are usually milder and of shorter duration. Varioloid occurs in persons who have been vaccinated. Sometimes the eruption begins on the feet. In some cases it is confined to the feet and hands. Occasionally the eruption is extensive and the symptoms are severe. The most severe type of smallpox is the hemorrhagic (bloody). It occurs in two forms. In one the case goes on in the usual way until about the ninth or tenth day, when blood makes its appearance in the pock. This form is sometimes called black smallpox. In the other form the eruption may be blood colored from the second day, and bleeding may take place from the nose or mouth or from the rectum. The face is greatly swollen and the eyes are deeply bloodshot. Death occurs during the first week, sometimes as early as the second day. Before the characteristic eruption appears it is frequently very difficult to determine the existence of smallpox. It is easily confounded with other eruptive diseases. The important points to remember are the intense pain in the back, the high fever, and bounding pulse, all of which precede the eruption, and that when the eruption appears the fever and all the severe symptoms subside. The temperature before the eruption may be up to 105° or 106° F. (40.5° or 41.1° C.). When the eruption appears it begins to decline and within 24 or 36 hours is down to about 100° F. (37.7° C.). When the secondary fever sets in the temperature rises again. Vaccination. This procedure prevents smallpox. Every child should be vaccinated before it is 6 months old, and again when it reaches school age. If the vaccination does not take, the operation should be repeated until it is successful. A small papule should appear in 48 hours, which soon changes into a vesicle. This gradually enlarges, until at the end of one week it is the size of a finger nail. It is then of a whitish color and is surrounded by a reddish area. At this time the patient may have a slight fever, headache, or some disturbance of digestion. On the tenth or thirteenth day these symptoms have usually subsided, the vesicle begins to dry up, forming a scab, and the redness of the surrounding area diminishes and finally disappears.. If the vaccination is kept dry and irritating substances, such as woolen shirts or coats, are not allowed to touch it, there is little danger of harmful germs gaining entrance through the wound. Some physicians advise the use of celluloid shields, but these shields are harmful as they exclude the air and are hot and uncomfortable. If care is taken not to break the vesicle, dressing is usually unnecessary; but if a dressing must be employed, the simpler the better. A little sterile vaseline or boracic-acid ointment, spread upon a piece of clean linen, generally suffices. This should extend beyond the inflamed area and be held in place by strips of narrow adhesive plaster. If a person has not been vaccinated during childhood, he should have this operation performed immediately in order to protect himself from smallpox. No one can tell when he might come in contact with this disease, and if not protected by vaccination he is extremely liable to contract it. After an interval of about seven years a second vaccination should be performed, and it should be repeated until successful. Smallpox has been practically eliminated from some countries by vaccination. DEATHS FROM SMALL POX IN COUNTRIES SWEDEN FOR EACH HULLIAN OF POPULATION Treatment. The patient should be placed in a cool, well-ventilated room and strictly isolated; and every person who has been in contact with the patient should be immediately vaccinated. No one should be allowed to come in contact with him except the nurse or attendant and the nurse or attendant should not be allowed to come in contact with other persons. While in immediate attendance on the sick he should wear overalls and jumper and a head covering, to be removed when he leaves the room, and immediately put on again when he returns. Separate dishes and necessary utensils should be provided. The food should be placed at a convenient place near the door of the sick room where the nurse can come and get it. Nothing should be allowed in the room except the articles absolutely necessary. The soiled clothing should be wrapped in a clean sheet (or in a sheet that has been dipped in a 1 to 1,000 solution of bichloride of mercury) and the bundle placed in a kettle of water and thoroughly boiled. If there is a sufficient supply of bedclothing, the soiled articles should be destroyed by fire (burned). The patient must be kept thoroughly clean. Good nursing is very important. IRELAND SCOTLAND GERMANY 3.5 16. DEATHS FROM SMALL POX IN COUNTRIES SWITZERLAND. AVERACE 18.5 161 RUSSIA 231 AUSTRIA 510 ITALY 556 963 FIG. 91. SPAIN In the early stage, when the fever is high, place the patient in a cold bath, or give him a cold sponge bath, note the temperature of the body, and repeat the bath every three hours if the thermometer registers above 103° F. (39.4° C.). If the bowels are constipated, give small doses of Epsom salt, 2 teaspoonfuls, every two or three hours. The food should be soft and nourishing and given at regular intervals. Cold drinks, lemonade, barley water, etc., may be freely given. Aspirin, 10 grains, may be given for the headache. The pain and tension in the skin may be relieved by cold applications. A piece of lint, wet with a one-half of 1 per cent solution of carbolic acid, may be applied cold to the face and frequently renewed. Holes should be cut into the lint corresponding to the eyes, nose, and mouth. When the pustules begin to form it is a good plan to touch each one with tincture of iodine (a camel's-hair brush may be used for the purpose), and a day later to puncture them with the point of a needle. The needle should first be boiled, and the point should then be dipped in tincture of iodine before making the puncture. When crusts being to form, olive oil or glycerin should be applied. If the hair is long it should be cut short early in the disease before the pustular stage begins. The eyes must be carefully cleansed several times a day, else blindness may follow. The mouth, throat, and nose also require attention. A saturated solution of boric acid may be used as an eyewash, a mouth wash, or a gargle (one teaspoonful of boric acid in a glass of water). When the crusts and scabs drop off they should be carefully gathered up and burned. The patient should then have a daily bath with soap and water. When the case is ended the room and all exposed articles must be disinfected by burning sulphur (4 pounds to every 1,000 cubic feet of air space). When the case occurs on shipboard, the ship, if near port when the disease breaks out, should be taken direct to the quarantine station, where the patient may be taken care of and the ship disinfected. CHICKEN POX. Chicken pox is a disease of children, but occasionally it occurs in adults. The child usually becomes sick 14 or 16 days after being exposed to the disease. The child is restless, has a slight fever, and complains of itching of the skin. A papular eruption appears upon the face, neck, or chest within 24 hours from the time the child is taken sick. In a short time the papules change to vesicles. These have the appearance of small blisters and are due to small quantities of liquid accumulating under the superficial layer of the skin. At first the vesicles are translucent but later are opaque as their contents become turbid. After a day or two the vesicles rupture, crusts are formed, which drop off in from 5 to 20 days. The vesicles are usually few in number and are found mostly upon the upper part of the body. They may, however, be thicker in places and may extend over the whole surface. Sometimes they are found in the mouth and throat. The temperature falls when the rash fades, and it is usually greatest when the eruption appears. It is important that chicken pox should be distinguished from smallpox. It should be remembered that the former occurs principally in children; that the eruption appears in the first day of the disease; that it only involves the upper layer of the skin and rarely produces pitting; that it appears in crops, some of the vesicles drying up while others are beginning to form; that there is seldom headache or backache, and the fever is usually low. There is no secondary fever as occurs in smallpox when the pustules are formed. The papule in smallpox is hard and shotlike and has a very different feeling from the soft, reddish spot of chicken pox. When the vesicle is ruptured with the finger it can be seen that it involves only the superficial layer of the skin, whereas the ruptured pustule in smallpox leaves an ulcer extending through the true skin. In spite of the distinctions between smallpox and chicken pox mentioned in the above paragraph it is often difficult to distinguish between a mild form of smallpox and chicken pox, and a physician should always be called in to see the patient if smallpox is present in the community. Prevention.-A child having this disease should not be allowed to go to school. If the child is an inmate of an orphan asylum or other children's institution it should be quarantined while chicken pox is prevalent. In private houses quarantine is unnecessary unless the other children are delicate, and it is especially desirable that they should not catch the disease. The disease is contagious as long as any crusts are present. Treatment. The child should be put to bed, and to relieve the itching sponged with warm water to which a small quantity of carbolic acid (half a teaspoonful to the pint) is added. The carbolic acid should be added while the water is hot, and care should be taken that it is dissolved in the water before using the water. Carbolized vaseline (carbolic acid 3 grains, vaseline 1 ounce) is often efficacious in relieving itching. A warm bath should be given each day until the scabs come off. MEASLES. Measles is an acute infectious disease which most commonly attacks children, but it may occur in adults. It usually spreads from person to person by exposure to a patient with the disease, as when going into the room where he is sick, riding in the same street car, or being in the same schoolroom. It generally makes its appearance from 12 to 14 days after exposure. One attack is nearly always a protection against a second one. Symptoms. It begins like an ordinary cold. There may be an initial chill; the patient's face looks flushed and sometimes slightly swollen about the nose and eyes and the eyes are reddened. There may be a tendency to sneeze, and an examination of the throat will disclose a reddening of the mucous membrane. The rash often appears first in the throat. Some cough may be present at the onset, with more or less headache. Fever is present with the onset of these symptoms. The eruption on the skin develops on the third or fourth day of the fever. It may be most marked on the forehead or about the ears, looks like fleabites, and gradually spreads over the entire body. The patient has considerable cough, with expectoration. In children there is some liability to a form of pneumonia called broncho-pneumonia, which renders the disease much more dangerous. It may also have the complication of diarrhea and vomiting, due to implication of the bowels and stomach. Prevention.-As soon as the case is discovered the patient should be put in bed and isolated in a room from which children are excluded and only those adults admitted who are directly concerned in the care of the case. Treatment. It is necessary to prevent the patient from becoming chilled, and he should therefore not be exposed to drafts, but fresh air should be admitted to the room. If the weather is cold, he should be provided with plenty of covering. The treatment of an ordinary case of measles is practically nil, as little or no medication is required. If there is much irritation of the eyes, the room should be darkened and the eyes washed with a saturated solution of boric acid in warm water. Take a glass of warm water and put into it all the boric acid it will dissolve and use it as a wash for the eyes, keeping it covered to prevent dust or other impurities getting into the solution. Everything applied to the eyes should be scrupulously clean. If the skin is dusky and the eruption is not well marked, the patient may be enveloped in sheets or blankets wrung from hot water, but care must be exercised that he does not become chilled afterwards. Only sufficient covering should be used to render the patient comfortable. If the cough is very troublesome, a tablet of Brown Mixture or a half teaspoonful of mixture pectoralis (expectorans) N. F. may be given every three hours. After the eruption has disappeared and the peeling of the skin has begun the patient should bathe daily in order that the skin may be freed from the scales. During the period of the disease the patient may be fed on broths, milk, soft-boiled eggs, etc. Disinfection is not now considered necessary after measles, as it is believed the disease is transmitted only by contact with a sick person, and experiments show that there is little danger of contracting the disease after the eruption appears. If it is desired to disinfect the room after the patient recovers, the following procedure should be carried out: The bedclothes should be boiled 20 minutes or soaked in a 3 per cent solution of carbolic acid or compound cresol for one hour. (See p. 104.) All the openings of the room should be closed, and it should be fumigated with formaldehyde gas made by placing formalin in a 10-quart pail and pouring permanganate of potash onto it. One pint of formalin and one-half pound of potash should be employed for every 1,000 cubic feet of air space. The time of exposure should |