formerly infested with typhus fever have led to its dis- appearance as an endemic disease, while the great epi- demics of typhus have become, even in the wars of recent times, almost unknown. Typhus never makes its first appearance in the cleanly and well-ventilated homes of the opulent classes. If it extends to them at all, it is by spreading from less fortunate localities. Upon the outbreak of an epi- demic, the isolation of the first cases in hospital, and the thorough cleansing and ventilation of the houses and rooms from which they are removed, with general sanitary measures to obviate the predisposing causes of the fever in the affected neighborhood, are important. The infected buildings should be thoroughly fumigated with sulphur or formaldehyde, ventilated, whitewashed, and allowed to stand unoccupied for a considerable time. The clothes and belongings of the patients should likewise be disinfected by prolonged exposure to heat or to the fumes of burning brimstone, or by boiling in water containing carbolic acid. The infected bed- nmi|iimnii|iiiuiiii|Miiiuniuimiii|illiliui|iiuiuii .1 4 4 4* THE CONTINUED FEVERS. 167 ding should be subjected to the same treatment, and the materials used for filling mattresses and pillows should be burned. Absolute cleanliness in the sick- room is to be insisted upon. The excretions should be promptly disinfected. Persons in attendance upon the sick must be allowed opportunities for proper rest and exercise in the open air. The general management of typhus fever is the same as that of enteric, regard being had to the early and grave prostration which so often characterizes the affec- tion under consideration. As there is no intestinal ulceration, and no danger of hemorrhage from or per- foration of the bowel, less caution in diet is necessary. Hygienic measures relate to ventilation, to cleanli- ness, and to diet. Typhus cases, when treated in hos- pital, should be placed in large rooms by themselves, and never more than four or six together; the windows, even in winter, should be kept open, so as to secure careful and thorough ventilation. All observers insist that confined air is more to be dreaded than cold. When cases are treated at their homes, as is necessary in the well-to-do classes, similar regulations are to be ob- served; and, in particular, all annecessary furniture, and all curtains and hangings which are liable to inter- fere with ventilation, on the one hand, and to absorb and retain the contagion, on the other, are to be taken away. Quietude is to be observed, and all visits, except such as are absolutely necessary, are to be prohibited. Stimulants are very generally required. Most chil- dren, and a large number of the adult cases, may, how- ever, be satisfactorily treated without them. Alcohol is 168 FEVER-NURSING. seldom required before the appearance of the eruption; it is most useful in the second week, and often necessary upon the approach of the crisis, even in cases where it has not before been required. Old people, and those previously greatly debilitated, almost invariably require alcoholic stimulants in the beginning of the disease. Persons of intemperate habits also commonly require alcohol from the onset of the disease, and in greater quantities than those unaccustomed to its use in health. Stimulants must be promptly given in cases of great prostration, with low delirium and a tendency to coma; also when the pulse is frequent, feeble, or undulatory. When the prostration is extreme and the patient is unable to swallow, brandy, or whiskey, or ether may be hypodermically administered; and, as will commonly happen in the severest cases, the condition of the patient may render it impossible to give the necessary food by the mouth. Under such circumstances, an endeavor to support the patient's strength and to prolong life must be made by means of rectal alimentation and medication. It is of the utmost importance that the patient's strength be husbanded from the beginning of his sick- ness. All mental and bodily effort is to be avoided. It is a common observation that those who struggle against the disease in its early days usually suffer from great prostration later. The patient should betake him- self to his bed as soon as the fever appears. If there be marked prostration during the first week, and under most circumstances during the remainder of his illness, the patient should not get out of bed for any purpose. THE CONTINUED FEVERS. 169 In typhus it is, in many cases, imperative that the patient do not assume the upright position. Fatal syncope may result. The management of the patient in delirium will often tax the patience and tact of the nurse to the utmost. In most cases restraint by forci- ble measures is unnecessary; it is always a last resort, and to be deplored. The disease described by Brill and for a time known by his name has been definitely determined to be a form of sporadic typhus fever. It has been frequently observed in New York, Philadelphia and other cities on our eastern seaboard, chiefly among immigrants from southeastern Europe. The cases are usually admitted to hospital as typhoid fever, and are characterized by intense headache, apathy and prostration, an abundant erythematous maculopapular eruption and subcontinu- ous fever terminating in crisis or rapid lysis in two weeks or less. The case mortality is low. The explana- tion of the fact that these sporadic cases do not give rise to epidemics lies in the circumstance that typhus is communicated by the louse, an insect that is compara- tively rare among communities in the United States. RELAPSING FEVER. Definition.—An acute, contagious fever, rarely occur- ring except as an epidemic, and in seasons of scarcity of food. It consists of—(a) a febrile paroxysm, char- acterized by abrupt onset, active fever, a moist, white tongue, epigastric tenderness, vomiting, and often jaun- dice, enlargement of the liver and of the spleen, and the absence of eruption, and terminating suddenly with 170 FEVER-NURSING. free perspiration about the fifth or seventh day; (b) an interval of complete apyrexia; and (c) an abrupt relapse on or about the fourteenth day from the begin- ning of the disease. This relapse runs a course similar to that of the initial paroxysm, and comes to an end by crisis on or about the third day. Convalescence usually ensues upon the termination of the relapse, but a second, third, or even fourth relapse has been ob- served. Fatal termination infrequent; enlargement of liver and spleen, but no specific lesion found upon ex- amination after death. Causation.—This fever has as its primary cause a minute organism, which from its spiral form has re- ceived the name of spirillum or spirochaete. It was discovered in the blood of relapsing fever patients in 1873 by Obermeier. These organisms are present in the blood only during the febrile paroxysms. Blood- sucking insects and especially the body louse—Pedicu- lus vestimenti transmit the disease. Upon the appearance of relapsing fever renewed efforts must be made to relieve the sufferings of the poor, and chiefly to provide them with a sufficient quantity of wholesome food. As far as is possible, overcrowding must be diminished in the districts most liable to become pestilential centres of the disease. The drainage is to be looked to, and, if defective, tempo- rary measures to drain away stagnant water must be immediately resorted to. All accumulations of filth and garbage must be at once removed. Especial atten- tion must be given to household vermin, particularly lice and bed-bugs. THE CONTINUED FEVERS. 171 Contagious as relapsing fever is, it does not spread, when cases occur in the large and well-ventilated houses of the opulent, nor to any great extent in the roomy and properly-aired wards of well-managed hospitals, except to those whose vocations bring them into close contact with the sick. Physicians visiting from house to house among the poor, remaining only a short time in the presence of the patients, and passing quickly again into the open air, are less liable to contract the fever than the resident physicians of hospitals or nurses who pass from bedside to bedside and are much more exposed to the danger of inoculation by vermin. Cleanliness of the abode and of the person is scarcely second in importance to abundant ventilation. The con- tagion is readily transmitted, by means of the clothing and bedding of the sick. Soiled clothes should be disinfected and thrown into boiling water as soon as taken off, and carbolic acid or carbolic acid soap used in the water with which they are washed. If patients be removed to a hospital, or after conva- lescence has set in, the apartment should be fumigated by burning sulphur or formaldehyde, then thoroughly aired, cleansed, and whitewashed. The bedding should also be subjected to the sun and air, and, if possible, fumigated. The cheaper materials used in filling mat- tresses, as straw, moss, fine shavings, and husks, should be burned. No method of treatment has been found to exercise any decided influence upon the course of the disease. It must therefore be treated upon the expectant plan. 172 FEVER-NURSING. The general management of patients ill of relapsing fever must be conducted by the nurse in accordance with the rules already laid down. The temperature is often extremely high, but this condition is not attended with the extreme danger which accompanies hyper- pyrexia in other fevers. Nevertheless, energetic anti- pyretic treatment may become necessary. The defer- vescence is critical, and attended with great depression of the powers of the organism. This condition calls for the prompt and energetic use of stimulants. INFLUENZA. Definition.—A continued fever, occurring in widely- extended epidemics ; characterized by early developing catarrhal inflammation of the mucous membrane of the air-passages, and in many cases also of the digestive tract; by quickly increasing debility, out of propor- tion to the intensity of the fever and catarrhal pro- cesses ; and by nervous symptoms. There is a strong tendency to inflammatory complications, especially of the lungs. Uncomplicated cases are seldom fatal, ex- cept in the very young, the aged, and others much debilitated by previous disease. An attack does not confer immunity from the disease in future epidemics. Synonymes.—Catarrhal Fever; Epidemic Catarrhal Fever. History.—Great epidemics of influenza have been observed and recorded at various times from the earliest history of medicine. Some of them have literally traversed the greater part of the civilized world, not THE CONTINUED FEVERS. 173 even sparing domestic animals, as the horse and the dog. Others less extensive have affected in the course of a few weeks or months the greater part of Europe or America, the disease in its milder or graver form overlooking scarcely an individual in the communities which it has visited. These great epidemics have oc- curred at long intervals, perhaps three or four times in a century. But more restricted outbreaks, passing over considerable areas of country, are of very common oc- currence. Causation.—Influenza is due to infection by a specific micro-organism or bacillus, described by Pfeiffer in 1892. This organism is found in great numbers in the secretions from the nasal and bronchial mucous mem- brane during the attack. It is readily transmissible; the disease is therefore highly contagious. Its spread in the great epidemics is as rapid as the ordinary methods of travel. Influenza differs from ordinary catarrhal fever, such as is common enough in sporadic cases or in little out- breaks affecting the members of a household, and usu- ally attributed to "catching cold," in two respects,— first, its general prevalence; second, the severity of the symptoms. Course and Symptoms.—Influenza presents the great- est variation as regards intensity,—from the most trifling indisposition to an illness of the gravest kind, which may even end in death. In severe cases the onset is usually abrupt. The attack begins with shivering or a chill, or with fits of chilliness alternating with heat. Fever is rapidly es- i 174 FEVER-NURSING. tablished. It is usually moderate; sometimes intense. During the course of the fever chilliness, flashes of heat, and more or less copious sweating occur at irregu- lar intervals. There is headache, pain in the orbits and at the root of the nose. Tickling in the throat, hoarseness, dry, paroxysmal cough, and shortness of breath also occur. Chest-pains, stitches in the side, sneezing, and loss of the senses of smell and taste attend the development of general catarrhal symptoms. There are also present pains in the limbs, loss of appetite, usually complete, thirst, constipation, and diminished secretion of urine. The pulse is full, but as a rule not rapid. It may be very weak. There is great restlessness and annoying inability to sleep. The defervescence is attended by an increased flow of urine and amelioration of the general symptoms. Ca- tarrhal symptoms outlast the fever for a few days, but cough and expectoration may not disappear for some time. There are marked evidences of functional disturb- ance of the nervous system ; great depression; loss of muscular strength ; lowness of spirits; mental weak- ness; sometimes even stupor or delirium. In some cases slight convulsions take place. Areas of burning pain in the skin, or of loss of sensibility, neuralgias, and various pains in the bones and muscles are very common and often severe. The duration of the mildest form of influenza is from two to three days. In well-developed cases without complications convalescence sets in between the fourth and tenth days. Severe cases with complications last THE CONTINUED FEVERS. 175 much longer, several weeks often elapsing before re- covery is complete. In the persistent pulmonary forms the influenza bacilli have been found in the secretions or lesions after many months. We must therefore admit the existence of chronic forms. During an epidemic aged persons, those enfeebled by chronic diseases, and in particular those subject to chronic bronchitis, consumption, emphysema, fatty heart, and Bright's disease, should be cared for with unusual solicitude and diligence, since they constitute the classes most prone to the graver complications of the disease, and from which its fatal cases are almost wholly derived. Such individuals should be warmly clad; they should shun, as far as possible, the vicissi- tudes of the weather, even keeping within doors. The treatment of influenza is expectant and sup- porting. The lighter cases seldom require medical treatment. The patients are uncomfortable and dispirited, easily fatigued, and unfitted for business. It is best for them to stay in the house or even to go to bed for two or three days. The diet should be restricted to a few simple and easily-digested dishes. Meat should be avoided. The custom of taking large amounts of hot beef-tea is a bad one; it often increases the headache and languor. Such beverages as are proper for fever cases may be given. Both food and drink, however, should be of very moderate amount. In severe cases alcoholic stimulants are absolutely necessary. The brows and nose may be freely anointed with 176 FEVER-NURSING. washed lard, cold cream, or goose-grease. The mineral fats (cosmoline, vaseline) are less useful than animal fats. Warm or hot applications to the head usually give comfort, while cold almost invariably adds to the distress. It is a good plan for the patient to wear a flannel night-cap or wrap his head in a silk handker- chief. The air of the room should be rendered moist by the evaporation of water kept boiling in a broad, shallow vessel. Antipyretic treatment in this disease is neither neces- sary nor safe. The pains in the chest may be combated with mus- tard-plasters, turpentine stupes, or frequent inunctions of fatty substances containing extract of belladonna. YELLOW FEVER. Definition.—Yellow fever is an acute specific febrile disease of short duration, prevailing in more or less extensive epidemics in warm weather, and for the most part restricted to narrow geographical limits, though occasionally carried beyond them. It is characterized by sudden onset; fever of moderate intensity, 102° to 105° F.; headache; pain in the back; epigastric ten- derness and albuminous urine ; defervescence, occurring at the end of twelve or fifteen hours, or not for several days, is followed by the " stage of calm," which lasts some hours. From this point recovery may be rapid and uninterrupted ; or the surface becomes mottled and cold; the pulse feeble; vomiting, if not previously present, comes on, and hemorrhages are apt to occur. The vomiting of altered black blood is perhaps the THE CONTINUED FEVERS. 177 most characteristic event of this fever. Hemorrhages also occur from the gums, nose, eyes, uterus, kidneys, and under the skin. Lemon-yellow jaundice, from which the fever receives its name, is rarely absent in grave cases. Suppression of urine occurs in the worst cases. Causation.—The infecting principle is a specific organism, probably a protozoon, which has not up to the present time been isolated. The recent work of the Yellow Fever Commission of the United States Army, conducted under the most rigid scientific precautions, has revolutionized our views in regard to the modes of transmission of this disease from the sick to the well. It is now established that it is not transmitted by direct or indirect contagion in the ordinary sense. In Cuba during the United States military occupation very few cases occurred among the nurses or doctors in attendance upon the sick. In 1900, in a hospital in Havana, five nurses who had never had the disease nursed more than one hundred cases of yellow fever without contracting it. The re- markable experiments of the Yellow Fever Commission at Camp Lazear, Cuba, go far to establish the fact that this disease is not transmitted by fomites. A frame house was built in such a manner as to shut out the sunlight and prevent the access of fresh air, but was thoroughly screened against mosquitoes. In this house Dr. R. P. Cooke and two privates of the hospital corps, none of them immune, occupied a room for a period of twenty days, sleeping there at night, and regularly each morning packing boxes with sheets, 12 178 FEVER-NURSING. pillow-cases, blankets, and the like contaminated by contact with yellow fever cases and their dis- charges, and unpacking them at night. In this series of experiments seven non-immune soldiers lived in contact with articles thus contaminated and did not develop the disease. Another series of experiments demonstrated the fact that yellow fever is transmitted by the mosquito, Stegomyia fasciata, previously fed upon the blood of persons suffering from the disease. A third series of experiments established the fact that the disease can be produced in non-immunes by the subcutaneous or by the intravenous injection of blood from yellow fever cases. The results of the labors of this Commission are of far-reaching importance to the world. Its work was laid out and conducted upon strictly scientific lines. It has settled the question as to the extent and nature of quarantine against yellow fever, and has shown conclusively that prevention consists in regulating the local conditions which favor the de- velopment of the mosquito, and preventing the access of mosquitoes to non-immune persons. The chief credit is due to Major Walter Reed, who has since died; but his associates heroically shared with him the labor and the risk, and Dr. Lazear died of the disease, a martyr to scientific zeal. The period of incubation is three to four days; in the experimental cases it varied from forty-one hours to five days and seventeen hours. In the management of this fever absolute rest and free ventilation are of the first importance. The sooner the patient goes to bed the better. Mustard-plasters THE CONTINUED FEVERS. 179 to the epigastrium and bits of ice from time to time swallowed are of use against the irritability of the stomach. High fever is to be treated by cold sponging, packs, baths, or large iced-water enemata. Alcohol, and especially dry champagne, are useful. Food must be given in the most sparing amounts, or not at all for many hours. Rectal alimentation is sometimes well borne, and may be necessary to sustain the patient while quite unable to retain food. It is all-important for the physician to encourage the patient, and inspire him with hope, and the services of a skilful and expe- rienced nurse are of inestimable value. The patient must be confined to strictly recumbent postures, and all nourishment and drink must be given by tubes or pap-cups. If he cannot void his urine in the recumbent posture, it is far better to use the catheter than to allow him to rise for the purpose. The bed must be changed by moving the patient to one side and then to the other, as the soiled linen is removed and fresh substituted. The night-shirt is to be cut so as to be easily drawn off, and replaced by another cut in the same way and basted after it is put on. DENGUE. Definition.—A peculiar febrile disease of short dura- tion, appearing epidemically in tropical and warm countries, characterized by a single paroxysm, with or without remissions, severe pain, stiffness in the joints and muscles, and a peculiar eruption. It is scarcely ever fatal. Synonymes.—Dandy Fever; Break-bone Fever. 180 FEVER-NURSING. History.—No historical records of any disease re- sembling dengue are to be found prior to the middle of the eighteenth century, when it prevailed in Spain, and was known as la piadoso, or la pantomina. It prevailed extensively in Philadelphia in 1780. Many epidemics have since occurred in tropical and subtropical countries. It has of late been prevalent in the Gulf States. Symptoms and Course.—Dengue begins suddenly, usually at night, without a chill, but with severe pains in back, limbs, and joints. The large and small joints are alike affected, either at once or successively. They are stiff, painful, and swollen. Fever is present from the beginning. It reaches usually 102°-103° F., but may attain 105° F.; the pulse is 80-120. The fever lasts four or five days, with, in many instances, a re- mission on the third or fourth day. The tempera- ture of the second rise never attains the elevation of the primary febrile paroxysm. The remission is at- tended by amelioration of the other symptoms. With the recurrence of fever an eruption makes its appear- ance on the face, neck, and chest, and extends in forty- eight hours over the entire body. This eruption is not uniform in character. It may resemble that of scarla- tina, measles, or nettle-rash. The superficial lymphatic glands are now observed to be swollen and tender. The eruption usually fades in the course of the first or second day after its appearance. The average duration of the disease is from three to six days. The pains in the joints and muscles disappear very slowly, and it is often some weeks after severe attacks before the patient fully regains his strength. THE CONTINUED FEVERS. 181 Dengue commonly prevails in the summer months, and ceases on the approach of winter. It is highly contagious. The treatment is symptomatic, and the nursing of the patient must be conducted upon the general prin- ciples already laid down. V. THE PERIODICAL FEVERS. Intermittent Fever — Remittent Fever — Pernicious Malarial Fever. The temperature undergoes rhythmical or periodical intermissions of much greater length than the febrile paroxysms, or remissions far greater in extent than those of health. This group comprises the Malarial Fevers, namely,— The Regularly Intermitting Malarial Fevers. The Irregular, Remittent, and Continued Malarial Fevers—-ZEstivo-autumnal Fever—Pernicious Fever. Malaria literally means bad air. The term gradu- ally came to mean also the disease or diseases sup- posed to be caused by a peculiar form of bad air associated with certain climates and localities. Many peculiarities of the bad air which was the hypo- thetical cause of this group of diseases were observed and studied for ages. The chief and most constant of these was that heat, moisture, and decomposing vegetable matter were necessary to its production; hence, that it most prevails in swampy districts and warm and hot climates, and when it occurs in tem- perate climates it is in the spring and autumn rather 182 THE PERIODICAL FEVERS. 183 than in the winter or summer. It was found that those passing a short time in malarious districts were much more apt to contract the disease if they were exposed at night than only by day; that the danger was less upon the hills than in the valleys and along the courses of streams ; that the attack does not con- fer immunity against subsequent attacks, and that cinchona bark, and especially its alkaloid quinine, are sovereign remedies. These and many other pecu- liarities of malaria were long known, but its true nature remained wholly unexplained until Dr. Lave- ran, a French military surgeon, stationed in Algiers, in 1880 discovered a blood parasite which is con- stantly present during the attack. Other investi- gators confirmed this observation and greatly en- larged our knowledge of this protozoon. It was suggested by Dr. King, of Washington, that not air, water, or perhaps articles of food, as had been thought, were the vehicles by which this organism entered the body, but that it might be inoculated by the sting of the mosquito, and this has since been proved to be the case—in fact, it has been shown conclusively that a certain variety of the mosquito— the Anopheles—is not only the definitive host of the parasite, plasmodium malarice, of which man is the intermediate host, but that it is also the only source of the malarial infection. These discoveries explain many of the obscure facts concerning the geographical distribution and prevalence of the malarial diseases and place the whole subject upon a scientific basis. Three forms of malarial organisms have been de- 184 FE VER-NURSING. scribed—the tertian, the quartan, and the sestivo- autumnal; and these correspond to the three different clinical forms of malaria from which they have de- rived their names. The malarial diseases are not trans- missible by direct or indirect contact—that is, they are not contagious by direct approach or by fomites. The tertian and quartan parasites cause fevers which are regularly intermittent—the agues. The aestivo- autumnal parasite gives rise to forms of fever which are irregularly intermittent, remittent, or continued. When the asstivo-autumnal infection is intense, as in the tropics, the Roman Campagna, and some parts of India, the resulting fever is of pernicious type. In highly malarious places a single exposure is very often quickly followed by fever; in temperate latitudes, repeated or prolonged exposure appears to be necessary, and the resulting fever may not make its appearance for a considerable time. THE REGULARLY INTERMITTING MALARIAL FEVERS. Intermittent Fever.—The paroxysm consists of—1, the cold stage, or chill; 2, the hot stage, or fever; and, 3, the sweating stage. 1. The Cold Stage.—Creepy sensations, chilliness of the surface and along the spine, yawning, lividity of the finger-tips, and goose-flesh are quickly followed by shivering, chattering of the teeth, and painful sensa- tions of coldness, not promptly relieved by the hot drinks, blankets, and external hot applications for which the patient asks. Nausea and vomiting are common symptoms. 5 I'l'lllllinil'illlllill'illlllllllllll'l ill Will' Ml* 111 j 11111 f11! 111 i 1 | [\/t hi •w n 1 i 1 l If 1 M 1 | 111 JT-Vt I 1 1! 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II "^fli p ' llll In Ml' 1 1 llll II I ATI llll 111 "I'"' IB P" * -^TT III ill 1111 llIM1 'ijWM' 1 PlrriT"|ll|lll^ Pi 1 ■rr ti W III!1"11 PnttHP'l II III Tit I W IMHilEllllliltH^mTIi mm ]^l Jil^ P'' II 1 II 1 ' 1 rllll Ittttb'' 1 1 vrft 1 HI' "Hill 1 1 i'fl'llll 2 n*!i ill1 ll P ,B P iTirtiiln iiiTTTin n in IN 1 1 i 1 P p U| | k y» P 1 ! i' i r1'""'Pi Hi Pi 5 r"r" .M.Ml '.jl;,,:! ;|M 'l;l'|!||!|| l| l}| |i ; 1 || w »t jpki | 1 |i PI Hm 3 pwrn hi ill i IllLfPi llll llllllLmTTtllTII ■jf n MH1^ w * vt 3 1 S 8 S S ^ ::::::: ~:.±: ::::::: n '■ "9 5 m 2 m 4 0 L y " y 0> -J tO • 0 • • • • « Fig. 18.—Scarlet fever. THE ERUPTIVE FEVERS. 193 head symptoms persist; the throat continues sore. As the eruption fades, the temperature falls by lysis, and there is in uncomplicated cases a general amelioration of the symptoms, so that by the end of the first week or the beginning of the second convalescence is established. When the rash has faded the outer skin (epidermis) peels off, sometimes in bran-like scales, sometimes (especially about the lower part of the abdomen and from the hands and feet), in extensive shreds or strips. The convalescence is in a considerable proportion of the cases interrupted by the occurrence of acute inflamma- tion of the kidneys (post-scarlatinal nephritis). The fever in some very mild cases is slight; as a general rule, it is high. It rises abruptly, and often attains 104°-105° F. on the first day, and may even rise higher on the second day. It remains high until the eruption fades, when it falls by lysis, very rarely indeed by crisis. If the fever extend into the second week, it is usually kept up by some complication. The pulse is almost always rapid. Sore throat is always present, though very different in kind and intensity in different cases. Severe sore throat with much swelling, and extension of the in- flammation to the deeper tissues, is almost always at- tended by enlargement of the lymphatic glands of the neck, which often terminates in the formation of ab- scesses. The infiltration of the neighboring tissues gives rise to much swelling and hardness, an appearance to which was formerly applied the descriptive term " collar of brawn." Diphtheria is frequently present as a complication. 13 194 FEVER-NURSING. It may appear at any time in the course of the disease. It adds much to the gravity of the attack, and is at- tended by high fever and severe general symptoms; by painful swelling of the glands about the angle of the jaw; by sore mouth, and by a foul, purulent dis- charge from the nostrils. In fact, nasal discharge of a purulent character is apt to be present in cases of marked sore throat of any kind. Inflammation of the parotid gland may occur in severe cases. Suppurative inflammation of the middle ear is com- mon. It occurs about the close of the attack, and is very frequently first made known by the appearance of pus on the pillow or at the ear, neither deafness nor earache having been previously noticed. In other cases earache is severe. The tongue, after the first coating clears off, presents a peculiar appearance, being red and dotted over with enlarged papillae, and is hence known as the " Straw- berry tongue." Scarlatinal inflammation of the kidneys does not often occur until after defervescence. It may be so mild as to escape observation, unless the urine be sys- tematically examined, when it reveals itself by those chemical (albumen) and microscopical changes (blood- disks, cells from the kidneys, casts) peculiar to it, or so severe as to overwhelm the patient and lead very quickly to a fatal result. Its onset is preceded or accompanied by fever. Soon puffiness of the face and eyelids with intense pallor are observed. The dropsy may become general. Fig. 19.—Desquamation upon face, neck, and chest after scarlet fever.— After Welch and Schamberg. THE ERUPTIVE FEVERS. 195 The urine becomes scanty and high-cole red, even bloody. It may be almost or even completely sup- pressed. This condition may be accompanied by uraemia, coma, or convulsions. Inflammation of the joints, resembling in some re- spects rheumatism, often comes on during the period of desquamation. It is, as a rule, of transient duration. Pneumonia may occur, and inflammation of the membranes of the heart. Diarrhoea is not a rare symptom, especially towards the end of the attack. We may distinguish four forms of scarlet fever: 1. Very mild or rudimentary; The fever is slight and transient; the rash faint or irregularly distributed; the child appears to be scarcely sick. Desquamation or late inflammation of the kid- neys may be the first intimation that scarlet fever has been present. 2. Simple or ordinary ; Varying grades of intensity. 3. The anginose form; So called on account of the prominence of the throat symptoms.* 4. The malignant; Under this heading are grouped those cases of scarlet fever in which the eruption is scanty or absent, the general symptoms, and especially those referable to the nervous system, being from the start extremely severe. These cases usually prove speedily fatal. * Anginose, angina, from a Latin verb, angere, to choke. 196 FEVER-NURSING. Many cases of scarlet fever are greatly protracted by complications. Relapses are rare. No case of scarlet fever ought to be regarded as favorable until convalescence is complete. The vicissi- tudes are not always to be foreseen. It sometimes happens that in a family where there have been several cases a child supposed to have escaped will be found later dropsical and very ill. The treatment of scarlet fever is in the mild cases expectant, in the severe symptomatic. Many physicians employ so-called specific medication. The diet should be composed of broths, milks, jellies, custards, and the like. The skin should be sponged twice a day or oftener, and anointed freely with carbolized or washed lard or goose-grease every six hours, or oftener if there is great restlessness or itching. These inunctions are a source of comfort to the patient, and, as they tend to prevent the scales or epidermis from blowing about, they are, when kept up during desquamation, to some extent a safeguard against the spread of the disease. The body-linen and bed-clothes may be, when necessary, changed, with due precautions against exposure or chilling; but too fre- quent changes are unadvisable, in view of the in- creased danger of spreading the infection which they occasion. The sick-room should be large and airy, preferably at the top of the house, and with a southern exposure. All carpets, curtains, hangings, ornaments, and unneces- sary furniture must be removed before the patient is THE ERUPTIVE FEVERS. 197 taken into it. The ventilation must be as complete as can be arranged. In cool weather an open fire should be kept burning. A sheet moistened with some disin- fectant solution to which glycerin is added should be carefully hung at the inside of the doorway. A small wash-tub should be ready to receive all clothing and towels, which are to be freely sprinkled with disin- fectants before going to the laundry and boiled before being handled. Soft rags must be used instead of handkerchiefs for the discharges from the nose and mouth, and absorbent cotton for purulent discharges. These must be burned as soon as soiled. Only the necessary attendants should enter the sick-room, and the physician should on leaving it pass at once from the house. He should provide himself with a white linen gown reaching to the feet, and a hood, in which his visits to the room are to be made. This overgarment should be kept just outside the door. On leaving the room he should thoroughly wash his hands in sublimate solution, afterward rinsing them in recently boiled water or water flowing from the hot spigot. This rule should be observed also in the case of the other highly contagious or readily transmissible diseases, as typhus fever, small-pox and varioloid, diphtheria, and the plague. It is within our power to effectually isolate and dis- infect a scarlet fever patient in any well-ordered and uncrowded house. I do not, therefore, as a rule, send the other children away. They have generally been equally exposed under the same circumstances with the 198 FEVER-NURSING. first patient, and usually in close association with him until the appearance of the eruption. Should they have been already infected, it is better that all the cases of a family should be treated under one roof; if by chance they have escaped, they are probably still as safe at home as elsewhere. The patient's mouth, nose, and throat should from the commencement of the illness, even in mild cases, be systematically and frequently cleansed by spraying with DobelPs solution, Listerine, Labarraque, hydro- gen dioxide in proper dilution, or with other suitable antiseptic fluids as the doctor may prescribe. For this purpose any one of the numerous hand-ball atomizers sold in the shops may be selected. Special hard- rubber spray apparatus is required for the solution of hydrogen dioxide. If the throat be very sore, and especially when there are diphtheritic deposits, it is proper to allow the pa- tient to breathe an atmosphere moistened with steam from a croup-kettle so arranged that the spout projects in the neighborhood of the child's face. The steam may sometimes be advantageously confined by erect- ing a sort of tent or closed canopy around the head of the bed. The nurse must be on her guard to detect the earliest symptoms of inflammation of the ears. The swelling of the glands of the neck must be treated at first with salves, applied as directed by the physician ; then with ice or poultices. When there is continuous high temperature, with great disturbance of the nervous system, with tremor, THE ERUPTIVE FEVERS. 199 twitchings, stupor, or grave delirium, it may become necessary to employ gradually cooled baths, not below 84°-80° F., which may be repeated several times in the course of twenty-four hours, and even to practise cold affusions while the patient is in the bath. The cold pack with repeated sprinklings is a gentler meas- ure often followed by equally beneficial results. In view of the possibility of depression of the circulation, wine or brandy must always be on hand, and will fre- quently be given with advantage. It is well to keep the patient in bed, or, at all events, in his room until the "skinning" is over; partly as a precaution against injudicious exposure and errors of diet, partly in order to detect the earliest symptoms of kidney-trouble, against the occurrence of which it is not always possible to guard; but over and above these reasons for prolonging the stay of the patient in his room is this, that it is necessary as a safeguard against his spreading the disease. If inflammation of the kidneys occur, it requires prompt and energetic medical treatment. Perspiration may be excited when there is suppression of urine by hot-air or vapor baths, which may be administered in bed, as follows : The covers being raised away from the patient's body by hoops, over which several blankets are stretched, and these well tucked in, hot bricks wrapped in dry or wet flannels, as the case may be, are slipped underneath the covers, with due precautions against burning the patient, until the heat is as high as can be comfortably borne. Or steam may be intro- duced by the long spout of the croup-kettle, or gener- 200 FE VER-NURSING. ated by slipping pieces of lime one after another into a pan of water under the covers, a towel having been arranged over the pan to prevent pieces of the lime or heated water from flying over the patient as it separates in slaking. Some skill and much care are required in giving a vapor-bath in this manner. I repeat that a convalescent must be kept away from all who are liable to contract or convey the disease until desquamation has wholly ceased. Before leaving the sick-room the patient must have two or three thor- ough warm soap-baths and be dressed in uncontam- inated clothing. Books and playthings ought to be destroyed by fire in the room, which must then be washed with corrosive sublimate solution, fumigated with sulphur in the presence of moisture or with formaldehyde, and opened to the sun and air for some days. Even then indi- viduals who have never had scarlet fever ought not to be permitted to occupy it for some time. Scarlet fever is the type of the eruptive diseases, and what has been said of its management may be said, with certain modifications, hereafter to be pointed out, of the management of the others. MEASLES. Definition.—Measles is an acute febrile disease, im- plicating in successive stages the mucous membranes and the skin; characterized by catarrhal symptoms from the beginning and a peculiar eruption, which ap- pears about the fourth day, fades about the eighth or ninth, and is followed by shedding of the outer skin in THE ERUPTIVE FEVERS. 201 minute branny scales; is highly contagious, usually prevails in more or less extensive epidemics, and occurs, as a rule, but once in the same person. Synonymes.—Rubeola; Morbilli. History.—Until about the close of the last century measles was not clearly distinguished from small-pox, of which it was generally regarded as a peculiar and benign manifestation. It is widely prevalent, and chiefly affects children. For this reason it is compara- tively rare among adults, but when it attacks them, is usually severe. I had under my care during a recent epidemic, at nearly the same time and in the same house, cases representing three generations: three children, their father, aged forty-two, and his mother, aged seventy-six. Measles is, as compared with scarlet fever, a mild disease, the appearance of which excites, as a rule, little apprehension in a community. It is, however, sometimes very severe, and becomes dangerous to life or subsequent health upon the occurrence of cer- tain complications. When introduced as a new disease, as happened some years ago on several occasions among the islands of the Pacific Ocean, it prevails as a malig- nant and extremely fatal pest. Individual immunity probably does not exist. Causation.—The infecting principle has not yet been recognized, nor is its method of transmission positively known. It is probably inhaled. The prevalence of the disease in epidemics is due to its extreme conta- giousness. It is not tenacious, as is the poison of scar- let fever, and for this reason its spread in households and communities, largely by way of the atmosphere, is 202 FEVER-NURSING. much less under our control. It can also be conveyed from the sick to the well for a considerable distance by those not themselves suffering from it, and in fomites of various kinds,—articles of apparel, toys, books, and the like. Course and Symptoms.—The period of incubation is eight or ten days. The outbreak is sudden, usually without premonitory symptoms, and is marked by sud- den rise of temperature,—102 °-l 04° F.,—catarrhal symptoms, sneezing, cold in the head, sometimes nose-bleeding, irritation and watering of the eyes, intolerance of bright light, cough, and hoarseness. There is restlessness, headache, and loss of appetite. During this stage there may be observed a reddish mottling of the palate and roof of the mouth. In a strong light there may be seen upon some of the spots upon the mucous membrane of the cheeks and lips minute bright whitish or bluish-white flecks, which ap- pear early and soon disappear—Koplik's sign. The eruption appears on the fourth day, less frequently on the third or fifth, first on the cheeks, forehead, and chin, and spreads rapidly over the whole surface. It consists of dark-red or even faintly brownish-red spots, varying in size from a mere point to that of a split-pea, slightly elevated and closely arranged, occasionally touching, but generally separated by a nar- row extent of nearly normal skin. The larger spots sometimes present an irregularly crescentic or half- moon arrangement. When the eruption is severe there is commonly some swelling of the skin, especially of the face, the expression being thus changed and disfigured, and of the backs of the hands. Distressing itch- n 1 E M E M E M E M E M E f D E Ml E %--£, DM, Airt 0- . -41" fe k A l\ n '\ I ] 1 \ fl V -f A t A A i 1 '\ e /\ / V V V -38" I A A " - / ' i \ -37' \ ■& „to - J*1 A 't* hi ,1 mi n )t' (1 -33* Dayo/Dis / i 3 ¥ J- ^ 7 ? Pulse. M y / /' ..--' Besp. Dale. M M y / ,M / THE ERUPTIVE FEVERS. 203 ing and burning often attends the eruption, and it may be complicated by nettle-rash or hives. The eruption reaches its full development in thirty- six or forty-eight hours, and then, after two or three days, rapidly fades. With the fading of the eruption the fever—which has increased on its appearance—and the catarrhal symptoms also decline, the defervescence being, in uncomplicated cases, usually critical. The desquamation of measles usually takes the form of the shedding of very fine scales, quite unlike the shreds and flakes thrown off in scarlet fever. If complica- tions do not occur, the convalescence is usually com- plete by the tenth or twelfth day. Diarrhoea is not uncommon at some periods of the attack. A very common symptom, especially in young chil- dren, is pain across the upper part of the abdomen. This pain has its seat in the muscles, and is of the kind known as myalgia. It is caused by the excessive use of the abdominal muscles in the act of coughing. The complications of measles, as a rule, consist in unusual intensification or extension of the catarrhal in- flammations characteristic of the disease. They may affect the eyes, nasal passages, throat, larynx, and chest. Inflammation of the middle ear also occurs. Epidemics of measles are very often preceded or fol- lowed by whooping-cough. There is, however, no well- established causal relation between these two diseases. The catarrhal inflammations of measles render certain patients especially liable to the development of pulmo- nary consumption. There is occasionally a tendency to the extravasation 204 FEVER-NURSING. of blood into the skin, constituting so-called " black- measles." The gravity of this symptom has been ex- aggerated, probably because in the past other diseases attended with petechial eruptions, and notably typhus fever, have been mistaken for measles. Very rare cases of undoubted measles with tendency to bleeding both into the skin and from the mucous surfaces have been described. Such cases are often severe; sometimes fatal. Variations from the ordinary form are much less common in measles than in scarlet fever, and consist in modifications in the intensity of the general symp- toms and in the absence or presence of complications, which are themselves merely exaggerations of symp- toms proper to the disease. The treatment of measles is expectant and sympto- matic. Its general management demands attention to ■the following points: The patient must be sedulously protected from draughts of cold air; the temperature of the room kept at 68°-72° F.; even in mild cases he must be confined in bed till the rash has faded and desquama- tion is over. The room may be slightly darkened, but must not be kept absolutely so. The eyes, nostrils, and mouth must be bathed at regular intervals with lukewarm water, to which a little borax or fluid ex- tract of witeh-hazel has been added. The edges of the eyelids ought to be once or twice a day lightly smeared with fresh cold cream or with vaseline. The throat and nasal passages may be advantageously sprayed as in scarlet fever. Inunctions of washed lard rubbed up with a few drops of carbolic acid to the ounce go far to THE ERUPTIVE FEVERS. 205 relieve the itching. For this purpose sponging with cold or lukewarm water containing borax or three or four drops of carbolic acid to the ounce, or Labarraque's solution, or Listerine, is also useful. A generous dietary is absolutely necessary. Alcohol in the form of milk-punches, eggnogg, wine-whey, or sound port may often be administered with advantage. Children of delicate organization, and especially those of families liable to scrofulous glandular enlargements and pulmonary consumption, must be cared for with solicitude for some weeks after the attack, or indeed until full health is regained. While it is not in all cases possible to prevent measles from extending when it has shown itself in a house- hold, it is always advisable to avoid unnecessary risk of infection, and our plain duty to see that all due pre- cautions are taken to prevent its spread beyond the limits of the house. To this end the children not yet sick must not be allowed to go to school or to make or receive visits. rotheln. Definition.—Rotheln is an acute infectious disease characterized by an eruption having superficial resem- blances to that of measles; by swelling of the lymphatic glands of the back of the neck, and by nearly complete absence of fever and catarrhal symptoms. It does not often occur a second time in the same individual. It is an independent affection, and has no relationship with measles or scarlet fever. Synonymes.—German Measles; French Measles; Rubella; Roseola; Epidemic Roseola. 206 FEVER-NURSING. History.—It is only within recent years that rotheln has been fully recognized as a separate and distinct disease. At one time it was regarded by some physi- cians as an irregular form of scarlet fever; by others, as an irregular form of measles; by yet others as a hybrid of those two diseases. Finally there were others who looked upon it not as a constitutional affection at all, but as a mere symptomatic rash analogous to the nettle-rash (urticaria) or rose-rash (erythema), which often show themselves in connection with derange- ments of the digestion, or after certain articles of food, as shell-fish, strawberries, or cheese. Rotheln was un- known to the majority of American physicians until within the last forty years. It is not, in fact, a fever in the ordinary sense, but is, as an infectious malady, highly contagious, self-limited, and self-protec- tive, properly described among the fevers, especially since much confusion still prevails in regard to its re- lation to measles and scarlet fever. Causation.—A specific, infecting principle, which must be, judging from its mode of distribution and effects, a germ. The disease is highly contagious, and contagious in the same way as measles. Hence its prevalence in epidemics and the especial liability of children. Course and Symptoms.—The period of incubation is between two and three weeks. The eruption is usually the first symptom observed. Constitutional disturb- ances are slight, often absent; occasionally they are manifest a few hours before the rash. Fever is slight and transient, sometimes absent altogether. The erup- THE ERUPTIVE FEVERS. 207 tion is irregular in character and distribution. It ap- pears first about head and face, and resembles sometimes that of measles, sometimes that of scarlet fever, but is paler, and appears and disappears irregularly over the surfaces, so that a fresh patch may make its ap- pearance just as a patch in some other region is fading. Slight catarrhal manifestations occur, and the glands of the back of the neck are more or less swollen. It is not often necessary to keep the patient in bed. At the end of about four days—sometimes five or six—the rash vanishes without desquamation, except when the eruption has been unusually intense. Very little treat- ment is required. SMALL-POX. Definition.—An acute contagious disease, character- ized by sudden onset, high temperature, and great constitutional disturbance; the appearance about the third day of a peculiar eruption which by stages de- velops about the ninth day of the disease into pustules, and upon the thirteenth or fourteenth day begins to form crusts, which dry and fall off in the course of the next week, usually, but not invariably, leaving upon the face numerous shallow but distinct characteristic scars. Second attacks are very uncommon. Synonyme.—Variola. History.—Small-pox has been a scourge of the human race since early historical periods. It ravaged Europe in destructive and constantly-recurring epidemics up till the time when the discovery of its preventive treat- ment by the immortal Jenner was, early in the nine- teenth century, firmly established upon a practical basis. 208 FEVER-NURSING. During recent years unmodified small-pox has pre- vailed in civilized communities only in limited out- breaks. Causation.—A specific infecting principle, the nature of which has not been demonstrated, but which in its natural history, mode of distribution, and enormous increase in the bodies of the sick shows itself to be a micro-organism. Liability to small-pox, except as lessened by vaccina- tion, is universal. The disease may occur at any age. One attack confers subsequent immunity, the exceptions to this rule being extremely rare. Small-pox is invariably the result of transmission by direct or indirect contagion from a person already ill with it. As in the other contagious diseases, however, it is not always possible to trace the mode of transmis- sion, since the poison may be conveyed by patients to a considerable distance and after the lapse of some time. The disease may be contracted from contact with the bodies of those dead of it. It can be produced by in- oculation. Course and Symptoms.—The period of incubation is variable, from ten to fourteen days being the average. The attack begins suddenly, without premonitory symptoms. There is chill, followed immediately by high fever, headache, pain in the loins. Severe consti- tutional symptoms, as stupor, delirium, restlessness, complete inability to take food, dry brown tongue, vomiting, attend this initial stage. The pulse is rapid, the temperature high. There is constipation, as a rule. On the second or third day there are to be seen irregu- THE ERUPTIVE FEVERS. 209 larly distributed and usually ill-defined rashes, which are sometimes associated with slight hemorrhages under the skin (petechia?). During the third or on the fourth day the fever sud- denly abates. At the same time there is usually great improvement in the general symptoms, so much so as to lead the patient to suppose himself convalescent. The variolous eruption now makes its appearance,— stage of eruption. The eruption begins upon the face and hairy scalp, next appearing upon the trunk and arms, and finally upon the legs. It appears at first as little red dots or spots, which in about two days form small knots, feel- ing to the touch like minute shot under the skin. On the top of these red knots a little water-blister or vesicle soon forms. This gradually increases in size, its con- tents becoming more opaque, until at length, by the sixth day of the eruption and the ninth of the disease, the characteristic pustule of small-pox is fully formed. The pustule has, as a rule, at its summit a little navel- like depression or dimple, and is hence spoken of as " umbilicated," and is surrounded by a red inflamma- tory border. There is, generally, especially when the pocks are thick-set, swelling of the skin, particularly that of the face, attended by considerable burning and itching pain. The countenance is much disfigured, the eyes closed by the swelling, and the hands puffed and painful. The mucous membranes of the mouth and throat, and to a less extent, of the vagina and rectum, are the seat of an analogous eruption, which does not, however, form pocks, but rather painful superficial 14 210 FEVER-NURSING. ulcers. These ulcers, especially in the mouth, some- times run together, and are the cause of great annoyance. In the larynx they occasion hoarseness, and may give rise to sudden dangerous symptoms of suffocation. The temperature falls with the efflorescence of the variolous eruption nearly or quite to the normal. Only, however, to rise again with the process of sup- puration, which is attended with return of the more serious symptoms of constitutional disturbance. It is at this period of the disease that serious complications are apt to arise. Towards the end of the second week the pustules begin to dry up,—stage of desiccation. The pus of the pocks, some of which have burst, dries into yellow or brownish-yellow crusts; the swell- ing of the skin subsides; the fever declines ; the general symptoms amend, and in the course of a few days the crusts fall off and convalescence is well begun. There is at this time troublesome itching of the skin. The site of the pocks shows a more or less distinct dark stain, —pigmentation,—and wherever the suppurative process has destroyed the skin there is a lasting scar. The hair falls out; but as a rule, to which there are occasional exceptions, it grows in again. The temperature of the initial stage is high, very often reaching 104°-106° F. It falls nearly or quite to normal at the time of the appearance of the erup- tion, and rises again with the suppuration. The second access of fever lasts a week or more. Defervescence is gradual. In severe cases abscesses, erysipelas, gan- grene, or bed-sores occur as complications. d J ? ? 8 % ?. b 9 7 Y > uj ------_ ------ '■?» £0 S __________>__________„ UJ ____ ( .... I TT S & 5 .....____,2____,._ "" UJ ______C 17 |>8 Jr" S ________WA. —+- UJ _______£___. + 7/ S ____.,;.____ _ . _, UJ _____?:__________ 77 o'S S ____= :;>.....________ _ UJ =;" Ti \,3 V S ::::::::::::::::::::::::::::;::= UJ ¥- ■_________ , ij S ... :=»__________i..::::: _ UJ =::______________e___________ ^ A* 2 .-»____________________:_____„ UJ |~C _,s---------------7- s ;; = > 3 UJ =::; i ;'---------------------w 4-. 5 - - --. K UJ .__C — -3- " T ;f M £ ...)______3___ -* UJ .J.______S - - T *?£? 5 ___..................__,; :........____\___......_ UJ _____i___________L_ k * i\ rf? 5 UJ ___":::v. ~" t ■i i i^ S — ;-e UJ ^ *' S +> :::::::::::-s"c« tt ^.f s T :-::!- .. ^ b UJ t] S -, UJ ::::::::::::::::::____l .... *.• i? s ___________________5____ ^ UJ ______________L... ■^0 £ s n 3.f <* 8 1 OJkO 0 A 0 0 0 ,. f. T «> ""it 2 Si i. o ' o o ' o o o vpuvjtoiutjf /D3JUW0 — O O wtt-tSsi&iS 0 0 0 . 0, 1 ^ ||| Fig. 22.—Discrete small-pox.—Royer. Fig. 23.—Confluent small-pox.—Royer. THE ERUPTIVE FEVERS. 211 Confluent small-pox is that form in which many of the pustules run together, forming more or less exten- sive areas of suppurative inflammation of the skin. Hemorrhagic small-pox is characterized by effusion of blood into the vesicles and by bleeding from mucous surfaces. It is also called black small-pox. It is apt to occur in elderly, feeble, or broken-down persons. There is another hemorrhagic form, only to be recog- nized as small-pox by its occurrence in connection with other cases, in which extensive irregular effusions of blood into the skin take place, without the development of pocks. It attacks young and robust persons, and proves fatal by the fifth or sixth day. It is known as purpuric small-pox. The preventive treatment of small-pox, which during the present century has proved such an inestimable boon to the human race, consists in vaccination. This operation should be performed in infancy, and again about the age of puberty. At the time of the preva- lence of epidemics of variolous diseases it is advisable for persons who have not already passed through an attack of varioloid or small-pox to be again vaccinated. The period of incubation of the vaccine disease is shorter by some days than that of small-pox. It is therefore proper for persons unprotected by vaccina- tion or a previous attack of small-pox, who have been exposed to the latter contagion, to at once submit to vaccination. By this means the severity of the subse- quently developing disease may be favorably modified. Small-pox in successfully vaccinated persons loses many of its terrors, and becomes the comparatively 212 FEVER-NURSING. mild affection to which the term varioloid or modified small-pox is applied. The essential identity of the two forms is shown, among other things, by the fact, of highest practical importance, that the mildest case of varioloid is capable of producing by contagion in un- protected persons the gravest forms of small-pox. VARIOLOID. {Modified Small-Pox.) The difference between small-pox and varioloid is not one of kind, but of degree of intensity. In truth, there is no distinct boundary-line between the two. At the bedside the striking difference is to be found in the fact that the pocks do not, as a rule, in varioloid undergo suppuration. Varioloid occurs usually in those who have been protected by vaccination. It may, however, exceptionally occur in persons possessing an extreme degree of insusceptibility to the action of the specific infecting principle. The initial stage of varioloid differs in no respect from the corresponding period of small-pox. But when the eruption appears the difference is at once manifest. The pocks are few in number and usually scattered chiefly over the trunk, instead of first appearing upon the face. They do not go on to sup- puration, but begin to dry up when they have reached the vesicular stage, not later than the sixth or eighth day of the disease. The whole duration of the attack is much shorter than that of small-pox. The secondary fever, or suppurative fever, does not occur, or if present Fic. 24.—One of two sisters suffering from small- pox; being unvaccinated, she developed a severe small- pox, and recovered, though considerably pitted. L. ,:. Fig. 25.—Sister of the preceding, was success- fully vaccinated in infancy; she contracted a mild varioloid and recovered without scarring. THE ERUPTIVE FEVERS. 213 at all, is slight. The temperature falls abruptly upon the appearance of the eruption, and does not rise again to any extent. The treatment of these diseases is symptomatic. The general management of the cases demands the careful observance of the rules of sick-room hygiene, complete isolation, effectual disinfection. The room must be large and airy ; sunlight should be excluded, since its action during the stages of suppuration in- creases the liability to pitting or scarring. The tem- perature should be maintained at 60°-70° F. Timid and unprotected persons should be excluded. The at- tendants ought to be selected from those who are fully protected and familiar with the disease. The nature of the disease demands a supporting treat- ment throughout. In the stage of suppuration alcohol must be freely administered. The mouth and nostrils should be systematically sprayed with diluted Dobell's solution, Listerine, or Labarraque, or a saturated solu- tion of boracic acid in rose-water. The utmost atten- tion must be paid to cleanliness. The skin must be bathed with tepid water at such intervals as are directed by the physician, and the clothing changed as may be required. Especially is care to be taken to prevent the accumulation of salves and lotions mixed with dis- charges from broken pustules and scabs upon the sur- face. In fact, there is at present a strong tendency among physicians to avoid the use of salves and oint- ments, and to pay more heed to cleanliness and the use of antiseptic lotions. The use of tincture of iodine, mercurial ointment, and countless other substances rec- 214 FEVER-NURSING. ommended as applications to prevent pitting, as well as the evacuation of the pustules with or without touching their bases with lunar caustic, fails of its purpose, and may well be omitted. Better results are found to fol- low the continuous application of iced or tepid com- presses wet with weak carbolated solutions. These are to be applied to the face, hands, and arms, their tem- perature being determined by the sensations of the patient. The management of the fever and of complications is to be conducted in accordance with general rules. So long as the scabs are exfoliating the patient must be from time to time bathed with soap and water and lightly anointed with carbolized vaseline. The crusts are to be burned. The complete disinfection or the destruction by fire of articles of clothing used about the patient, the effectual disinfection of the room and furni- ture, are to be vigorously enforced. The bodies of those dead of this horrible and loathsome disease should be disposed of by cremation. CHICKEN-POX. Definition.—Chicken-Pox is an acute infectious dis- ease of infancy and childhood, attended by transient mild constitutional symptoms, characterized by a scat- tered vesicular eruption, which comes out in successive crops and abruptly, and, soon undergoing desiccation, disappears in from three days to a fortnight, sometimes leaving shallow, sharply-defined permanent scars. It does not occur a second time in the same person. THE ERUPTIVE FEVERS. 215 Synonym.—Varicella. History.—Formerly regarded as a form of small- pox. Causation.—It is a disease of early life, contagious, and occasionally prevalent in an epidemic form, par- ticularly in hospitals and asylums for children. Course and Symptoms.—The period of incubation is on an average about two weeks. There are no pre- monitory symptoms. The disease appears suddenly, with small bright-red spots, which rapidly develop into water-blisters or vesicles about the size of a split pea, seated superficially upon the skin, and lacking the hard base of the variolous pock. These blisters are sur- rounded by a narrow, bright-red ring or areola. They are attended with little or no pain. They vary in num- ber from a dozen to one hundred or more, but are never thick-set, as is the eruption of small-pox. The greatest number usually is found upon the trunk; a few on the face and hairy scalp; still fewer on the extremities. Three or four may often be discovered upon the mucous membrane of the palate or elsewhere in the mouth. As the eruption appears in crops, we often see fresh vesi- cles side by side with those which are drying up. Each vesicle dries quickly about the time the fluid loses its clearness and acquires a milk-like opaqueness. They very rarely go on to pustulation. Children rarely show any great disturbance of the general health beyond slight feverishness, loss of appetite, pains in the limbs, and trifling catarrhal inflammation of the throat and nose. Even these symptoms rapidly pass away. Com- plications as such do not occur. Exceptionally there 216 FEVER-NURSING. is high fever—103°-105° F.—of brief duration and corresponding general disturbances* Recovery always takes place. No special treatment is necessary beyond confinement to the room or bed for a few days, and measures to prevent the irritation of the pocks by picking or scratching. Any mechanical injury to the delicate roof of the vesicle increases the danger of the formation of conspicuous lasting scars. VII. FEVERS WITH MARKED LOCAL MANIFESTATIONS. Rheumatic Fever—Pneumonia—Cerebro-Spinal Fever—Diph- theria—Bubonic or Oriental Plague. The temperature range, if we except pneumonia, does not conform to a type, nor does defervescence occur on definite days. Fever is, it is true, a controlling symptom, but the evidences of local mischief are con- spicuous and characteristic. This group includes Rheumatic Fever. Pneumonia. Cerebro-Spinal Fever. Diphtheria. The Bubonic or Oriental Plague. RHEUMATIC FEVER. Definition.—Rheumatic fever is a non-contagious, constitutional, febrile disease, characterized by acute inflammation of the joints, occurring irregularly and terminating without suppuration ; inflammation of the membranes of the heart is of very frequent occurrence. The disease does not run a definite course either in its duration or in the sequence of the symptoms ; it de- pends upon constitutional peculiarities, either inherited or acquired, and is not self-protective. On the con- trary, the very fact of an individual's once having 217 218 FEVER-NURSING. suffered from rheumatic fever indicates a liability to develop it under unfavorable circumstances again, or even repeatedly. Synonymes.—Acute Articular Rheumatism; Inflam- matory Rheumatism. History.—Rheumatic fever is prevalent in temperate countries, and rare alike in cold and in tropical lati- tudes. It is endemic in Europe and the United States, but is by no means uniform in its distribution and frequency. Some districts are almost free from it, while its prevalence where it is common varies from a few scattered cases at one season to such frequency at another as almost suggests an epidemic. Rheumatic fever is common after the sixth year of life; most fre- quent between fifteen and forty; rare after that period. Causation.—Exposure to cold and especially to damp cold. But why such exposure should cause rheumatism in certain persons, while others escape or suffer from other diseases, as pneumonia or bronchitis, is not clearly understood. Notwithstanding the great diversity of the manifestations of acute rheumatism, the older theories of its causation have been abandoned and it has definitely taken its place among the specific infections. The pri- mary exciting cause is a staphylococcus, probably that variety described by Poynton and Paine and now gen- erally known as the Streptococcus rheumaticus. Course and Symptoms.—The chief symptom of rheu- matic fever is an acute inflammation of the joints, of which several, and commonly the larger, are simultane- ously or successively affected. It is not common for many of the joints to become inflamed at the same time. In fact, it is characteristic of this disease that FEVERS WITH LOCAL MANIFESTATIONS. 219 the inflammation which is attended by the symptoms of swelling, redness, and pain makes its appearance suddenly, and often subsides rapidly. A joint that is inflamed to-day may be well to-morrow, or it may re- main inflamed, while others previously free from dis- ease are suddenly affected. In this way the disease is said to fly from joint to joint. Very often, however, the signs of inflammation very slowly pass away. This sudden inflammation of the joints is often the first symptom of the disease. Usually there are slight premonitory symptoms, as general sensations of discom- fort, chilliness, trifling sore-throat. Fever is seldom wholly absent, often slight, usually moderate, 102°-103° F. Its course is not typical, being irregularly intermittent, and corresponding in intensity to the activity of the local inflammation and the number of joints implicated. There is rarely a marked initial chill, and many of the familiar symp- toms of fever, as complete loss of appetite, great thirst, headache, drowsiness, and delirium, are absent. The skin is often bathed in perspiration, which has an acid odor and reaction, but which bears no necessary or constant relation to a fall of temperature. The course of the attack shows alternations of im- provement and aggravation of the joint-pains and the fever, and may extend over one or two, or, if not well treated, over as many as five or six weeks. The subsi- dence of the symptoms is gradual and the convalescence slow. It is apt to be interrupted by relapses. The patients are usually quite helpless, every move- ment being attended with agonizing pain. In many 220 FEVER-NURSING. cases the mere weight of the bed-clothes is insup- portable. The physician will be on his guard to detect by daily examinations the first signs of implication of the heart. The rheumatic inflammation affects most frequently the lining membrane and the valves,—endocarditis; less commonly its enveloping membrane,—pericarditis. These heart-troubles are probably more common than generally supposed. Sometimes they are too slight to give rise to easily detected changes in the heart-sounds; very often they occasion no appreciable symptoms. They constitute a most serious element of rheumatic fever, however, for the reason that they often lead to, and in fact are, the commonest cause of permanent heart-disease. There is a form of rheumatic fever which differs in certain particulars widely from the disease as ordinarily seen. It is attended by alarming nervous symptoms, and has therefore received the name of " cerebral rheu- matism" ; there is almost always an extremely high temperature, as high as is encountered in any form of sickness, which is spoken of as " rheumatic hyperpy- rexia." This condition may develop in the course of an attack which has not differed in any respect from the ordinary disease, or it may be preceded by unusual nervous symptoms, as headache and delirium, from the outset. The development of the symptoms is, as a rule, abrupt. There is great uneasiness, delirium, sometimes spasmodic twitchings of the extremities, or spasms of the muscles of the face, with stiffness of the jaw as in tetanus (lock-jaw). There may be general convulsions. FEVERS WITH LOCAL MANIFESTATIONS. 221 There is great pallor and lividity of the face and ex- tremities, and small, rapid, running, almost uncount- able, pulse. The temperature at first rises suddenly to 105°-106° F., and goes on to 107°-110° F. without remissions. The hyperpyrexia attains its highest point just before or shortly after death. Recovery from this form of rheumatic fever very rarely occurs. Fortu- nately, it is of most uncommon occurrence, many phy- sicians in large practice never having met with a single case. The special conditions which cause it are not well understood. The medicinal treatment of rheumatic fever by sali- cin, salicylic acid, and the salicylates has in recent years been attended by brilliant results, which have largely led to the disuse of the older methods. General hygienic and dietetic treatment are of great importance. An even temperature must be maintained in the sick-room. Draughts, cold, dampness, and sud- den changes of temperature are followed by intense pain and constitutional disturbance. The joints may be wrapped in cotton batting, or preferably in sheets of carded wool. The patients must, even in the mildest cases, be strictly confined to bed. My rule is, if pos- sible, to keep them in bed ten days or two weeks after the acute inflammation of the joints has subsided. This is of more importance than is commonly supposed whenever there has been the slightest implication of the heart. The diet should consist of soup, eggs, custards, jellies, and milk in moderation. If the fever has subsided, or is moderate, bread, toast, fresh fish, oysters, the 222 FEVER-NURSING. white meat of fowl, and game in small quantities may be permitted. For lingering joint-pains massage and galvanism are useful. The occurrence of hyperpyrexia demands the prompt and energetic use of the cold bath. If this measure cannot be employed, cold may be applied by means of ice, cold affusions, ice-bags, wet compresses, and injec- tions of iced-water. Every effort must be made to keep the temperature below 105° F. Chest compli- cations will not preclude active antipyretic measures. Alcohol may be required to counteract the flagging ten- dencies of the circulation. When the temperature falls under the influence of external cold, the thermometer must be used every hour. When the temperature again rises to 104° F., the bath must be again employed. In all cases of rheumatic fever in which there are nervous symptoms, the thermometer must be regularly used at intervals not exceeding two or three hours. Those who have ever suffered from an attack of rheumatic fever are to be warned of the danger of its recurrence, and they should avoid cold and damp dwellings, over-exertion, and subsequent exposure. They ought to habitually use daily cold sponge-baths, rapidly taken, only part of the body being exposed and bathed at once, and followed by brisk friction, the whole process occupying not more than ten minutes. PNEUMONIA. Definition.—An acute specific fever, characterized by the invariable presence of more or less extensive FEVERS WITH LOCAL MANIFESTATIONS. 223 changes of an inflammatory kind in one, less fre- quently in both lungs. These changes are attended by chest symptoms, among which are pain, cough, and rust-colored expectoration. The fever is of sudden onset, considerable intensity, and of variable duration, critical defervescence taking place, however, in a large proportion of the cases, on or about the seventh day. Pneumonia is not self-protective. Synonymes.—Lung Fever; Lobar Pneumonia; Fi- brinous Pneumonia; Pleuro-Pneumonia; Croupous Pneumonia. The old term lung fever corresponds very closely with the views at present held concerning the nature of pneumonia. Lobar pneumonia expresses the fact that one or more lobes of the lung are affected. It is used in contradistinction to lobular pneumonia, by which an essentially different lung-disease is known. Fibrinous and croupous pneumonia are terms intended to indicate the nature of the inflammatory substance thrown out into the lung, and are in contrast to the terms catarrhal or broncho-pneumonia, which describe an entirely different affection. Pleuro-Pneumonia in- dicates that there is inflammation of the membrane covering the lung as well as of the lung itself. The doctrine until recently almost universally entertained, that pneumonia is an inflammation of the lung, and the accompanying fever merely a symptomatic fever, is no longer tenable. History.—Pneumonia has been more or less clearly recognized as an independent disease from the early days of medicine. It is a common disease, and is en- 224 FEVER-NURSING. demic among the civilized races. It is occasionally so prevalent in localities that it assumes the guise of an epidemic visitation. Causation.—The primary exciting cause of pneu- monia is the diplococcus pneumoniae. In some cases other organisms are present. It is probable that several different micro-organisms may cause pneumonia. The disease is most frequent in the winter and spring. It may occur at any period of life from infancy to ad- vanced age, but the greater number of cases are observed in youth and middle age. It is somewhat more com- mon in men than in women. Course and Symptoms.—Pneumonia usually begins suddenly with prolonged chilliness or a decided chill. The patient in the course of a few hours experiences pain in the affected side, which is intensified on deep breathing. The respiration is quickened, shallow, and often irregular. At a later stage there may be urgent shortness of breath. Cough is usually troublesome from the beginning of the attack. As the cough is attended with pain, it is apt to be partly suppressed ; hence it is often short, muffled, and frequent. The characteristic tough, rusty expectoration is seen on the second day. It may, however, be absent throughout. Fever-blisters —herpes—often appear on the lips and nose. Appetite is lost, thirst not excessive; vomiting may occur, espe- cially early in the attack; constipation is the rule, diarrhoea the exception. Headache, sleeplessness, and delirium are met with in severe cases. The fever is almost always high from the beginning, —104° F.,—and conforms to a typical course. It is M E Irti E M E f 1 E MElM.E H 1 E M,E MIE MiE M E Ml E M E M E iM E I F 107° 1 "* |106° 3100° ^10-1" 103= ic;? 1C1= 100" S9C 1 90° 1 97° Day&Ihs DaU I r f r B / t n ; T . j I r A i A .E N n ^ ' TIM i i \ l\\ 1 I r 1 1 l\ 1 | ll ) 1 1 11 /-I— 1 /] ( i \ -39° H u I \ / \l \ 4J V I 1 ' y \ -V 1 i> f I t L ,\ - -r1 - — r t r 1 n 1 ' if "H" — 1 i 4i \ i Til M» 1 1 1 'IM! i 1 > j t i \ 1 \ -37" — — J •f J" L 7 r ,J*V I't-.'iJ"-' ■"""i. '4» J«" a',i |D«-- '°ii '% >% u -iV M* ^ ^".•-•' *n yO •' 0"M ' ^ ^'« i- J l/i °> I rl 5 J" K° U I s: s J-s n v> •C T - 3 5s - Pi V> -4=-"--n------ 5 1 if* ^J ^ t-^^TT' 2 r i n Jc (."" 5m^ — --- 3 pi V> «4 z ~, ... ■ / ] n \ \ 5 n IT 8 *3 03 CO \> o S & "V ■> Fig. 27.—Pneumonia; pseudocrisis, 5th day ; crisis 8th day. FEVERS WITH LOCAL MANIFESTATIONS. 225 subcontinuous in type. There are occasionally marked remissions in the early days of the sickness. The teriipcrature occasionally reaches 105°-107° F. As a rule the violence of the constitutional disturbance cor- responds to the intensity of the fever; but this is not always the fact, very grave cases, and even those ending in death, occasionally showing very moderate fever, 101°-103° F. The fall of temperature generally occurs as a distinct crisis. It frequently takes place at night, and often reaches subnormal grades in the course of a few hours. There is usually more or less abundant perspiration. Much less frequently defervescence is gradual. The fifth or seventh, and less commonly the ninth, twelfth, and thirteenth days of the attack are critical days. The lung-symptoms do not at once pass away with the fever, but as a rule the improvement in every respect is very marked. The frequency of the pulse is from the beginning greatly increased. It reaches 100 or 120. A pulse- rate of 140 or 160 indicates danger to life, although great frequency of the pulse is less ominous in chil- dren than in adults. A small, weak, irregular pulse is also of unfavorable omen. It is apt to be present in cases where, on account of feeble heart-action, dangerous attacks of collapse occur. Jaundice occurs in a certain proportion of the cases. When very deep or associated with serious general symptoms it adds to the causes of alarm. Light jaun- dice is sometimes present in benign cases. In children the initial chill is absent; vomiting is, 15 226 FEVER-NURSING. however, common at the beginning. Drowsiness, de- lirium, and convulsions are often present at the onset, and may obscure the real nature of the sickness. Rusty expectoration is very seldom seen in children under ten years of age. Old persons are extremely liable to pneumonia, and are apt to succumb to it. It often begins insidiously, and is marked by great weakness and debility from the onset. Marked nervous symptoms are common. Pneumonia is very common and very fatal in drunk- ards. The lung-symptoms are often masked by those caused by disturbance of the nervous system. The case presents all the appearances of a severe attack of De- lirium Tremens. Neither cough, shortness of breath, nor pain in the chest are prominent symptoms. Pre-existing diseases render pneumonia much more dangerous. Much difference of opinion prevails among physicians in regard to the treatment of pneumonia. Bleeding, formerly much practised, is not at present regarded as admissible, save in exceptional cases. The usual plan of treatment is symptomatic. The three prominent symptoms which especially demand relief are pain, cough, and difficulty in breathing. The pain is often relieved by the application of ice- bags, cold compresses, warm compresses, hot poultices, mustard-plasters, or dry cups. Hypodermic injections of morphine are used by many physicians. Leeches and cut cups are employed in cases for which they appear suitable. The high temperature does not usually require active antipyretic treatment. Cold baths are FEVERS WITH LOCAL MANIFESTATIONS. 227 seldom necessary. The tepid bath, into which the patient is to be lifted without any effort on his part, is said to be followed by very good results, especially when there are marked nervous symptoms or great difficulty in breathing. Its temperature should be about 80° F., and the duration of the bath not more than five to ten minutes. The most generous diet that can be digested is to be given, and wine or spirits, in cases for which their effects are necessary, may be administered without stint. Par- ticularly is very free stimulation needed in the case of feeble and elderly persons and of drunkards. CEREBRO-SPINAL FEVER. Definition.—A malignant continued fever, occurring in general or limited epidemics, and caused by a specific micro-organism. It is of sudden onset, mostly of rapid course, and very fatal. The symptoms point to profound disturbance of the functions of the brain and spinal cord; associated headache, vomiting, and painful contraction of the muscles of the back of the neck are characteristic. Delirium, stupor, coma, and palsies occur. In many instances eruptions, chiefly herpetic and petechial, attend the disease. There is uniformly great nervous depression. The changes found after death are constant, varying only in the degree of their development. They are the results of an acute diffuse inflammation of the investing mem- brane of the brain and spinal cord. Synonymes.—Epidemic Cerebro-Spinal Meningitis ; Epidemic Meningitis ; Spotted Fever. History.—Cerebro-spinal fever was first recognized as 228 FEVER-NURSING. a distinct affection about the beginning of the nineteenth century. Prior to that date it was regarded as a peculiar form of typhus fever. It has during the present century prevailed in every country of Northern Europe and in most parts of the United States. It made its appearance in Philadelphia in 1863, and prevailed annually in an epidemic form until towards the close of that decade, while occasional cases were observed up to 1873, in which year a small but fatal epidemic prevailed in every district of the city, even those most widely separated. Since 1873 it has not occurred here as an epidemic. Many cases have occurred in widely separated localities of the city during the years 1905, 1906, and 1907. Causation.—The primary cause of cerebro-spinal fever is the diplococcus intracellularis meningitidis. Much less is known of the laws which govern its origin, its distribution, its action in communities and upon in- dividuals, than is known of the active causes of the other infectious diseases. The unaccountable appear- ance of the disease at the same time in widely separated localities, its diffusion by isolated attacks rather than by direct advances, its erratic and often long-continued prevalence in epidemics, the extraordinary diversity of the symptoms at different times and in different cases, baffle the comprehension and render futile every effort to account for the origin of this remarkable disease. Cerebro-spinal fever may occur at any period of life. It is by far more common during the first twenty years of life than later. It is equally common in the two sexes in infancy and childhood; in adult life the pre- ponderance of cases is among males. FEVERS WITH LOCAL MANIFESTATIONS. 229 Cerebro-spinal fever is not contagious in the ordinary sense,—that is, like scarlet fever, small-pox, or typhus, —but that it is communicable from the sick to the well under favorable circumstances is very probable. Course and Symptoms.—Cerebro-spinal fever pre- sents a great diversity of symptoms in different cases. Like other epidemic diseases, its course is attended by the greatest variations in intensity, duration, and the prominence of particular phenomena, not only in dif- ferent epidemics, but in the same epidemic. In this respect, however, it not only resembles other epidemic diseases, but it also far surpasses them. No acute dis- ease whatever appears in such various arrays of symp- toms. Stille has well called it a " chameleon-like dis- order." It is this that has rendered it more difficult to describe satisfactorily than to recognize at the bedside. It is this also that has led to the great diversity of opinions concerning it that have been entertained by different observers. In by far the greatest number of cases the attack is ushered in by symptoms of the most formidable char- acter. The patient is seized writh a violent chill; ago- nizing headache, nausea and vomiting supervene. He is restless, tossing about the bed and oppressed with an overwhelming sense of illness. His countenance be- tokens his profound distress. His face is seldom flushed, usually pale, sometimes wearing the expression of those under the influence of narcotic poisons. In a short time dragging pains in the neck come on, which spread to a greater or less extent along the spine and into the extremities, and are soon followed by that 230 FEVER-NURSING. tetanic stiffness of the muscles of the spinal region that is one of the characteristic features of the disease. Pain is now experienced in attempting to bend^the head for- ward, or to turn it from side to side. The muscular stiffness extends to the extremities, and movements are made with awkwardness and difficulty. The head is drawn back, the spine curved, the forearms flexed upon the arms, the legs upon the thighs. Cramps in the muscles of the legs and elsewhere, and spasmodic twitchings of the lips, eyelids, etc., come and go. General convulsions may occur, especially in children. A slight pinch, or an attempt to separate the eyelids for the purpose of examining the eye, will often call forth an expression of pain, even when insensibility is pro- found. The greatest suffering is, however, from the headache, which often causes restlessness and expres- sions of suffering during insensibility. It is described as sharp, lancinating, or boring, and may be either in the forehead or occiput, or may shoot about in all di- rections. Sometimes it is felt as a constricting band; sometimes it cannot be located, but is spoken of as an unutterable anguish. Pain of a like nature is felt in the lumbar, epigastric, and umbilical regions. The ab- dominal pain is usually an early symptom, and some- times precedes the vomiting. Vertigo persists. It re- curs upon every attempt to rise, and is often distressing when the patient lies quiet, compelling him to seize hold of the bed. The vomiting continues. At first the contents of the stomach, afterwards bilious matters, and gastric mucus are thrown up. The high mental excitement which marks the onset Fig. 28.—Epidemic cerebro-spinal fever. JL............_>,___......J Fig. 2EX 263 Ice, application of, 88 Iced-water compresses for nose-bleed, 100 enemas, 92 Immunity of nurse, 13 from enteric fever by vacci- nation, 152 Immunization in diphtheria, 247 Impairment of mental facul- ties, 65 Infantile remittent fever, 118 Infecting principle of essen- tial fevers, 57 transmission of, 15 Infection, 15 Infectious disease, definition of, 16 Infectious fevers, 57, 60 Inflammatory rheumatism, 218 Influenza, 172 alcoholic stimulants in, 175 causation of, 173 chronic forms of, 175 complications in, 175 contagiousness of, 173 course of, 173 definition of, 172 diet in, 175 duration of, 174 history of, 172 infecting principle of, 173 symptoms of, 173 nervous system, 174 synonymes, 172 treatment, 175 for pains in chest, 176 Injections (see Enemas), 113 Inoculable diseases, 60 264 INDEX Insects as conveyors of disease, 19 Instruments, washing of, from sick-room, 31 Intercurrent relapse, 129 Intermittent fever, (see Mala- rial fever), 54, 182 Intestine, perforation of, in enteric fever, 124 hemorrhage from, treat- ment of, 133 in enteric fever, 124 Intubation, 248 Irregular malarial fever (see Malarial fever), 186 Isolation of patient, 22 in infectious diseases, 36 in diphtheria, 243 in measles, 205 in scarlet fever, 197 Jail fever, 154 Jaundice in pneumonia, 225 Jelly, calves'-feet, 109 Joints, in rheumatic fever, 218 in scarlet fever, 195 Junket, preparation of, 108 Kefir, 108 Kidneys, inflammation of, in scarlet fever, 193, 194, 199 Klebs-Lceffler bacillus, 237 Koplik's sign, 202 Koumiss, 108 Laryngeal diphtheria, 239 Leiter's coils, 88 Light in the sick-room, 98 Lime as a disinfectant, 33 Lobar pneumonia, 223 Louse, a carrier of relapsing fever, 170 the carrier of typhus in- fection, 158 Low fever, 118 Lung complications in enteric fever, 125 Lung fever (see Pneumonia), 223 Lysis, 55 Malaria, 182 Malarial cachexia, 185 fevers, 182 estivo-autumnal, 186 continued, 186 intermittent, 184 cold stage, 184 hot stage, 185 management of, 185 medicines in, 186 sweating stage, 185 irregular, 186 organisms of, 183 pernicious, 184, 187 algid or congestive form, 187 comatose form, 188 hemorrhagic form, 188 remittent, 186 transmissibility of, 184 parasites, 183 Malt extracts, 111 Matzoon, 108 Measles, 200 abdominal pain in, 203 alcohol, use of, in, 205 INDEX 265 Measles, black, 204 catarrhal inflammations in, 203 causation of, 201 complications of, 203 contagiousness of, 201 course of, 202 definition, 200 desquamation of, 203 diet, 205 eruption of, 200, 202 German or French (see Rotheln), 205 history of, 201 infecting principle of, 201 Koplik's sign, 202 nurse's duties in, 204 prevention of its spread, 205 symptoms of, 202 synonymes, 201 temperature in, 202 treatment, 204 variations in form, 204 whooping-cough asso- ciated with, 203 Meat juice as a food, 107 how to extract, 109 Medical thermometry, 39 Medicines, care of, 84 Membranous croup (see Diph- theria), 236, 239 Meningitis, cerebro-spinal (see Cerebro-spinal fever), 227 Menstruation in enteric fever, 127 Mental faculties, impairment of, 65 Mexican typhus, 155 Milk foods, 107 forms of administration, 103 laboratories, 106 modified, 106 of lime, 33 pasteurized, 103 peptonized, 104 sterilized, 103 Modified milk, 106 Mosquitoes as carriers of ma- laria, 19, 183 of yellow-fever organisms, 178 Mouth, care of, 100 condition of, in enteric fever, 125 Muscles, spasmodic twitching of, 69 Myalgia in measles, 203 Nasal diphtheria, 239 Nausea, 71 Nephritis, post-scarlatinal, 193, 194 treatment, 199 Nervous fever, 118, 125 symptoms in enteric fever, 125 i in rheumatic fever, 220 treatment of, 94 system, symptoms of, in fever, 64 Noises in ears, 70 of the household, 98 Normal temperature, 47 Nose, collections in, 99 picking of, 99 bleeding, 70, 100 in enteric fever, 123, 125 OEX 266 INI Nurse and doctor, 82 dress of, 15 duties of, in sick-room, 82 immunity of, 13 precautions of, against infec- tion, 39 qualifications of, 12 relief of, 39 Odors in sick-room, 17 how removed, 84 Organo-therapy, 81 Organs of special sense, care of, 98 involvement of, in fever, 70 Oriental plague (see Plague), 248 Oyster-juice, 110 Pack, cold, 89 Pains in back and limbs, 65 treatment of, 95 of rheumatic fever, 219 Paralysis after diphtheria, 241 Paratyphoid, 153 Pasteurized milk, 103 Patient, bathing of, 85 care of, 83 hair of, 85 toilet of, 85 Peeling of skin, 74 Peptonized milk, 104 Perforation of intestine in en- teric fever, 124 Pericarditis, 220 Periodical fevers, 54, 59, 182 Peritonitis in enteric fever, 124, 128 treatment of, 134 Permanganate-formalin meth- od of disinfection, 29 Pernicious fever (see Malarial fever), 187 Person, disinfection of, 31 Pestilential fever, 154 Petechie, 154 of typhus fever, 162 Pfeiffer's influenza bacillus, 173 Phenol, a disinfectant, 31 Photophobia, 70 Picking of nose, 99 Plague, 248 causation of, 249 course of, 250 definition of, 248 duration of, 252 hemorrhages in, 251 history of, 248 individual predisposition, 250 infecting organism of, 249 predisposing influences, 249 preventive inoculations, 253 prophylaxis of, 251 symptoms of, 250 synonymes, 248 temperature in, 250 transmission of, 249 treatment of, 252 Plans of treatment, 75 Plasmodium malarie, 183 Pleuro-pneumonia, 223 Pneumonia, 222 blood-pressure in, 73 causation of, 224 course of, 224 crisis in, 225 IND Pneumonia, definition of, 222 diet in, 227 history of, 223 in the aged, 226 in children, 225 in drunkards, 226 infecting organism of, 224 jaundice in, 225 sjmaptoms of, 224 synonymes, 223 temperature in, 54, 224 treatment of, 226 of pain, 226 tympanites in, 71 Post-scarlatinal nephritis, 193 Preagonistic rise of tempera- ture, 55 Prevention of disease, 61 Preventive medicine, 79 Privies for camps, 137 Privy-vaults, disinfection of, 35 Prophylactic vaccination, 151 Prostration, 68 treatment of, 96 Pulse, 72 counting of, 114 in cerebro-spinal fever, 231 in enteric fever, 126 in pneumonia, 225 in typhus fever, 161, 164, 165 Purpuric small-pox, 211 Putrid sore throat, 237 Pyemia, 16 Pyrexia, definition, 11 hyper-, 48 mild, 48 severe, 48 EX 267 Qualifications of nurse, 12 Quarantine, against yellow fever, 178 practical regulations for, 36 isolation not practica- ble, 38 with a trained attend- ant, 36 without a trained at- tendant, 37 Quartan ague, 185 parasite, 184 Quicklime, 33 Quinine in malarial fevers, 186, 187, 188 Quotidian ague, 185 Rash of cerebro-spinal fever, 232 of dengue, 180 of enteric fever, 123 of measles, 202 of scarlet fever, 192 of small-pox, 209 of typhus fever, 161 Rational treatment, 78 Reaumur temperature scale, 40 Record keeping, 39 Recrudescence, 56 Rectum, feeding by, 112 Reduction of thermometric readings, 40 Regularity of duties in the sick-room, 38 Relapse, 56 in enteric fever, 128 in typhus fever, 166 intercurrent, 56, 129 multiple, 56 268 INDEX Relapsing fever, 117, 169 causation, 170 cleanliness in, 171 contagiousness of, 171 definition of, 169 disinfection in, 171 infecting principle of, 170 prevention of, 170 treatment of, 172 ventilation in, 171 Remittent fever (see Malarial fever), 54, 186 Respiration, 73 how to observe the, 114 Respiratory symptoms, 114 system, symptoms of, in fever, 73 Rheumatic fever, 217 alcohol in, 222 causation of, 218 cold applications and baths, 222 course of, 218 definition, 217 diet in, 221 heart troubles in, 220 history, 218 infecting organism of, 218 joints in, 218 nervous symptoms in, 220, nurse's duties in, 221 pain of, 219 recurrence of, 222 skin in, 73 symptoms of, 218 synonjmaes, 218 temperaturein,219,221,222 treatment, 221 hyperpyrexia, 220 Rheumatism, cerebral, 220 Rigors, 65 relief of, 95 Ringing in ears, 70 Rose rash of enteric fever, 123 Roseola (see Rotheln), 205 Rotheln, 205 causation, 206 contagiousness of, 206 course of, 206 definition, 205 eruption of, 206 history of, 206 symptoms of, 206 Rubella (see Rotheln), 205 Rubeola (see Measles), 200 Sapremia, 16 Scarlatina (see Scarlet fever), 189 Scarlet fever, 189 anginose form, 195 causation, 190 complications, 193 contagiousness of, 191 course, 192 definition, 189 desquamation in, 193 diet, 196 disinfection after, 200 diphtheria in, 193 ear, inflammation of, in, 194 fever of, 193 history of, 190 immunity from, 191 infecting principle of, 190 INDEX 269 Scarlet fever, isolation of patient, 197, 200 period of, 199 joints in, 195 malignant form, 195 mild or rudimentary form, 195 nephritis after, 193, 194 prevention against spread- ing infection, 197 rash of, 192 sick-room in, 196 simple or ordinary form, 195 skin, care of, in, 196 sjmaptoms, 192 sjmonjmaes, 190 throat troubles in, 193 tongue, appearance of, in, 194 treatment, 196 baths, 199 of the ears, 198 of mouth and nose, 198 of nephritis in, 199 of throat, 198 urine in, 195 Schering's formalin lamp, directions for use of, 27 Schick test for susceptibility to diphtheria, 247 Sepsis, 16 Septicemia, 16 Septicopyemia, 16 Serum therapy, 81 in diphtheria, 245 technic, 246 in plague, 253 Ship fever, 154 Shivering, relief of, 95 Shock, temperature of, 46 Sick-room, 84 disinfection of, 23 furnishings of, 14, 84 in cerebro-spinal fever, 236 in measles, 204 in scarlet fever, 196 in small-pox, 213 in typhus fever, 167 light in, 98 odors in, 17, 84 protection from insects, 19 regularity in, 38 ventilation of, 14 Sinks, in camps, 137 Skin, care of the, 115 in scarlet fever, 196 desquamation of, 74 hyperemia of, 74 in fever, 73 peeling of, 74 sudamina, 74 Slaked lime, 33 Small-pox, 207 applications to prevent pit- ting, 214 causation, 208 complications of, 210 confluent form, 211 course of, 208 definition, 207 disinfection after, 214 eruption of, 207, 209 hemorrhagic, 211 history, 207 hygiene in, 213 incubation of, 208 liability to, 208 270 INI Small-pox, nurse's duties in, 213 prevention of, 211 purpuric form, 211 sick-room in, 213 stage of desiccation, 210 of eruption, 209 symptoms, 208 temperature of, 208, 210 transmission of, 208 treatment, 213 Solid food, 111 Somnolence, 68 Sordes, 71 Special sense, organs of, care of, 98 Specific treatment, 79 Sphygmomanometer, 72 Spirillum of relapsing fever, 170 Sponging, cold, 87 Sporadic cases, 79 Spotted fever (see Cerebro- spinal fever), 227 Sputum, care of, 115 Sterilized milk, 103 Stimulants in typhus fever, 167 Stools, disinfection of, 33 in camps, 138 Strawberry tongue, 194 Streptococcus rheumaticus,218 Stupes, turpentine, 113 Stupor, 68 Subcuticular eruption of ty- phus, 162 Subfebrile temperature, 48 Subnormal temperature, 47 Subsultus tendinum, 69 Sudamina, 74 Sulphur dioxide as a disinfect- ant, 24 Surface thermometers, 42 Symptomatic fever, 12 treatment, 76 Symptoms of fever, 62 cutaneous system, 73 digestive system, 70 nervous system, 64 organs of special sense, 70 respiratory system, 73 urinary system, 74 Tabardillo, 155 Taste, perverted, 70 Tea, beef, 109 Temperature, excessively high, 50 febrile high, 48 intense, 49 moderate, 48 in collapse, 46 in continued fevers, 117 in convalescence, 50 in diphtheria, 239 in disease, 46 in enteric fever, 46, 54, 126, 135 in fever, conditions influenc- ing, 50 in health, 44 after eating, 45 in infants and children, 45 in measles, 202 in plague, 250 in pneumonia, 54, 224 in rheumatic fever, 219, 221, 222 in scarlet fever, 193 INDEX 271 Temperature in shock, 46 in small-pox, 208, 210 in typhus fever, 161, 165 normal, in disease, 47 preagonistic rise, 55 range of deviation from normal, 46 recording of, 51 reduction of, 86, 94 subfebrile, 48 subnormal, 47 sudden fall of, 93 taking of, 39 in children, 45 in sickness, 45 positions available for, 42 axilla, 42 mouth, 43 rectum, 44 vagina, 44 Temperature charts, 51 Tertian ague, 185 parasite, 184 Test for susceptibility to diph- theria, 247 Thermometers, clinical, 39 Centigrade scale, 41 Fahrenheit scale, 40 Reaumur scale, 40 self-registering, 41 surface, 42 Thirst, 71 relief of, 100 Throat troubles in scarlet fever, 193, 198 Toilet of patient, 85 Tongue, biting of, in convul- vulsions, 98 in fever, 70 Tracheotomy, 248 Transmission of infecting prin- ciple, 15 Treatment of fevers, 75 methods of, 76 expectant, 77 hydrotherapy, 78 organo-therapy, 81 rational, 78 serum-therapy, 81 specific, 79 symptomatic, 76 vaccination, 81 Tremor, 69 Turpentine stupes, 113 Tympanites, 71 in enteric fever, 133 Typhoid carriers, 129 Typhoid fever (see Enteric fever), 118 Typhus fever, 154 absolute rest imperative, 168 alcohol, internal use of, 167 causation of, 156 contagiousness of, 156 period of, 158 course of, 159 crisis of, 165 definition, 154 delirium of, 154, 163 disinfection in, 166 duration of, 166 eruption of, 153, 161 distribution of, 162 fomites of, 157 general management of, 167 )EX 272 INL Typhus fever history, 154 hygienic measures, 167 incubation of, 158 immunity from second attack, 159 infecting principle of, 156 Mexican, 155 prevention of, 166 pulse in, 72, 161 rectal alimentation and medication, 168 relapses in, 166 stimulants in, 167 symptoms, 159 sjmonymes, 154 temperature in, 161, 165 termination of, 165 abortive cases, 165 fatal cases, 164 transmission of, means of, 156 Uremic convulsions, 69 Urinal, the, 85 disinfection of, 35 Urine, disinfection of, 35 in enteric fever, 134 in fever, 74 color, 75 quantity, 74 in scarlet fever, 194, 195 inspection of, 115 Utensils, disinfection of, 35 washing of, from sick-room, 31 Vaccination, 81, 211 prophylactic, against enteric fever, 151 technic, 152 Varicella (see Chicken-pox), 214 Variola (see Small-pox), 207 Varioloid, 212 treatment, 213 Ventilation, 14 in relapsing fever, 171 Vertigo, 65 Visitors, 36 conveyors of disease, 22 Vomiting, 71 Walking typhoid, 127 Warm bath in convulsions, 98 Water, administration of, in mental disturbances, 97 Water as a drink, 100 as a remedy, 101 Water-borne diseases, 61 Water-closets, disinfection of, 35 Whey, preparation of, 107 Whitewash, a disinfectant, 33 Whooping-cough preceding or following measles, 203 Yellow fever, 117, 176 absolute rest in, 179 causation of, 177 definition, 176 food in, 179 hemorrhages in, 176, 177 incubation of, 178 infecting principle, 177 management of, 178 quarantine, 178 symptoms of, 176 transmission of, 177 vomiting of blood in, 176 Zoolak, 108 S?8 I Q> % NLM052868342