NURSING IN ACUTE FEVERS.

TYPHOID OR ENTERIC FEVER.

Typhoid fever is an acute infectious disease, excited by the typhoid bacillus. It is most prevalent in the autumn, although it occurs at all seasons. The disease is not directly contagious, and can only be acquired by taking the special bacillus into the alimentary canal. This is usually accomplished through the medium of polluted water, milk contaminated with infected water, raw vegetables (celery, lettuce, water-cress) which have grown in infected soil, or raw shell-fish (oysters) taken from the beds of polluted streams. Occasionally physicians and nurses are infected directly in handling the patient or his clothing which has become soiled with his discharges.

The bacilli are contained in nearly all the secretions of the patients, especially in the stools and urine.

While the bacilli are widely distributed through tissues, the only characteristic lesions of the disease are in the glands of the intestines (Peyer’s patches), which in the first few days become red and swollen, about the beginning of the second week soft and pale, and in the third week ulcerated. If the patient survive, cicatrization usually begins in the fourth week.

Death may result from exhaustion, the result of the systemic poisoning, from perforation of the bowel by an ulcer, from intestinal hemorrhage, the result of erosion of a blood-vessel, or from some complication, like pneumonia.

Symptoms.—The initial symptoms, which may last a week or two before there is any fever, are headache, weakness, loss of appetite, nose-bleed, and perhaps slight diarrhea.

The fever rises gradually, reaching its maximum (104°-105° F.) in about a week; it remains stationary for one, two, or three weeks, and then falls, reaching the normal in another week, thus making the febrile period of the disease of four or five weeks’ duration. Throughout its course the evening temperature is apt to be two or three degrees higher than the morning temperature.

The abdominal symptoms consist of distention of the abdomen (tympanitis), pain and tenderness in the right iliac region, and often diarrhea.

Between the seventh and ninth days a rash usually appears on the abdomen, consisting of small rose-red spots. These come out in crops and disappear on pressure.

The pulse becomes rapid and feeble, and the heart sounds become weak and dull.

The respiratory symptoms include cough, hurried breathing, and slight expectoration.

Nervous symptoms are not always marked. In severe cases there may be delirium, stupor, twitching of the muscles, picking at the bed-clothes, and coma.

The face is dull and listless. The tongue is coated and tremulous. In severe cases it becomes dry, brown, and fissured, and sordes tend to collect upon the teeth.

Relapses are common. In some cases they are due to the too early use of solid food, to excitement, or to overexertion.

When typhoid fever is prevalent, the most reliable preventive measures consist in thorough boiling of all water and milk used for drinking purposes and the avoidance of uncooked vegetables, oysters, and shell-fish.

Management.—Unless otherwise directed take temperature, respiration, and pulse every three hours, in mouth or axilla, as desired. If for any reason a change is made in taking temperature, it should be noted on the chart. Note the effect of sponging or of bathing upon temperature and pulse. Note the character of pulse, and effect, if any, which stimulants have had upon it. Note the amount of cough, and the character and quantity of the expectoration; also any pain that may occur in the chest.

Note the amount of flatulence and the number and character of the stools; especially be on the lookout for blood or undigested food in the discharges.

Note carefully any abdominal pain, any increase in the distention, as these symptoms, with or without a rather abrupt fall in temperature, chills, and pinched features, are suggestive of perforation.

Treatment for Hemorrhage.—Stop all orders immediately, including diet. Elevate the foot of the bed. Give morphin sulphate, gr. ¼ (gm. 0.015), hypodermically, and apply an ice coil or iced compresses to the abdomen until the physician arrives.

Note the occurrence of vomiting and the character of vomit.

Be on the lookout for retention of urine, which is quite common. Note the amount of urine passed in a day and any abnormalities connected with its appearance.

Note the condition of the skin and tongue.

Note the amount of sleep, its character, whether quiet or restless and whether or not there have been delirium, stupor, or twitching of the muscles.

Note the exact amount and character of nourishment taken, and the time it was given; also the amount, time of administration, and effect of medicines and stimulants.

Cleanse the mouth and teeth frequently with some antiseptic wash, such as listerine, 1 part; water, 3 parts.

Bed-sores can nearly always be prevented by keeping the patient and bedding perfectly clean, the skin absolutely dry, and the bed-linen smooth. Changes of position are also important. Parts subjected to pressure and soiling should be washed at least twice daily with soap and water, thoroughly dried, gently rubbed with alcohol, and then dusted with a powder like the following:

Boric acid, 1 part;

Starch, 1 “

Zinc oxid, 1 “

If the skin be reddened and tender it may be painted with collodion and then dusted. When the part cannot be kept dry, it should be smeared with zinc ointment and powdered. In very prolonged cases it usually becomes necessary to use water- or air-pillows or water- or air-beds.

To disinfect the feces and urine, use a solution of chlorinated soda (Labarraque’s solution). Cover the urine and feces with the solution and leave the contents stand for an hour. Cleanse pan thoroughly and pour into it the Labarraque solution.

PNEUMONIA.

Pneumonia is a general infection, excited by a special organism—the pneumococcus—and manifested by a local inflammatory process in the lung and severe systemic disturbances.

Exposure to cold and lowered vitality from overwork, alcoholism, or some previous disease render persons liable to infection.

Symptoms.—These consist in a decided chill, pain in the side, fever rising rapidly to 104°-105° F., and lasting for five, seven, nine, or eleven days, and then rapidly falling; cough; tenacious bloody expectoration, shortness of breath, delirium and stupor, and physical signs indicating a solid condition of the affected lung.

In fatal cases death usually results from exhaustion, the result of the systemic poisoning, but occasionally it is due to a failure of the heart to propel the blood through the solid lung, to suffocation, or a complication, such as inflammation of the covering of the heart (pericarditis) or lining of the heart (endocarditis).

Management.—The room should be well ventilated, but free from drafts. The temperature should be maintained between 65° and 70° F. Cool water should be given freely. The points mentioned in connection with temperature, respiration, and pulse in dealing with typhoid fever are applicable here. Note the frequency of cough, the amount and character of expectoration, and whether the latter is raised readily or with difficulty. Note the occurrence of pain and its location; also amount of sleep, amount of nourishment, amount of urine, number of stools, etc., and the effect of sponging, of medicines, and of local applications. Clean the mouth and teeth at intervals, being extremely careful, however, in all manipulations not to tire or exhaust the patient.

SCARLET FEVER.

Scarlet fever is an acute, highly contagious disease characterized by a sudden onset with chill, vomiting, or convulsions; a high fever of from a week to ten days’ duration; a very rapid pulse; severe sore throat; a bright red rash, appearing on the second day, lasting about a week, and followed by desquamation and a marked tendency to nephritis.

The most serious complications are nephritis, suppurative inflammation of the middle ear (otitis media), inflammation of the endocardium or pericardium, and pneumonia.

Scarlet fever, while contagious at all periods, is probably most so during the period of desquamation. The organism may cling to furniture, clothing, etc., and reproduce the disease after very long periods. The contagion may be carried by persons coming in contact with the sick, or the disease may be transmitted through the air of the sick-room or through clothing, utensils, etc., which have been used by the sick.

Prevention of contagion consists in isolating the patient; in disinfecting everything that has been in contact with him; in anointing the patient’s body with an antiseptic oil until desquamation is complete; and in thoroughly disinfecting the room after the patient’s removal.

Management.—Have the patient, if possible, in a large, airy room, preferably at the top of the house. Keep the temperature uniform and the room well ventilated. Wear a loose wrapper and cap, and leave these inside the room when obliged to leave it.

With cloths moistened with a 3 per cent. solution of carbolic acid wipe the floor, furniture, sills, door-knobs, mantelpiece, etc., once a day, but never dust or sweep. Thoroughly disinfect the secretions of the patient and all articles used by him before they leave the room.

Allow the patient no food except what has been ordered, which will usually be milk, koumiss, junket, fruit-juices, and gruels. Encourage the patient to drink water freely. Apply to the body, at least once a day, a bland ointment. Note temperature, respiration, pulse, stools, quantity of nourishment, sleep, and effect of baths and medicine as in typhoid fever. Note especially the quantity and appearance of the urine, and have a sample in a clean bottle ready each day for the physician’s examination.

Keep the nose and throat clean with mild antiseptic sprays or washes. Relieve pain in the throat, unless otherwise directed, with ice-poultices or hot-water compresses.

MEASLES.

Measles is an acute contagious disease characterized by moderate fever of about a week’s duration; by an eruption on the skin, appearing on the third or fourth day as small red spots that soon coalesce into crescentic blotches, remain three or four days, and then disappear with a branny desquamation; and by catarrhal symptoms involving the eyes, nose, and bronchial tubes (conjunctivitis, coryza, and bronchitis). The most common complications of the disease are catarrhal pneumonia, inflammation of the gastro-intestinal tract, and inflammation of the middle ear.

Management.—The preventive measures described in connection with scarlet fever are applicable in measles. The room should be maintained at a temperature of 70° F., and should be moderately darkened. The bed should be so arranged that the face will be directed away from the light. Milk, broths, and gruels are suitable forms of nourishment. The temperature, pulse, respiration, hours of sleep, quantity of nourishment, amount of urine, and the effects of therapeutic measures should be carefully noted as in other fevers. Daily inunctions of the body with cold cream or olive oil are useful. Spraying the nose and throat with a mild antiseptic solution, and washing the eyes with boric acid solution (15 grains to the ounce of water) are usually ordered. Hot baths and hot drinks are indicated when the rash is delayed. Fever is generally controlled by sponging. Great care is necessary during convalescence to avert complications.

DIPHTHERIA.

Diphtheria is an acute contagious disease characterized by moderate fever of an irregular type, and of from one to two weeks’ duration; by considerable weakness and prostration; and by the formation of a grayish or whitish false membrane upon the throat, nose, larynx, and adjacent parts. The exciting cause of disease is the bacillus of diphtheria, which is found chiefly in secretions of the affected mucous membrane. The constitutional symptoms are due to the absorption of a toxin produced by this bacillus.

Diphtheria involving the larynx is sometimes termed true croup or pseudomembranous croup. This form is characterized by irregular fever, hoarseness of the voice, croupy cough, and progressive difficulty in breathing. Death frequently results from suffocation, unless tracheotomy or intubation of the larynx be performed.

The chief complications of diphtheria are pneumonia, degeneration of the heart-muscle, inflammation of the middle ear, and paralysis the result of an inflammation of the nerves.

Preventive measures consist in isolation of the sick, the thorough disinfection of the bedroom, bedding, clothing, and all articles used by the sick, and the administration of an immunizing dose (500 units) of antitoxin (see page 25) to those who have already come in contact with the patient or who have otherwise been exposed to the contagion. The sick-room should be well ventilated and maintained at a temperature of 70° F. The atmosphere should be made moist by slaking lime in the room or by generating steam in a kettle. In membranous laryngitis treatment in a steam-moistened tent is desirable. On account of the tendency to sudden heart failure absolute quiet and rest are to be enjoined. The diet should consist of milk, unseasoned broths, koumiss, junket, and eggs.

The patient’s temperature, pulse, respiration, nourishment, urine, sleep, and bowel movements should be noted as in other fevers. Local applications of boric acid solution, hydrogen peroxid (1: 3), or normal salt solution are usually ordered; they should be made with utmost gentleness. Externally, ice-poultices or hot fomentations are useful in relieving soreness.

The utmost care should be exercised during convalescence to guard the patient against undue effort, as at this time sudden heart failure is especially liable to occur.

POLIOMYELITIS.

Poliomyelitis—Infantile Paralysis.—This disease occurs in all countries and was recognized more than a hundred years ago. The first of the great epidemics appeared in 1905, and it was then proved that the malady is a contagious disease. Peculiar facts connected with previous epidemics of poliomyelitis have made it appear possible that the disease when not spread directly from one person to another, like the most acute infectious diseases, may be dependent upon some intermediate agent, or perhaps upon some other host, or a living reservoir, or upon the combination of the two. If the disease is communicated by human contact, mild cases, abortive cases, and convalescents may carry the germs for years. A normal carrier is an individual who is not suffering from the disease and may carry the germs and transmit them to another without being the least suspected. Laboratory experiments would seem to show that the disease is passed directly from one affected human individual to another through immediate contact involving the transfer of the virus from the first person to the nasal passages of the second, and spread through the agency of dust or by various other means, a population other than human, one acting as an undercurrent and influencing the progress of the epidemic. There seems to be no relation between the sanitary conditions and the incidence of cases. Poliomyelitis is most prevalent during the warm months, even when it is not epidemic. Under the same conditions of temperature, rainfall, humidity, cloudiness, sunshine, wind, dust, etc., the outbreak will progress in one part of the city and subside in another. The course of the epidemic is not materially modified by weather conditions. No age, no sex, or race is exempt; the incidence is greater under five years of age, and the blonde children appear to be especially susceptible, while the colored race are rarely attacked, and the strongest children seem to be the greatest sufferers. That this disease can and often does end fatally has been clearly shown by the history of the past epidemics, and it has been frequently demonstrated by clinicians in various parts of the world that complete recovery from paralysis is not only possible but it is by no means uncommon.

Summary Results from Public School Reports.—1. A large number of children with poliomyelitis show pathologic conditions of the nose and throat, either diseased and hypertrophied tonsils and adenoids, or both.

2. A large number show marked hyperemia of the nasopharynx and throat, often resembling a scarlet or streptococcus throat.

3. Only a small percentage of cases previously operated for tonsils and adenoids were found to be affected with the disease, and in this group of cases the percentage of recovery was very much higher than in unoperated cases. The number of cases in this group is, of course, rather small to draw from it any definite conclusion, but it is at least suggestive. In another investigation of 1404 children in the public schools, made to determine whether any of them whose tonsils had been removed had been ill with poliomyelitis during the recent epidemic, a similar result was obtained. Of the 1404 children whose tonsils had been operated upon not one developed poliomyelitis during this epidemic, although in 18 instances cases developed in the family, and in 93 instances cases developed in the same house.

Poliomyelitis defined: Polio (gray), myel (marrow), itis (inflammation), meaning inflammation of the gray matter of the spinal cord.

Pathology of the disease: Infantile paralysis is a general infection, with lesions most marked in the central nervous system. Clinical manifestations exhibit a wide-spread and scattered motor paralysis or weakening. The large majority of all cases are of the central nervous system, but there are variations in which the symptoms are not of the usual kind.

Classification.—1. Non-paralytic or Abortive Type.—These are cases in which the nerve-cells are not sufficiently injured to produce paralysis; and those classed as meningitis cases, tuberculous meningitis without motor disturbances, often called encephalitic; in these cases the motor cortical areas are not involved, but there is evidence of disturbance of the sensorium.

2. Ataxic Type.—Here the motor cells are evidently not involved, but there is a lack of co-ordination—ataxia, nystagmus.

3. Cortical Type.—The upper motor neuron is here affected, with resulting spastic paralysis.

4. Ordinary Spinal or Subcortical Type.—Here the lower motor neuron is affected, with resulting flaccid paralysis; a manifestation of poliomyelitis difficult to classify is blindness. The most important symptoms of the disease may be described under the non-paralytic or abortive cases and those of ordinary spinal form.

Symptoms of Onset.—There is no typical onset for this disease. It is believed that there is an interval of from a few days to two weeks between the time of exposure and the appearance of symptoms. No one symptom or group of symptoms will always be found to identify it before the paralysis is apparent. Fever is the most constant of all symptoms; it varies a great deal; there may be much or there may be little. Vomiting occurs quite frequently, and in a child old enough to talk headache may be complained of. Sometimes there is considerable pain in the back. The child is often very drowsy and desires to be alone. Movements of any kind seem to cause pain, and muscle tenderness is plainly evident. Marked irritability and sweating are also often prominent features. Such symptoms may all appear suddenly following a day of great activity and good health. These symptoms may continue for from two to four days, when it is noticed that the child is unable to move a hand, an arm, a foot, or a leg. There may merely be a paralysis of one side of the face or only weakness in an arm or leg. In some mild cases it is occasionally hard to convince parents of the true nature of the disease. In some instances the first knowledge of a child’s indisposition is the discovery that it cannot walk or has difficulty in using an arm. Cases of this character are often attributed to “catching cold,” to going in bathing for too long, or perhaps a fall.

In the majority of cases temperature is down to normal within a week and there is seldom an extension of the paralysis after that time. In most instances all the paralysis which is going to occur is present at the time it is first noticed.

Within two weeks all the tenderness has usually left the muscles, which are now found to be soft and flabby from lack of use. No matter what extremity may be affected by the paralysis, there is one condition which is nearly always present in these cases. If the child’s shoulders are raised up from the bed, the head drops back almost as if on a string. The child is unable to keep its head in a line with the body, and if the head is raised and forcibly bent forward so as to cause the chin to touch the chest, marked pain results.

Treatment.—By the end of three weeks in favorable cases there may be some motion obtained by the patient in the limb which was paralyzed, or there may be evidence of threatened deformity. It is at this time and in the weeks and months to follow that so much depends upon treatment. The muscles of a leg or arm may waste away so as to make them useless if not promptly cared for. If contractions of muscles are not prevented, a club-foot, toe-drop, or some similar deformity may develop. Such deformities may be hastened by the pressure of the bed-clothes. At times it is well to put a wire cradle over the affected limbs. Well-padded splints seem to take the strain from unaffected muscles.

By some wonderful adaptation of nature there is a great effort to make other nerve channels take up the work of the destroyed cells, and hence the value of keeping the muscles artificially active by the use of massage and mild electric treatment. This treatment should be used early in the case, and then only with the advice and supervision of a competent physician.

The destruction of nerve-cells in the segment of the spinal cord is sometimes so extreme that a total paralysis of one or more extremities follows. This is a grave shock to the growing child, and it may be that all growth of that member will stop. The long bones will not lengthen. If one group of muscles remain active and unopposed in their action, deformity will follow. These deformities can be corrected by the orthopedic surgeon, and can usually be checked if the physician’s advice is sought.

Serum Treatment.—The serum injections were given even as long as thirty years ago. Intraspinal injection of an immune serum is effective when introduced in the preparalytic stage.

Prophylaxis.—The virus or germ of poliomyelitis is found in the nose, the mouth, and intestinal tract (it is also found in various other parts of the body). As house-flies may carry the virus after crawling over the person suffering from the disease, all insects are a dangerous asset to any household. Disinfection of secreta and excreta should be carried out. The mouth and nose should be disinfected.

Quarantine should be rigidly enforced, and all the necessary precautions taken to prevent the spread of a contagious, infectious disease.

DISINFECTION OF FECES AND URINE.

Disinfect the feces and urine by mixing with each evacuation double its volume of 1 per cent. chlorid of lime solution or double its volume of 5 per cent. carbolic acid solution. Cover the vessel and allow it to stand for from one to two hours before emptying its contents into the closet.

Put all typhoid linens in cans used for that purpose only. Sprinkle with formalin and keep covered until sent to laundry.

N. B.—While performing work in which the hands come in contact with soiled linen and bed-pans, fill finger-nails with soap to keep them clean and to prevent them from acting as carriers of disease.

A WASHING FLUID FOR SOILED CLOTHES.

One can of lye, 10 cents;

Lump of ammonia, 5 “

Salts of tartar, 5 “

Put in a stone jar and set it in the open air. Pour over it 1 gallon of boiling water. Use ½ cupful to a boiler of clothes and add ½ bar of soap. Soak clothes over night in cold water; then place clothes into the boiler and boil for twenty minutes. Plain pieces need very little rubbing. Rinse two or three times in clear water before hanging clothes out to dry.

INCUBATION PERIOD AND QUARANTINE.

A constant period of incubation is not to be expected. In most instances, as will be seen from the following table, the difference between the maximum and the minimum period is not very great. It seems remarkable, however, that a disease should show such extremes as typhoid fever:

Normal. Maximum. Minimum.

Variola 12 days. 14 days. 9 days.

Varicella 14 “ 19 “ 13 “

Measles 10 “ 14 “ 4 “

Rubella 18 “ 21 “ 8 “

Scarlatina 2 “ 7 “ 1 day.

Influenza 3 “ 5 “ 1 “

Diphtheria 2 “ 7 “ 2 days.

Typhoid fever 12 “ 23 “ 5 “

Mumps 19 “ 23 “ 12 “

It is a peculiar fact that the diseases in which the period of incubation is shortest are those in which the infection persists the longest.

The period of quarantine must be guided largely by the period of incubation, hence the subject is an important one for a variety of reasons. The “Medical Magazine” (London) states that the period of quarantine should be at least a day longer than the maximum period of incubation for each disease. This is a very uncertain rule, however, for the patient should be free from all signs of illness, and especially from fever. The period of infection is very doubtful. It may be greatly prolonged by complications. This is especially true of small-pox, diphtheria, typhoid and scarlet fevers. The period during which a disease may be infectious cannot be stated definitely. It varies with different diseases, and must be determined according to the symptoms and character of the case. Measles, chicken-pox, and mumps lose the direct power of infection very early, and the infective principle does not remain active for a long period in the room in which the patient has been ill. Measles, mumps, and chicken-pox may be infectious in the earlier stages before becoming definite in character. Smallpox is not actually dangerous until the eruption appears.