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COMMUNICABLE DISEASE NURSING

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Lynch, Theresa I n e z .
1 94 C
Communicable d i s e a s e n u r s i n g . . .
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T H IS D IS S E R T A T IO N HAS BEEN M IC R O F IL M E D E X A C T L Y AS REC EIVED .
COMMUNICABLE DISEASE NURSING
THERESA I . LYNCH
Subm itted in p a r t i a l f u lf illm e n t o f the
requirem ents f o r th e degree of Doctor of
E ducation in th e School o f Education of
New York U n iv ersity
I
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PREFACE
T his book on Communicable D isease Nursing p re s e n ts th e su b jec t a s i t
i s tau g h t in modern h o s p ita ls and a s i t is p ra c tic e d in both th e h o s p ita l
and th e home.
The p rin c ip le s o f, and reaso n s f o r , th e nursing te c h n ic s
as o u tlin e d in th e te x t are given to help the stu d en t in h er a p p lic a tio n
of th e se te c h n ic s in any s itu a tio n ; experience in teach in g b o th student and
graduate nurses has proved to me t h a t s k i l l s employed in communicable d isease
nursin g are acquired only when the reaso n s f o r th ese te c h n ic s are thoroughly
understood.
Thus, w hile th e s u b je c t-m a tte r of th e t e x t , which includes
those d ise a se s suggested fo r study in th e C urriculum Guide fo r Schools of
N ursing, published by th e N atio n al League o f Nursing Education in 1937,
has been in flu en ced by t h i s Curriculum Guide, i t s u sefu ln e ss t o th e p rac­
tic in g graduate nurse, as w ell as to th e stu d e n t and in s tr u c to r , has been
kept in mind.
The book re p re s e n ts e s p e c ia lly , th e r e f o r e , an e f f o r t d i ­
re c te d toward sim p lify in g th e g e n e ra l in s tr u c tio n of b o th graduate and
student nurses in communicable d is e a s e n u rsin g , and toward acquainting
them w ith th e o p p o rtu n itie s a v a ila b le f o r e f f e c tiv e ly applying t h e i r exper­
ience in the v ario u s n u rsin g f i e l d s .
An e f f o r t i s made, a ls o , to show the
importance of th e s o c ia l as w ell as o f th e te c h n ic a l phases o f communicable
d ise a se n u rsin g .
Divided as i t i s in to th re e p a r ts (P a rt I , P a rt I I , P a rt I I I ) , th e
te x t may be adapted by in s tr u c to r s to s u i t t h e i r in d iv id u a l o u tlin e s or
schedules f o r te a c h in g .
A? 1 6 a v
Each p a rt i s com plete in i t s e l f : one p a rt may
ii
be used alo n e, or the th re e .nay he used in sequence o r in p a r a l l e l , one
with the o th e r,
p a r t I , which is im portant in o rie n tin g the student to
communicable d isease n u rsin g , should be stu d ie d f i r s t , in i t s e n tir e ty ;
P art I I d escrib es the m edical a sp e c ts and n u rsin g care of th e communicable
1/
d ise a se s;
P art I I I is a lig n e d with th e tre n d toward in te g ra tin g public
h e a lth in the curriculum of the n u rsin g school and w ith the idea of fam il­
ia riz in g student and g rad u ate n u rses w ith th e value of t h e ir experience in
communicable d isease n u rsin g .
The procedures as suggested in th is textbook, in which emphasis has
been placed upon s im p lic ity as w ell as upon p r in c ip le s , a re not advanced
as p e rfe c t fo r u n iv e rsa l a d a p ta tio n ;
n e ith e r are they f i n a l , as nursing
goes forward w ith th e p ro g ress of medical science and the procedures of
today may be outmoded tomorrow.
They are merely suggested fo r nurses gener­
a lly who have not the tim e or th e necessary experience to devise th e ir own
te c h n ic s.
For a s sis ta n c e in read in g the m anuscript and checking on the medical
and nursing inform ation p re se n te d , I am a p p re c ia tiv e ly indebted to the
follow ing p h y sician s and n u rse s:
Dr. Josephine 3. N eal, A ssista n t D irecto r
of the Bureau of L a b o ra to rie s, Department of H ealth of the City of New York,
and A ssociate P ro fesso r o f N eurology, College of P hysicians and Surgeons,
Columbia U n iv ersity ; Dr. Maurice Lenarsky, A ssociate V is itin g Physician to
the W illard P arker H o s p ita l, New York C ity ; Miss Josephine Goldsmith, of
the Department of H o s p ita ls , New York C ity , and form erly D irecto r of the
Nursing S erv ic e, Department of H ealth , S t. L ouis, M issouri; Miss Helen
Spangler, E ducational D ir e c to r, E a stern Maine Oenteral H o s p ita l, P o rtlan d ,
iii
Maine; Mies P au lin e Schoonover, S upervisor o f the Co/timuni cable D isease
Nursing S e rv ic e , M edical C enter, Jersey C ity , New J e rse y ; and to Miss
Edna Witham, E d u catio n al D ire c to r, W illard P arker H o sp ita l, New York C ity.
Theresa I . Lynch.
iv
CONTENTS
FART I
THE BACKGROUND OF COMMUNICABLE DISEASE NURSING
Chapter
I
Page
H is to r ic a l In tro d u c tio n ...............................................................
Communicable D iseases and A ncient C iv iliz a tio n s ,
In d ia , 2; The C hinese, 3; The E gyptians, 3; The
Jews, 3; The Greeks, 4; The Romans, 4; P rogress
o f Communicable D isease C ontrol in Europe, Middle
Ages, 5; The R enaissance, 7; The Seventeenth Cen­
tu ry , 7; E ig h teen th to Tw entieth C en tu ries, 8;
P ro g ress o f Communicable D isease Control in
America, 9.
Chapter
II
P re p aratio n f o r Communicable D isease Nursing .................
Care o f A d u lts, 15; Care of C hildren, 15; P ro te c ­
tiv e H e alth Measures fo r th e N urse, Immunization,
16; P h y sica l Exam ination, 16; Personal Care, 17;
Care of the Hands, 17; Care of th e Eyes, 17; Care
of th e H a ir, 17; The N urse’s Uniform, 17; Care of
th e Nurse in I l l n e s s , 17; The Nurse as a Teacher
o f H ea lth , 18.
C hapter
14
III
In fe c tio n and R esista n ce to D isease ......................................
Presence of I n f e c tio n , 20; In fe c tiv e Agents, 20;
Sources of I n f e c tio n , 20; P o rta ls o f Entry of In ­
fe c tiv e A gents, 21; F acto rs In flu en cin g th e Occur­
rence of I n fe c tio n , 21; Means of D isease Production,
22; Body R eactions to I n fe c tiv e A gents, 22; Incuba­
tio n P e rio d , 23; P o rta ls of E xit o f Organisms, 23;
Transm ission of Communicable D iseases, 23; Period
o f Communicability o f In fe c tiv e Agents, 24; Immunity.,
24; Types o f Immunity, 25; E s s e n tia l P o in ts to Remem­
b e r, 27.
v
1
20
Chapter
IV
P revention and C ontrol of Communicable D iseases . . . .
F ederal H ealth A gencies, 28; L e g is la tio n f o r H ealth,
29; S ta te Agencies f o r Disease C o n tro l, 29; M unici­
p a l H ealth A gencies, 30; County Health U n its, 30;
U n o ffic ia l H ealth A gencies, 31; R egulations of the
U nited S ta te s H ealth S ervice on Communicable Dis­
ease C o n tro l, 31; The In fected In d iv id u a l, C ontacts,
and Environment, 32; Recognition of the D isease and
R eporting, 32; I s o la tio n , 32; D is in fe c tio n , 33;
Concurrent D is in fe c tio n , 34; Terminal D is in fe c tio n ,
34; Q uarantine, 34; Immunization, 35; I n v e s tig a tio n ,
of Source of In fe c tio n , 35; General Measures, 35;
Epidemic M easures, 35.
Chapter
V
V accines, Immune S era, and Serum Reactions .....................
V accines, 38; P re p aratio n of V accines, 38; Uses of
V accines, 39; Immune S era, 39; P rep aratio n o f S era,
39; Uses of Immune S era, 40; Supervision of B iologic
P ro d u cts, 40; Serum R ea ctio n s, 40.
Chapter
VI
M edical A sepsis ...............................................................................
V a ria tio n in Method, 44; C ro ss-in fe c tio n , 44; Hand
C lean sin g , 45; Terminology in Medical A sep sis, 46;
M edical A septic Technic in the H o s p ita l, 47; Clean
and Contaminated A reas, 47; Srub S tands, 47; In d i­
v id u a l Equipment, 47; Gowns, 48; Gown Technic, P u t­
t in g on the Gown, 48; Removing the Gov«n, 49; Masks,
50; Care of C lothing and V aluables, 50; Taking the
Temperature, P u lse , and R e sp ira tio n , 51; D isposal
of Linen, 51; Methods of D isin fectio n and S t e r i l i ­
z a tio n , 52; D isposal of D ischarges, 54; Ward Kitchen
T echnic, 55; P o r te r ’s Technic, 56; Care of Contamin­
a te d M attresses and P illo w s, 56; Care o f Contaminated
Rooms and C ub icles, 56; D isposal of R efuse, 57; Care
of F lo o rs, 57; V is itin g R egulations, 57; C lin ic a l
Records, 58; Signing of Documents, 58; M edical Asep­
t i c Technic in a G eneral H o sp ita l, 58; E s s e n tia l
P o in ts to Remember, 59.
NURSING GASS OS COMMUNICABLE DISEASES
Chapter
711
M e a s le s ................................................................................................
D e fin itio n , 61; H isto ry , 61; P rev alen ce, 61; E tio lo g y , 61; Sources of I n f e c tio n , 62; Mode of T rans­
m issio n , 62; S u s c e p tib ility , 63; P athology, 63;
Incubation P eriod, 64; Course of th e D isease:
Period of Invasion, 64; P erio d of E ru p tio n , 65;
P eriod of Convalescence, 65; C om plications and
Sequelae, 65; P eriod of Com m unicability, 66;
M o rta lity , 66; P ro p h y lax is: Convalescents* Serum,
66; P a ren tal Serum, 67; P la c e n ta l E x tra c t (Immune
G lo b u lin ), 67; Treatm ent, 67; Methods of C ontrol:
R ecognition and R eporting, 68; I s o l a tio n , 68;
Q uarantine, 68; Immunization, 68; Nursing Care,
I s o la tio n , 68; Environment, 69; Comfort o f the
P a tie n t, 69; Personal Hygiene: Care of th e S kin,
69; Care of the Eyes, 69; Care of the Nose, 70;
Care o f the Mouth, 70; Care of th e E a rs , 70;
E lim in atio n , 71; D ie t, 71; C om plications: O t i t i s
Media, 71; Broncho-pneumonia, 72; C ervical Adeni­
t i s , 72; L a ry n g itis, 73; D ia rrh e a , 73; Convales­
cence, 73; D isin fectio n ! C oncurrent, 73; Term inal,
73; E s s e n tia l P o in ts to Remember, 74; Home Care,
Nursing In s tru c tio n s , 74; Community P r o te c tio n , 74.
Chapter V III
Rubella ................................................................................................
D e fin itio n , 76; H is to ry , 76; P rev alen ce, 76; E tio ­
logy. 76; Source of I n fe c tio n , 76; Mode of Trans­
m ission, 76; S u s c e p tib ility , 77; Incubation P e rio d ,
77; Course of th e D isease: P eriod of In v asio n , 77;
Period o f E ruption, 77; C om plications, 77; P eriod
of Communicability, 77; P ro g n o sis, 78; Methods of
C ontrol: Recognition and R ep o rtin g , 78; I s o la tio n ,
78; Q uarantine, 78; Imm unization, 78; Nursing Care,
78; perso n al Hygiene: Care of th e S k in , 78; Care of
the Eyes, Nose, and T hroat, 78; D ie t, 78; D ie t, 78;
D isin fe c tio n : C oncurrent, 79; T erm inal, 79; Essen­
t i a l P o in ts to Remember, 79; Community P r o te c tio n , 79
C hapter
IX
Chickenpox .........................................................................................
D e fin itio n , 80; H is to ry , 80; P rev alen ce, 80; Sources
of In fe c tio n , 80; Mode of T ransm ission, 80; Suscep­
t i b i l i t y , 80; P ath o lo g y , 80; P eriod of In cu b atio n ,
81; Course of th e D isease: Period of In v asio n , 81;
P eriod of E ru p tio n , 81; Period of Convalescence, 81;
Complications and S equelae, 82; P eriod of Communi­
c a b ility , 82; P ro g n o sis, 82; Treatm ent, 82; Methods
o f C ontrol: R ecognition and R eporting, 82; I s o la tib n ,
82; Q uarantine, 82; P ro p h y lax is, 82; Nursing Care,
I s o la tio n , 83; Comfort of the P a tie n t, 83; Personal
Hygiene: Care o f th e S k in , 83; Care of the Mucous
Membranes, 83; D ie t, 83; D is in fe c tio n : Concurrent,
83; Term inal, 84; E s s e n tia l P o in ts to Remember, 84;
Home Care, Nursing I n s tr u c tio n s , 84; Community Pro­
te c tio n , I n v e s tig a tio n , 84.
C hapter
X
Smallpox ............................................................................................
D e fin itio n , 86; H is to r y , 86; P revalence, 87; E tio logy, 87; Source o f I n f e c tio n , 87; Mode of Trans­
m ission, 87; S u s c e p ti b i lity , 87; Pathology, 87;
Incubation P e rio d , 87; Course of th e D isease:
P eriod of In v a sio n , 88; P eriod of E ru p tio n , 88;
Convalescence, 88; Types of th e D isease, 88; Com­
p lic a tio n s and S eq u elae, 89; Period o f Communica­
b i l i t y , 89; P ro g n o sis, 89; M o rta lity , 89; Treatment,
89; Methods o f C o n tro l: R ecognition and R eporting,
89; I s o la tio n , 89; Q u arantine, 89; E ducation, 90;
Nursing C are, 90; I s o l a t i o n , 90; P ersonal Hygiene:
Care of th e S kin, 91; Care o f the Mouth, 91; Care
of the Eyes, 91; D ie t, 91; C om plications: C onjuncti­
v i t i s , 91; In fe c tio n s o f the S kin, 91; Septicem ia,
92; P sychosis, 92; Broncho-pneumonia, 92; Care in
Convalescence, 92; D is in fe c tio n : C oncurrent, 92;
Term inal, 92; E s s e n tia l P o in ts to Remember, 92;
Home Care, N ursing I n s tr u c tio n s , 93; Community Pro­
te c tio n , 93; V accin atio n a g a in s t Smallpox, D efin i­
tio n , 93; H is to iy , 93; C h a r a c te r is tic s of the V irus,
94; P re p a ra tio n o f Vaccine V iru s, 94; Procedure,
95; Course of E ru p tio n o f V accination: F i r s t Vac­
cin a tio n (prim ary " ta k e ” ) , 96; Second V accination,
(modified " ta k e " ), 96; Recording the V accination,
96; Complications o f V accin atio n , A utovaccination,
96; Secondary I n f e c tio n , 96; E n c e p h a litis , 96.
v iii
Chapter
XI
S c a rle t Fever . . ............................................................................
D e fin itio n , 98; H is to ry , 98; P revalence, 98; E tio l­
ogy, 99; Sources of I n fe c tio n , 99; Mode of Trans­
m issio n , 99; S u s c e p tib ility , 99; P athology, 100;
In cu b atio n P e rio d , 100; Course of the D isease:
P eriod of In v asio n ; 100; Period of E ru p tio n , 100;
P eriod o f Desquamation, 101; Period o f Convales­
cence, 102; Types of the D isease: Mild Form, 102;
S ep tic Form, 102; Toxic Form, 102; S u rg ica l Form,
102; Com plications and Sequelae: S ep tic Complica­
t i o n s , 102; Toxic C om plications, 103; P eriod of
Com m unicability, 103; F rognosis, 103; M o rta lity ,
103; p ro p h y la x is: The Dick T e st, 103; A ctive Im­
m unization, 104; P assive Immunization, 104; T re a t­
ment, 105; Methods o f C ontrol: R ecognition and
R ep o rtin g , 105; I s o la tio n , 105; Q uarantine, 106;
Im m unization, 106; Nursing Care, I s o la tio n , 106;
Comfort o f th e P a t i e n t, 106; Reduction of Fever,
106; P erso n al Hygiene: Care o f the S kin, 106;
Care of th e Nose, Mouth, and T hroat, 107; Elim­
in a tio n , 107; D ie t, 107; Com plications: O tit is
Media, 108; M a s t o i d i iti s , 108; C ervical A d e n itis,
108; A r t h r i t i s , 108; N e p h ritis , 109; Cardiac In­
volvem ent, 109; Convalescence, 109; A s sis tin g w ith
the A d m in istratio n o f Serum, 109; Serum S ickness,
109; D is in fe c tio n : Concurrent, 109; Term inal, 110;
E s s e n tia l P o in ts to Remember, 110; Home Care,
N ursing I n s tr u c tio n s , 111; Community P ro te c tio n ,
111.
Chapter XII
D ip h th eria ........................................................................................
D e fin itio n , 113, H is to ry , 113; P revalence, 114;
E tio lo g y , 114; Sources of In fe c tio n , 114; Mode of
T ransm ission, 114; S u s c e p tib ility , 115; Pathology,
115; In cu b atio n P e rio d , 115; Complications and
S equelae, 116; P erio d of Communicability, 116;
F ro g n o sis, 116; M o rta lity , 116; P rophylaxis: The
Schick T e3t, 116; A ctive Immunization, 117; P assive
Im m unization, 118; C a rrie rs , 119; Treatm ent, 119;
A d m in istratio n of A n tito x in , 120; Serum R eactions,
120; Methods o f C ontrol: R ecognition and R eporting,
120; I s o la tio n , 120; Q uarantine, 121; Immunization,
121; Nursing Care in Nasal D ip h th eria , 121; Comfort
o f the P a tie n t, 121; ■t'ersonal Hygiene: Care o f the
Nose, 121; D ie t, 122; Com plications: C ervical Ad­
e n i t i s , 122; O t i t i s Media and S in u s it is , 122;
Nursing Care in Pharyngeal D ip h th eria, 123; Comfort
of the P a tie n t, 123; P ersonal Hygiene: Care of th e
S kin, 124; Care o f the Eyes, 124; Care of th e Nose
and Throat; 124; care of th e Mouth, 124; E lim in atio n ,
124; D ie t, 125; Complications and Sequelae: Myocardi­
t i s , 125; P a la ta l P a r a ly s is , 125; Ocular P a r a ly s is ,
125; P a ra ly sis of th e R esp irato ry M uscles, 126; P a r a l­
y sis o f the E x tre m itie s, 126; Nursing Care in Laryn­
g e a l D ip h th eria , 126; G eneral C are, 127; M edications,
127; Personal Hygiene: Care of th e Mouth, 127; Elim­
in a tio n , 127; D iet, 128; In tu b a tio n , 128; Tracheotomy,
129; C om plications: Acute S u ffo c a tio n , 129; Broncho­
pneumonia , 129; D isin fectio n * i;C oncurrent, 129; Term inal,
130; E s s e n tia l P o in ts to Remember, 130; Home Care,
Nursing I n s tr u c tio n s , 130; Community P ro te c tio n , 131.
Chapter X III
S ep tic Sore T h r o a t .......................................................................
132
D e fin itio n , 132; H isto ry , 132; P rev alen ce, 152; E t i ­
ology, 132; Sources of In fe c tio n , 132; Mode of Trans­
m ission, 133; S u s c e p tib ility , 133; pathology, 133;
In cubation P erio d , 133; Course of the D isease: C lin i­
c a l P ic tu re , 133; Period o f Convalescence, 133; Com­
p lic a tio n s and Sequelae, 133; Period of Communicability,
133; P ro g n o sis, 134; M o rta lity , 134; Treatm ent, 134;
Methods o f C ontrol: Recognition and R eporting, 134;
I s o la tio n , 124; Quarantine , 134; Nursing Care, I s o la ­
t i o n , 134; Comfort o f the P a tie n t, 134; P ersonal
Hygiene: Care of the Mouth and T hroat, 135; D ie t,
135; Com plications: Septicem ia, P e r i t o n i t i s , C ervical
A d e n itis, N e p h ritis , Broncho-pneumonia, O t i t i s Media,
135; Convalescence, 135; D is in fe c tio n : C oncurrent, 135;
Term inal, 135; E sse n tia l P o in ts to Remember, 136; Home
Care, Nursing In s tr u c tio n s , 136; Community P ro te c tio n ,
136.
Chapter XEV
V in cen t’ s A n g i n a ......................................................
D e fin itio n , 137; H isto ry , 137; P rev alen ce, 137;
E tio lo g y , 137; Sources of I n fe c tio n , 138; Mode o f
Transm ission, 138; S u s c e p tib ility , 138; Pathology,
138; In cu b atio n P erio d , 138; Course of the D isease,
138; Com plications and Sequelae, 138; Period o f
Communicability, 139; P rognosis, 139; Treatm ent,
139; Methods of C ontrol: R ecognition and R eporting,
139; I s o la tio n , 139; Q uarantine, 139; N ursing Care,
x
137
I s o la tio n , 139; Comfort of th e P a tie n t, 139; Care
of the M@uth, 139; D ie t, 140; D is in fe c tio n : Con­
c u rre n t, 140; Terminal, 140; E s s e n tia l P o in ts to
Remember, 140; Home Care, N ursing I n s tr u c tio n s ,
140; Com u n itysiP rotection, 141,
Chapter XV
Mumps....................................................................................................
142
D e fin itio n , 142; H isto ry , 142; P rev alen ce, 142;
E tio lo g y , 142; Source o f I n f e c tio n , 142; Mode of
Transm ission, 143; S u s c e p tib ility , 143; P athology,
143; Incubation P erio d , 143; Course o f th e D isease:
C lin ic a l P ic tu re , 143; P erio d o f Convalescence, 144;
Complications and Sequelae, 144; P eriod of Communic a b ility , 144; P rognosis, 144; T reatm ent, 144;
Methods of Control: R ecognition and R ep o rtin g , 144;
I s o la tio n , 145; Immunization, 145; N ursing c a re ,
I s o la tio n , 145; Comfort of th e P a tie n t, 145; personal
Hygiene: Care o f the Mouth and Nose, 145; D ie t, 145;
Com plications: O rc h itis , 145; O o p h o ritis , 146; Pan­
c r e a t i t i s , 146; M en in g o -en cep h alitis, 146; Convales­
cence, 146; D isin fe c tio n : C oncurrent, 146; Term inal,
147; E s s e n tia l P oints to Remember, 147; Home Care,
Nursing In s tru c tio n s , 147.
Chapter XVT
148
Whooping C o u g h ................................................................................
D e fin itio n , 148; H isto ry , 148; P rev alen ce, 148;
E tio lo g y , 148; Source o f I n f e c tio n , 149; Mode of
Transm ission, 149; S u s c e p tib ility , 149; Pathology,
149; Incubation P erio d , 149; Course of the D isease,
149; Period of Convalescence, 150; Com plications
and Sequelae, 151; P eriod of Com m unicability, 151;
P rognosis, 151; M o rta lity , 151; P ro p h y lax is: Sauer
Vaccine, 152; Kreuger’ s Undenaturad B a c te ria l A ntigen,
152; Treatm ent, 152; Methods o f C o n tro l: R ecognition
and R eporting, 152; I s o l a tio n , 152; Q uarantine, 152;
Immunization, 153; Nursing C are, I s o la tio n , 153; En­
vironm ent, 153; Comfort of th e P a tie n t , 153; Personal
Hygiene: Care o f the Mouth, 154; E lim in a tio n , 153;
D ie t, 154; P sychological E lem ents, 155; Complications
and Sequelae: Broncho-pneumonia, 155; C onvulsions,
156; Hemorrhages, 156; H ernia, 156; O t i t i s Media,
156; Marasmus, 156; Pulmonary T u b e rcu lo sis, 156;
B ro n ch iectasis, 156; Convalescence, 156; D is in fe c tio n :
xi
Concurrent, 157; Term inal, 157; E s s e n tia l P o in ts
to Remember, 157; Home Care, Hursing I n s tru c tio n s ,
157; Community P ro te c tio n , 158.
Chapter XVII
159
Meningococcus M en in g itis ...........................................................
D e fin itio n , 159; H is to ry , 159; P revalence, 159;
E tio lo g y , 160; Source of I n fe c tio n , 160; Mode of
Transm ission, 160; S u s c e p tib ility , 160; Pathology,
160; Incubation P e rio d , 161; Course of the D isease,
161; Types of the D isease, 162; P eriod of Convales­
cence, 162; C om plications and S equelae, 162; Period
of Communicability, 162; P ro g n o sis, 163; M o rta lity ,
163; Treatm ent, 163; Methods of C ontrol: Recognition
and R eporting, 163; I s o la tio n , 163; Q uarantine, 163;
Immunization, 163; Nursing Care, I s o la tio n , 163; Com­
f o r t of the P a tie n t, 163; Personal Hygiene: Care of
the Skin, 164; Care o f the Mouth and Nose, 164; Care
of the Eyes, 164; E lim in atio n , 164; D ie t, 165; Medi­
ca tio n : S e d a tiv e s, 165; Lumbar P uncture, 165; Serum
S ickness, 165; C om plications, 165; Convalescence,
166; D is in fe c tio n : C oncurrent, 166; Term inal, 166;
^ s e n t i a l P o in ts to Remember, 166; Home Care, Nursing
In s tru c tio n s , 166; Community P ro te c tio n , 167.
C hapter XVTII
168
P o lio m y e litis ....................................................................................
D e fin itio n , 168; H is to ry , 168; P revalence, 169;
E tio lo g y , 169; Sources of I n fe c tio n , 170; Mode of
Transm ission, 170; S u s c e p tib ility , 170; Pathology,
170; Incubation P e rio d , 171; Course of the D isease,
171; Types o f the D isease: S pinal Type, 172; Bulbar
Type, 173; P eriod o f Convalescence, 173; Complica­
tio n s and Sequelae, 173; Period of Communicability,
173; P ro g n o sis, 173; M o rta lity , 173; Treatm ent, 174;
Methods of C ontrol; R ecognition and R eporting, 174;
I s o la tio n , 174; Q uarantine, 174; Immunization, 174;
Nursing Care, I s o la tio n , 175; Comfort of the P a tie n t,
175; Personal Hygiene: Care o f the Skin, 176; Care
of the Nose and T h ro at, 176; E lim in atio n , 176; Care
of the B ulbar Type, 176; Care of the P a tie n t in the
R esp ira to r, 176; C om plications, 179; Convalescence,
179; D is in fe c tio n : C oncurrent, 180; Term inal, 180;
E s s e n tia l P o in ts to Remember, 180; Horae Care, Nursing
I n s tr u c tio n s , 180.
Chapter XIX
Page
Epidemic E n c e p h a litis ...................................................................
D e fin itio n , 182; H is to ry , 182; P revalence, 183;
E tio lo g y , 183; Sources of In fe c tio n , 183; Mode of
Transm ission, 183; S u s c e p tib ility , 184; Pathology,
184; In cubation P e rio d , 184; Course of the D isease:
C lin ic a l P ic tu re , 184; Complications and Sequelae,
185; Period o f Communicability, 185; P rognosis,
185; Treatm ent, 185; Methods of C ontrol: Recog­
n itio n and R eporting, 185; I s o la tio n , 186; Quaran­
t i n e , 136; Immunization, 186; Nursing Care, I s o la ­
t i o n , 186; Comfort of the P a tie n t, 186; Personal
Hygiene: Care of the Slcin, 186; Care of the Eyes,
187; Care o f the IPouth, 187; E lim in atio n , 187;
D ie t, 187; C om plications, 187; C lin ic a l Recording,
138; Convalescence, 188; E s s e n tia l P o in ts to Remem­
b e r, 188; Home Care, Nursing I n s tr u c tio n s , 188.
Chapter
182
ZK
L e p r o s y ................................................................................................
190
D e fin itio n , 190; H isto ry , 190; P revalence, 191;
E tio lo g y , 191; Sources of In fe c tio n , 191; Mode of
Transm ission, 191; S u s c e p tib ility , 191; P athology,
191; Incubation p e rio d , 192; Course of the D isease,
192; Types of th e D isease: Nodular Leprosy, 192;
A nesth etic Leprosy, 192; Mixed Leprosy, 193; Com­
p lic a tio n s and Sequelae, 193; Period of Communicab i l i t y , 193; P ro g n o sis, 193; Treatm ent, 193; Methods
of C ontrol: Recognition and R eporting, 193; I s o la tio n ,
193; Q uarantine, 193; Immunization, 194; Nursing Care,
I s o la tio n , 194; Personal Hygiene, 194; Mental Hygiene,
194; D ie t, 194; Com plications, 194; D is in fe c tio n :
C oncurrent, 194; Term inal, 194; E s s e n tia l P o in ts to
Remember, 194.
Chapter
XII
S c a b i e s ................................................................................................
D e fin itio n , 196; H isto ry , 196; P revalence, 196;
e tio lo g y , 196; Source of In fe c tio n , 196; Mode of
Transm ission, 196; S u s c e p tib ility , 197; P athology,
197; Incubation P erio d , 197; Course of the D isease:
C lin ic a l P ic tu r e , 197; Complications and Sequelae,
197; period of Communicability, 197; P rognosis, 197;
Treatm ent, 197; Methods of C ontrol: Recognition and
x iii
196
Page
R ep o rtin g , 198; I s o la tio n , 198; Q uarantine, 198;
Nursing Care, 198; D is in fe c tio n : C oncurrent, 198;
Term inal, 198; E s s e n tia l P o in ts to Remember, 199;
Home C are, Nursing I n s tr u c tio n s , 199,
Chapter
mi
200
T e ta n u s ................................................................................................
D e fin itio n , 200; H isto ry , 200; P revalence, 200;
E tio lo g y , 201; Sources of In fe c tio n , 201; Mode of
Transm ission, 201; S u s c e p tib ility , 202; P athology,
201; In cu b atio n P erio d , 202, Course of the D isease:
C lin ic a l P ic tu r e , 202; Period o f Convalescence, 203;
Period o f Communicability, 203; P rognosis, 203;
M o rta lity , 203; Treatment: S p e c ific P ro p h y la x is,
203; G-eneral P rophylaxis, 204; A ctive Treatm ent,
204; Methods of C ontrol: Recognition and R ep o rtin g ,
204; I s o la tio n , 204; Immunization, 204; N ursing c a re ,
I s o la tio n , 205; Comfort of the P a tie n t, 205; P erso n al
Hygiene: Care of the Skin, 205; Care of th e E yes,
205; Care of th e Mouth and Nose, 205; E lim in a tio n ,
205; D ie t, 206; Com plications, 206; Serum R e a c tio n s,
206; Convalescence, 206; D isin fe c tio n : C oncurrent,
206; Term inal, 206; E s s e n tia l P o in ts to Remember,
206; Home Care, Nursing In s tru c tio n s , 207; Community
P ro te c tio n , 207.
Chapter 3GCIII
Rab ie
..................................................................................
208
D e fin itio n , 208; H isto ry , 208; p rev alen ce, 208;
E tio lo g y , 209; source of In fe c tio n , 209; Mode of
Transm ission, 209; S u s c e p tib ility , 209; P ath o lo g y ,
209; In cu b atio n P erio d, 209; Course o f the D isease,
210; Rabies in the Dog, 210; Types of the D isease:
F urious R abies, 210; P a ra ly tic R abies, 210; P eriod
of Communicability, 210; Rabies in Man, 211; Stages
of th e D isease: Premonitory S tage, 211; Excitem ent
S tag e, 211; P a ra ly tic S tage, 211; Period o f Communi­
c a b i l i t y , 211; Prognosis and M o rta lity , 211; Prophy­
l a c t i c Treatm ent: A ntirabic V accine, 211; Sample Modi­
f ic a t io n of A n tira b ic Vaccine, 212; C a u te riz a tio n , 212;
A ctive Treatm ent, 213; Methods of C ontrol: R ecognition
and R ep o rtin g , 213; I s o la tio n , 213; Q uarantine, 213;
Immunization, 214; Nursing Care, t y s i l a t i o n , 214; Com­
f o r t o f the P a tie n t, 214; D is in fe c tio n : C oncurrent,
xiv
215; Term inal, 215; E s s e n tia l P o in ts to Remember,
215; Community P ro te c tio n , 215.
Chapter 3QCI7
P s itta c o s is ........................................................................................
217
D e fin itio n , 217; H is to ry , 217; P rev alen ce, 217;
E tio lo g y , 218; Source of I n fe c tio n , 218; Mode of
Transm ission, 218; S u s c e p tib ility , 218; Pathology,
218; Incubation P e rio d , 218; Course of the D isease:
C lin ic a l P ic tu re , 218; p e rio d of Convalescence, 219;
Com plications and S equelae, 219; P eriod of Communicab i l i t y , 219; P ro g n o sis, 219; M o rta lity , 219; T re a t­
ment, 219; Methods of C ontrol: R ecognition and Re­
p o rtin g , 219; I s o la tio n , 219; Q uarantine, 219; Immun­
iz a tio n , 219; Nursing Care, 220; D is in fe c tio n : Con­
c u rre n t, 220; Term inal, 220; E s s e n tia l P o in ts to
Remember, 220.
Chapter }SC7
221
Yellow Fever ....................................................................................
D e fin itio n , 221; H is to ry , 221; P rev alen ce, 222;
E tio lo g y , 223; Source of I n f e c tio n , 223; Mode of
Transm ission, 223; S u s c e p tib ility , 224; Pathology,
224; In cubation P erio d , 224; Course of th e D isease:
C in ica l P ic tu re , 224; Period of Convalescence, 225;
Complications and S equelae, 225; P eriod of Communi­
c a b i l i t y , 225; P ro g n o sis and M o rta lity , 225; Methods
of C ontrol: R ecognition and R ep o rtin g , 225; I s o la ­
tio n , 226; Q uarantine, 226; Immunization, 226| Trans­
p o rta tio n R eg u latio n s, 226; E lim in atio n of Breeding
P la ce s, 227; Nursing Care, I s o la tio n , 227; Comfort
of the P a tie n t, 228; P ersonal Hygiene: Care of th e
S kin, 228; Care of the Eyes, 228; Care o f the Mouth,
228; E lim in atio n , 228; D ie t, 228; Convalescence, 229;
D isin fe c tio n : C oncurrent, 229; Term inal, 229; Essen­
t i a l P o in ts to Remember, 229; Community P ro te c tio n ,
229.
XV
Chapter XXVI
M alaria .................................................................................................
D e fin itio n , 231; H is to ry , 231; P rev alen ce, 232;
E tio lo g y , 233; Source o f I n f e c tio n , 235; Mode of
T ransm ission, 235; S u s c e p tib ility , 235; Pathology,
235; In cu b atio n P e rio d , 235; Course of th e D isease,
23G; C om plications, 237; P erio d of Communicability,
237; P ro g n o sis and M o rta lity , 237; Treatm ent, 237;
Methods o f C o n tro l: R ecognition and R eporting, 239;
I s o la tio n , 239; Q uarantine, 239; Immunization, 239;
P ro p h y lax is, 239; N ursing C are, I s o la tio n , 240;
Comfort o f th e P a tie n t, 240; M edication, 242; Elim­
in a tio n , 242; D ie t, 242; C om plications, 243; D isin ­
f e c tio n , 243; E s s e n tia l P o in ts to Remember, 243;
Home Care, N ursing I n s tr u c tio n s , 243; Community P ro­
te c tio n , 243.
Page
231
PART I I I
C01MJNICABEE DISEASES AND THE COMMUNITY
C hapter T O I
Care o f Communicable D iseases in th e Home . ..........................
The P a t i e n t ’s Room, 246; The Bathroom, 247; Eonipment, 247; Procedure To Be Followed in Caring f o r
th e P a tie n t, 248; The N urse’s Uniform, 249; The
P h y sic ia n ’ s Gown, 249; Hand C leansing, 250; Taking
th e Tem perature, P u ls e , and R e s p ira tio n , 250; Serv­
ing th e T ray, 251; Care o f Contaminated D ishes, 251;
Care of Contaminated L inen, 252; D isposal of N astes,
253; Care o f D airy M ilk B o ttle s , 253; P ost Mortem
Care, 253; Term inal D is in f e c tio n , 254; E s s e n tia l
P o in ts to Remember, 254.
245
C hapter 1QCVIII
The Communicable D isease Nurse in th e Community .................
N ursing O p p o rtu n itie s , 256; H o sp ita l N ursing, 257;
P u b lic H ealth N ursing, 258; V oluntary A gencies, 258;
O f f ic ia l A gencies, 259; School N ursing, 259;
I n d u s tr ia l N ursing, 260; The American Red C ross, r'S0;
P riv a te P r a c tic e , 260; The Nurse of Tomorrow, 260*
Appendices ....................................................................................
G lossary
............................................................................
Index
.............................. ......................................................
xvi
256
263
308
318
LIST OF DRAWINGS, GRAPHS, CHARTS
F ig .
1.
Drawing of s a g i t t a l s e c tio n through th e head
F ig .
2.
Temperature c h a r t: m easles and broncho-pneumonia
F ig .
3.
Temperature c h a rt: ru b e lla
F ig .
4.
Temperature c h a r t :
smallpox
F ig .
5.
Temperature c h a r t:
s c a r l e t fev er
F ig .
6.
Graph showing c u ra tiv e a c tio n in use of a n tito x in
F ig .
7.
Graph showing d eath r a te s fo r d ip h th e ria in New York C ity
F ig .
8.
Temperature c h a rt: n a s a l d ip h th eria
F ig .
9.
Temperature c h a rt: pharyngeal d ip h th e ria and serum sick n e ss
F ig . 10.
Temperature c h a rt: whooping cough and broncho-pneumonia
F ig . 11.
Temperature c h a rt: p o lio m y e litis (b u lb ar type)
F ig . 12.
Temperature c h a rt: ra b ie s
F ig . 13.
Temperature c h a rt: m alaria ( te r tia n type)
F ig . 14.
Temperature c h a rt: m alaria (quartan type)
F ig . 15.
Temperature c h a rt: m alaria (estivo-autum nal type)
PAST
I
TH2 BACKGROUND OF C01MJNICABL3 DI3FA3F 1MUR3ING
CHAPTER I
HISTORICAL INTRODUCTION
Communicable diseases have played a dominant ro le in the destiny o f
the human race.
They have defeated armies and have changed the economic
l i f e o f whole nation s.
They have destroyed explorers and colon izers,
scattered whole settlem ents, and with dramatic suddenness have struck
down great leaders and peoples in a b r ie f period of tim e.
Some of these
d iseases already have succumbed to the growing knowledge of the s c ie n t is t .
Others no longer are as d estru ctive as in the p a st, but they s t i l l per­
s i s t , though in lessen in g power.
A few continue to ravage and demolish
l i f e , eluding a l l s c ie n t if ic e f fo r t s to conquer them.
Prim itive man had no conception o f in f e c t iv it y .
The cure of a d is­
ease was accomplished by inducing i t to leave the body, and i t s egress
could be hastened, he thought, in such su p e r stitio u s ways as by adm inister­
ing disagreeable medicines, by b eatin g the sick p erson ,, or by th e shaking
o f r a t t le s to frighten him.
He thought i t p o ssib le , a ls o , to coax a disease
out o f the body into a more congenial p lace or, by means o f drums and incan­
ta tio n s , to transfer it to another person. The p red iction of d iseases in
prim itive tim es was founded upon the various ideas of astrology and omens and
upon the d ifferen ces in the appearance of the v is c e r a of slaughtered animals.
A ll these ideas are bound up with th e supernatural, and thus arose the i n t i ­
mate connection between prim itive medicine and p rim itive r e lig io n .
Evidence
to in d ica te why prim itive r e lig io n la id p articu lar s tr e s s on clea n lin ess is
2
not c le a r , but i t would seem th a t, lik e a r t, hygienic observances sprang
from re lig io u s r it u a l.
From th e f a c t , probably, th a t men do not make records of ordinary
even ts, but only o f str ik in g ones, nursing i s seldom mentioned in ancient
h isto r y .
The sick have always been nursed as a matter of course, and not
u n til c i t i e s grew large and the problems of illn e s s became acute, requiring
that provision be made fo r them, did nursing assume s u f f ic ie n t importance
to be s c ie n t if ic a lly considered.
Early nursing h isto ry i s , th erefore, lo s t
in obscurity, since the only records a v a ila b le are those o f h o sp ita l nursing
a f te r i t became an esta b lish ed fa ct in in s titu tio n s fo r the care o f the sic k .
In order to thoroughly understand hhd appreciate the r e s u lts o f scien ­
t i f i c research in m edicine, a b r ie f review of the h isto ry o f communicable
d isea ses and th eir r e la tio n to world h isto ry i s desirab le fo r th e student
nurse.
Literature abounds with referen ces which portray the d isastrous e f ­
f e c t s o f ravaging d ise a se s upon n a tio n s, one o f the most v iv id o f them being
found in Byron's d escrip tio n o f the d estru ction of Sennacherib's array.1
Communicable D iseases and Ancient C iv iliz a tio n s
India.
The Vedas, the sacred books o f India, d iscu ss many d ise a se s, in ­
cluding those of ch ild ren .
They contain in stru ctio n in hygiene, and they se t
fo rth the theory th a t the prevention of d isease i s more important than the
cure.
In a l l th eir teachings an unconscious hint o f the germ theory o f d is ­
ease i s apparent.
1.
Inoculation again st smallpox originated among the Hindus
George Gordon Byron (Lord Byron), The P o e tica l Works o f Lord Byron.
London: Oxford U n iversity P r e ss, 1935, p. 82.
3
and the Chinese.
A fter about 200 B .C ., Hindu medicine deteriorated and care
o f the sick p r a c tic a lly ceased.
The Chinese.
Chinese medicine i s based upon the works o f Huang-ti
(2697 B .C .), and references to gonorrhea are attrib u ted to him.
S y p h ilis
i s said to go back to the Ming dynasty.^
According to m ission aries, inocu2
la tio n against smallpox in China i s as old as the d ise a se .
The Chinese b elieved th a t e v il s p ir it s caused d isea se, and th e ir tr e a t­
ment of sickness was d irected toward g ettin g rid of these s p i r i t s .
The fear
o f handling a sick person or a dead body was based upon the idea that the
s p ir it s might enter the person who touched them.
These su p erstitio u s b e lie fs
prevented the development o f nursing care.
The Egyptians.
Even as a l l e a r ly races, the Egyptians were h e lp le ss in
the presence o f epidemic d ise a se s.
In s p ite o f th is f a c t , th e ir hygienic
conditions were very good, and in th e ir custom o f keeping snakes in th e ir
houses to drive the ra ts away i t i s evident they had observed an a sso cia tio n
between rats and p e s tile n c e .
They seem to have r e lie d upon fumigation to
check the spread of in fe c tio u s d ise a s e s .
The Jews.
The Influence o f Egyptian id e a ls and p ractices o f public health
are apparent in the Mosaic law, the f i r s t r u le s estab lish ed as a d e fin ite le g a l
code and enforced upon a whole nation .
The p ra ctica l ap p lication o f th is code
can be appreciated when i t i s rea lized that the regulations were intended for
a nomad group and that Moses was in charge o f a camp of more than a m illio n
people.
This Jewish law Incorporated the p rin cip les o f modem sa n ita tio n ,
1.
F ield in g Garrison, An Introduction to the H istory o f Medicine, p. 65.
2.
John G. M illingen, C u rio sities o f Medical Experience. 8nd E dition Revised,
London*. R. B entley, 1889, pp. 1 4 -1 5 .
4
and i t s methods are in accord w ith modern b acteriology.
Provisions are in ­
cluded in i t fo r the in sp ection and s e le c tio n of food, fo r th e d isp osal of
excreta, fo r n o tific a tio n o f the a u th o r ities in cases of communicable d is ­
ea se, and for quarantine and d is in fe c tio n .
S p ecific d irection s are given
as to segregation and d is in fe c tio n , the lep er being required to liv e out­
sid e the camp and to remain away from public p la ces.
The p r ie sts acted as
p o lic e o f hygiene.1
The Greeks.
The plague appeared in Athens in 430 B .C ., when t h is re­
public was a t war with Sparta and at th e height of i t s culture under P e r ic le s .
A fter two years i t subsided, but returned a year la te r .
When f in a lly i t d is ­
appeared, more than one third o f the population o f Athens had been destroyed.
Having no c le a r idea of the ln f e c t iv it y o f d ise a se s, the Greeks did nothing
to check the spread o f them by is o la tio n .
ture of the symptoms of the
Thucydides g iv es a graphic p ic ­
plague, as w e ll as of the physical sufferin g
and moral degradation r e su ltin g from i t s spread.
The Romans.
Boms.
2
Throughout h isto ry great epidemics have l e f t t h e ir mark on
In s p ite o f i t s high le v e l of cu ltu re, the Graeco-Roman world was
powerless to deal with p e s tile n c e s , which were frequent and ex ten siv e.
In
164 A .D ., the great Antonine plague began and raged throughout f if t e e n con3
secu tive years. In 543 A.D., the plague of Justinian , so graphically de­
scribed by Gibbon in h is "Decline and F a ll of the Roman Empire," decimated
the population.
Malaria, endemic in many of the provinces, was constantly
1.
The Holy Bible (Old Testament), Book of L eviticu s, Chapters VII, XI,
X III, XIV, XV; Book of Deuteronomy, Chapters XII, XIV, XXIII.
2.
Thucydides, H istory of the Peloponnesian War, pp. 129-134.
3.
Edward Gibbon, The Decline and F a ll of the Roman Empire, V ol. IV,
pp. 371-374.
undermining the n a tio n a l physique.
H istorians generally concede th e
frequent occurrence o f communicable d isea ses t o be an important fa cto r in
the Roman Empire's dow nfall.
Progress o f Oomnmnicable D isease Control in Europe
Middle Ages.
The most strik in g fa c t that emerges from consideration
of h ealth in the Middle Ages i s the h i$ i incidence of d isease, although
the experience gained in dealing with leprosy when th is disease devastated
Europe had engendered in the minds o f physicians th e thought of contagion
and even of preventive m edicine.
Leprosy became widespread in Europe as a r e s u lt of the vast m obiliza­
tio n o f nations in the Crusades.
Once an individual was pronounced a le p e r ,
he was a s o c ia l outcast and regarded as a ctu a lly dead.
The clergy adopted
r e s tr ic t iv e measures in the handling of lep ers, the f i r s t laws being promul­
gated at Lyons, France, in 583 A.D.
A more rigorous system of control was
developed in m inutest d e t a il in the follow in g few cen tu ries.
By the tw e lfth
century is o la tio n camps were to be found in nearly a l l parts of Europe, and
in the next century there were over 19,000 leper homes in Europe, including
2,000 in France a lo n e .
This s t r ic t is o la tio n p ra ctica lly eradicated leprosy
in Europe, and Bolduan regards it as one of the f i r s t great v ic t o r ie s in preventive m edicine.
i
The recogn ition o f contagious d iseases came slow ly.
At f i r s t f iv e , and
f in a lly tw elve, were id e n tifie d during th e th irteen th century.
1.
These were:
C. F. Bolduan and N. W. Bolduan, Public Health and Hygiene, p. 22.
lep rosy, in flu en za , gonorrheal ophthalmia, trachoma, scab ies, im petigo,
anthrax, d ip h th eria, e r y s ip e la s , typhus (including typhoid), plague, and
consumption.
S y p h ilis , as a form o f pox, was included in the fifte e n th
century.
The "Black Death," a severe pandemic which most a u th o r ities b eliev e
was pneumonic plague, was carried to Europe in 1347 a fte r devastating Asia
and A frica .
H istorian s estim ate th a t one fourth of the population of the
earth was destroyed by t h is d ise a s e .
d a ily at th e H otel Dieu in P a r is.
As many as f iv e hundred deaths occurred
The s is t e r s who nursed the sick died in
large numbers, but t h e ir ranks were constantly replenished by fresh r e c r u its
who courageously carried on th e ir d u ties in the face o f certain death.
In order to erad icate the "Black Death," the ch ief maritime commercial
c i t i e s o f the Mediterranean (Venice, Ragusa, M arseilles, and Genoa) adopted
and enforced a forty-d ay detention period fo r a l l v e s s e ls entering th e ir
ports from 1377 to 1403.
This regu lation marked the beginning of modem
maritime quarantine methods, the term "quarantine" being derived from the
Ita lia n word quarantine, which means a period of forty days.
While re­
s tr ic t iv e measures were being adopted, r a ts , the carriers of the plague,
continued to run rampant.
With no s c ie n t i f ic knowledge of the nature of the e x istin g d iseases a v a il­
a b le, i t i s d i f f i c u l t to determine the e s s e n tia l c h a r a c te r istic s of the var­
ious epidemics which devastated the world in early tim es.
I t is known th at
bubonic plague, smallpox, typhus fev er, and influenza con stitu ted the more
common p e s tile n c e s and th a t very few people escaped smallpox, but many d is ­
eases now recognized as d is tin c t e n t it ie s were not d iffe r e n tia te d .
P e s t i­
lences were b eliev ed to be in f lic t e d on man by the Deity as punishment;
7
sickness and d is e a s e were co n sid ered th e work of e v il s p i r i t s .
Thus ig n o r­
ance and s u p e r s titio n , la c k of s a n ita tio n , th e prevalence of verm in, and the
low stan d ard s o f liv i n g , to g e th e r w ith crowds of wandering sc h o la rs and vaga­
bonds and th e in d isc rim in a te h o s p ita lity found everywhere, r e s u lte d in th e
almost continuous presence o f plagues in Europe.
The only a c tu a l c o n trib u tio n to the h e a lth f i e l d in th e M iddle Ages was
th e idea o f th e h o s p it a l .
The f i r s t one designed f a r th e c are of le p e rs and
the in d ig en t s ic k was th e Almshouse of S t . B a s il, e s ta b lis h e d in Cappadocia.
A sso c iatio n s, m ilita r y and c i v i l , were formed to care f o r th e s ic k .
Of th e s e ,
th e e a r l i e s t was th e Order o f S t . Lazarus, connected with S t. B a s il’ s hospices
f o r le p e r s .
C h r is tia n ity made i t s g r e a te s t o b je c tiv e c o n trib u tio n to s o c ia l
hygiene in i t s care f o r th e s ic k and poor.
The R enaissance.
The f i f t e e n t h century ushered in th a t p erio d of i n t e l ­
le c tu a l a c t i v i t y known as th e R enaissance, and i t was during t h i s tim e th a t
E raca sto r o f Verona (1483-1553) advanced h is b e lie f t h a t c e r ta in d ise a se s are
spread by ’’seeds” which have th e power o f propagating them selves.
The Seventeenth C entury.
Seventeenth century p ro g re ss in th e understand­
ing o f canmuniceble d ise a se s was made in Germany when A thanasius K ircher
(1620-1680), a J e s u it monk, examined the blood of a plague v ic tim under a
crude len s and fran. h i s fin d in g s s ta te d th e d o ctrin e o f ”contagium animatum”
as th e cause o f in fe c tio u s d is e a s e s ; a ls o , when Anton van Leeuwenhoek
(1632-1723), a Dutch lin e n d ra p e r, constructed a microscope by means of viiich
he d escrib ed v ario u s form s o f b a c te r ia .
Both these men may be co n sid ered the
fa th e rs of th e germ th e o ry .
The sev en teen th cen tu ry a ls o marks th e occurrence o f the G reat Plague of
London (1665) in which thousands p e rish e d .
The e f f e c ts o f t h i s plague on th e
8
people o f London are c le a r ly shown in the frequent references to i t in
Samuel Pepys’ Diary.
1
The Great Fire
2
which followed the plague destroyed
the r a t-in fe ste d dw ellings and thus texminated the scourge.
Since then,
not only has there been no more heard of the plague in England, but the
ea rly years of the succeeding century witnessed i t s complete disappearance
from Western Europe.
Eighteenth to Twentieth C enturies.
In the eighteenth century smallpox
took a heavy t o l l of liv e s throughout the world.
This was the century a lso
in which the epochal discovery of vaccination by Edward Tenner, an English
p h ysician , was made, resu ltin g in an enormous reduction in the prevalence
o f smallpox and proving to be the outstanding contribution to preventive
medicine during the eighteenth century period.
discovery (1798), Lady Mary Wortley Montagu
Previous to Dr. Jenner’s
(1809-1762) had introduced in ­
to England the Turkish method o f inoculation w ith viru s from a smallpox
p a tie n t.
The century’ s foremost physician, von P len ciz of Vienna, main­
tained in 1762 that not only were a l l in fectio n s caused by micro-organisms,
but th at the in fe c tiv e m aterial must of n e c e ssity be a liv in g organism.
He
attempted to explain the variation in incubation periods o f the in fe c tio u s
d ise a s e s .
Among the important contributors to progress in th e f ie ld of communi­
cable d isea ses in the nineteenth century were:
Henle (1809-1885), who
described the r e la tio n of micro-organisms to in fe c tio u s d ise a se s, and who
1.
Samuel Pepys, The Diary of Samuel Pepys.
1930.
New York:
E. P. Dutton Company,
2.
Daniel De Foe, The Plague in London. E tc. London: George B e ll and Sons,
1896. "An H isto rica l Narrative of the Great and T e r r i b l e Fire of
London, S ep t. 2nd, 1666,** pp. 209-248.
9
a ls o defined the character o f bacteria;
Semmelweis, who in 1847 discovered
that when h is medical students washed th e ir hands in soap, lim e, or chlorine
the number o f puerperal fever cases among h is m aternity p a tien ts was reduced probably the f i r s t s c ie n t if ic hand-washing experiment;
P asteur, who gave
h is germ theory to the world in 1870, and who, ten years la t e r , gave the vac­
c in e s fo r anthrax and rabies;
L iste r , whose experiment (1863-1870) in th e
a n tis e p tic treatment o f wounds exerted a powerful in fluence on the doctrine
o f b a cter ia l in fec tio n ;
Koch, who discovered the tubercle b a c illu s in 1882,
and who w ith h is p o stu la tes helped to esta b lish ca refu l irethods of research
and c r i t i c a l examination of proofs before any microbe was accepted as the
causal organism o f a d isea se;
Klebs and L o e ffle r , who discovered the diph­
th eria b a c illu s in 1883 and 1884, resp ectiv ely ;
Roux and von Behring, who
gave impetus to further research in curbing the spread of d isea se and the pre­
vention o f epidemics by th e ir d iscoveries of a n tito x in and sera;
and Florence
N ightingale (1820-1910), who demonstrated in the Crimean War (1854) what e f ­
f ic ie n t and s c ie n t if ic nursing care could accomplish in the saving of l i v e s .
The s c ie n t i f ic advances of the nineteenth century made p ossible th e re­
markable achievements of the tw entieth century.
The experiences of the World
War (1914-1918) and in the present European war convincingly demonstrate the
e ffic a c y of a n tise r a , vaccin es, and san itaiy engineering in the prevention
and control of communicable d isea ses.
Progress of Communicable Disease Control in America
America, the New World, f i r s t inhabited by the American Indian, whose
picture-writing"*" indicated a recognition of several d isea ses as communicable,
1.
Garrick M allery, Picture Writing of the American Indians, Tenth Annual
Report o f the Bureau of Ethnology to the Secretary o f the Smithsonian
I n s titu tio n . Washington, D. C.: Government P rinting O ffice, 1893,
pp. 588-589.
10
has met the challenges o f the Old World In progressive thought about health
in a l l i t s a sp e cts.
From the time o f the co lo n ia l s e t t le r s , who brought with
them from the Old World a wealth o f su p erstitio n and u n sc ie n tific p ractices
but who soon made concerted e ffo r ts to prevent the 3pread of d isease in fe c tio n ,
America has manifested an a c tiv e and in te llig e n t in te r e s t in communicable d is ­
ease co n trol.
Today the physician and nurse are marching hand in hand in in ­
te n s iv e , cooperative e ffo r t to educate the public in those p rin cip les and
p ra ctices which w i l l reduce the incidence o f preventable d isea ses.
One o f the f i r s t preventive step s taken by the c o lo n ists was the building
o f pest-houses to receive s a ilo r s and passengers on incoming v e s s e ls who had
been exposed to communicable d ise a se s.
From 1665-1721 epidemics of smallpox
were ravaging the c o lo n ie s, when Cotton Mather, clergyman and w riter, spon­
sored the movement to combat them.
The inocu lation method of prevention was
used.
During the Revolutionary War (1775-1781) d isea se took i t s t o l l among the
s o ld ie r s , but no constructive e f fo r t was made in methods of con trol.
When an epidemic of yellow fever occurred in Philadelphia in 1793, the
College of Physicians formulated regu lation s to prevent the spread of th is
d ise a s e .
In 1800 the f i r s t vaccinations against smallpox in the United S tates
were made by Benjamin Waterhouse, of Boston, upon h is four children, and with­
in a short time the smallpox vaccine was introduced into Baltimore, New York,
and P hiladelphia.
During the C iv il War (1861-1865) communicable d isea ses spread rapidly
among the troop s, e s p e c ia lly in the p rison s.
A fter th i3 war pest-houses were
provided throughout the United S ta tes for the care o f p atien ts with smallpox
or other highly communicable d ise a se s.
11
The p rin cip les of nurse trainin g as advanced by Florence Nightingale
were not put in to practice in t h is country u n til 1873.
Up to th is time
nursing care, so important in th e e ffe c tiv e n e s s of preventive measures, was
often incompetent and sloven ly.
In many places i t was e n tir e ly dependent
upon re cru its from almshouses and j a i l s .
A report in 1874 from the Depart­
ment o f C h a rities, New York C ity, describes the nursing care of patients
with in fec tio u s d iseases in Bellevue H ospital as follow s:
"In the fever
ward (fo rty beds) the only nurse was a woman from th e workhouse under six
months’ sentence for drunkenness.
The only bathing conveniences consisted
o f one t in b asin , a piece o f soap and a ragged b it o f cloth passed from bed
to bed."
1
In 1877 one of the e a r lie s t handbooks fo r h o sp ita ls was published by the
New York State C harities Aid A sso cia tio n .
I t recommended the provision o f
is o la tio n huts for the care o f communicable d iseases..
This year a lso saw the
establishm ent of a smallpox h o sp ita l in Boston, and by 1886 student nurses
were caring for communicable disease p a tien ts in the Boston City H ospital.
In the smallpox epidemic in S t. Louis (1883-1885) the S iste r s of S t. Mary
cared for 1,500 p a tien ts, the R eligiou s Orders, gen erally, supplying most of
the nursing care of in fec tio u s d isea ses at that tim e.
Gradually, however, the
N ightingale influence was being absorbed, and more in te llig e n t women were
entering the lay nursing f i e l d .
Nursing textbooks published in 1890-1900
gave s p e c ific d irections fo r the nursing care of communicable disease p a tien ts.
The Providence City H ospital, in Rhode Islan d , in stitu te d the Chapin method of
1.
New York State C harities Aid A ssociation , Annual Report, New York City:
Department of C harities, 1874.
12
medical asepsis in 1910, and at the W illard Parker H ospital, New York City,
the same method was adopted in 1925;
throughout the United S ta te s .
today i t i s being used in hospitals
Dr. Chapin's technic was founded on th e prin­
c ip le s of nursing care as a p p lied in th e Pasteur I n s titu te , Paris.
The f i r s t public h ealth laboratory in the world for the b acteriological
diagnosis of disease was opened in New York City in 1893, by Dr. William Q.
Park.
In 1901 the R ock efeller Foundation was estab lish ed and, through it s
International Health D iv isio n , formed in 1909, has made invaluable contri­
butions through research toward erad ication of communicable d isea ses.
The outstanding names in th e annals of preventive medicine in the United
S ta tes include:
Theobold Smith, Trudeau, Gorges, Reed, R ick etts, and many
others who have devoted t h e ir l i v e s to the conquest of man's most insidious
enemy - communicable d ise a se .
Increased knowledge o f m atters pertaining to community health is being
translated in to law and supported by public opinion.
The National Health
Survey (1935-1936) demonstrated the need fo r medical care among a large group
of the population o f the lower economic le v e ls and showed that disabling i l l ­
ness due to communicable d is e a s e s accounted fo r th e majority of ch ild p atien ts.
Federal, s t a t e , and municipal governments are attempting to reduce these to a
minimum by making g en era lly a v a ila b le the products of s c ie n t if ic research and
by in stru ctin g the public in the measures of communicable disease control.
1.
Dorothy F. Holland, The D isabling D iseases of Childhood, Public Health
Reports, LV (February 9, 1940), pp. 235-236.
13
S elected References
Bolduan, Charles F . , and Bolduan, N ils W., Public Health, and Hygiene.
2nd Edition Revised. P h ilad elp h ia: W. B. Saunders Company, 1937,
P. 372.
Delmege, James Anthony, Towards N ational h e a lth .
Company, 1932. P . xiv + 234.
New York:
The Macmillan
Dock, Lavinia L ., and Stewart, Isa b el M., A Short H istory of Nursing. 3rd
Edition Revised. New York: G. P. Putnam’ s Sons, 1933. P. xiv-+- 404.
Garrison, Fielding H ., An Introduction to the History of Medicine. 3rd
Edition Revised. Philadelphia: W. B. Saunders Company, 1921. P. 942
Gibbon, Edward, The Decline and F a ll of the Roman Empire.
Dutton and Company, 1931. V ols. I-V I.
New York:
Goodnow, Minnie, O utlines o f Nursing H isto ry . 6th Edition Reset.
delphia: W. B. Saunders Company, 1939. P . 490.
Eo P.
P h ila­
Montagu, Lady Mary VJortley, L etters of the Right Honourable Mary Montagu.
London: P. A. De Hondt, 1763. P. 134.
Park, William H., and W illiams, Anna W., Pathogenic Microorganisms. 11th
E dition Revised. Philadelphia: Lea and Febiger, 1939. P. 1056.
Thucydides, History of the Peloponnesian War. Translated by Richard Chawley.
New York: E. P. Dutton and Company, 1926. P. xv +• 614.
CHAPTER II
PREPARATION FOR COMMUNICABLE DISEASE NURSING
S u ffic ie n t knowledge fo r a student nurse to understand c le a r ly the
methods by which d ise a se s are transm itted i s presupposed when she i s as­
signed to a communicable d isease ward or s p e c ia l h ospital*
This includes
experience in m edical, s u r g ic a l, and p ed ia tric nursing, as w e ll as i n t e l l i ­
gent comprehension o f m icrobiology, immunology, and personal hygiene.
The nursing and medical p rofession s have emphasized care a fte r in fec­
tio n has occurred, minimizing measures to prevent occurrence*
Every day on
the wards th e nurse i s in contact with p a tien ts who are incubating communi­
cable d is e a s e s , who have communicable d isea ses which have not been recognized,
or who are c a r r ie r s o f pathogenic micro-organisms*
o f a sep sis in p r a c tic a lly a l l procedures.
She ap p lies the p rin cip les
For example, a fte r taking the tem­
perature o f a p a tie n t, she thoroughly d is in fe c ts th e thermometer before placing
i t in the mouth o f another p a tien t; she thoroughly cleans and b o ils or auto­
claves zubber tubing before la b elin g i t "ready f o r use” ; she washes her hands
a fte r caring fo r each p a tie n t.
The p rotection of others as w ell as of her­
s e l f i s con stan tly in th e n u rse's mind and, i f she has previously applied
the p rin c ip le s o f m icrobiology in her d a ily general nursing care, she w i l l
have l i t t l e d if f ic u lt y in acquiring th e additional s k i l l s required in com­
municable d isea se nursing.
(14)
15
Care of A d u lts.
The general care of adult p atien ts with communicable
d isea ses d iffe r s from th a t given on other serv ices only in rela tio n to spe­
c i a l measures employed in th e care and treatment of these d ise a se s.
Books,
papers, p u zzles, and the radio may help to keep the patients happy during
convalescence*
Care of Children.
The m ajority o f p a tien ts with communicable d ise a se s
are children, so the student nurse must understand child nature before she
can in t e llig e n t ly care fo r them; her experience in pediatric nursing w i l l
help her to a d ju st more rea d ily to th is service*
Nursing the ch ild d iffe r s
from nursing th e adult only in so fa r as i t i s affected by the mental and
ph ysical c h a r a c te r istic s p ecu liar to children*
Nursing care includes mental as w e ll as physical w elfare.
As soon as
the stage o f acute i lln e s s i s over, the ch ild wants to play, and play i s en­
couraged because o f i t s unquestioned hygienic value.
Wards are equipped with
washable to y s, books, p u z zles, magazines, and art m aterials fo r the ch ild ren ,
and games can be adapted to the in te r e s ts of th e ir ages.
Singing together
a lso p leases c h ild re n , and the nurse may lead the singing o f simple songs
from the center o f the ward**
In the nursing care o f children the nurse’ s knowledge o f her part in the
community h ealth program may be applied to the ch ild welfare movement*
Medi­
c a l eare for ch ild ren , which includes nursing care, i s incorporated in the
programs of th e White House Conference, o f the S o cia l Security Board, and o f
voluntary agencies*
The tw en tieth century id eal o f care i s embodied in the
Children’s Charter*2
1.
Gladys S elle w , The Child in Nursing, p . 560.
2.
White House Conference on Child Health and P rotection, Addresses and
A bstracts o f Committee Reports. New York: Century C o., 1931, pp.
46-46.
16
Protect ive Health Measures fo r th e Nurse.
Safeguarding the nurse’ s
health i s necessary to p rotect her again st th e viru len t organisms with
which she comes in contact on the communicable disease serv ice.
The
important fa c to r s in doing t h is follow :
Immunization.
The nurse should be protected against smallpox, diph­
th eria , sc a r le t fe v e r , and typhoid fever by a r t i f i c i a l immunization as soon
as she en ters a nursing sch o o l, and again, i f necessary, before coming to the
communicable d isea se s e r v ic e .
The W illard Parker H ospital issu e s s p e c ific in stru ctio n s for the immuni­
zation o f prospective students.
These are as follow s:
At le a s t 8 months before reporting at the h o sp ita l, the nurse must
be tested fo r s u s c e p t ib ilit y to diphtheria by means of th e Schick t e s t .
I f t h is t e s t i s p o s itiv e , 3 doses o f diphtheria to x in -a n tito x in or toxoid
must be administered at weekly in te r v a ls . Four to s ix months la te r , a
second Schick t e s t must be done. I f t h is should again be found p o s itiv e ,
a second se r ie s o f 3 in je c tio n s must be given .
To determine s u s c e p t ib ilit y to s c a r le t fe v e r , a Dick t e s t is done.
This t e s t should be made 4 months before reporting to the h o sp ita l. I f
found p o s itiv e , the nurse i s immunized by the use of increasing doses
o f sca r le t fev er to x in , administered at 7-day in te r v a ls
Immunity
conferred by th e se in je c tio n s i s apparent three weeks a fte r the la s t in ­
je c tio n , as i s shown by th e Dick t e s t , which must be repeated at th is tim e.
Nurses are required to have bad a su ccessfu l smallpox vaccination w ith­
in 2 years; and t r ip le typhoid vaccine must bave been given w ith in the
same period.
Upon a rriv a l at th e h o sp ita l, th e student i s te ste d fo r s u s c e p tib ility to
sca rlet fev er and d ip h th eria.
I f th e t e s t s are p o s itiv e , she is not permitted
to remain, but may return at a la te r date when she has been properly immunized.
P h y sicia l Examination.
The student should have a complete physical exam­
ination before coming to th e communicable d isease serv ice, to determine the
condition o f her general h ea lth .
te eth , t o n s i l s , and sin u se s.
S p ecial atten tion should be given to her
Much importance i s attached to the x-ray report
of her ch est.
1 . D irection s to A f f ilia t in g Schools Concerning the Immunization of Student
Nurses. New York C ity: W illard Parker H osp ital, 1934.
17
Barsonal Care.
Important fa cto rs in r e s istin g in fe c tio n are:
the
d a ily bath; frequent shampoos; eig h t hours of sleep; n u tritio u s food, in ­
cluding fresh f r u it s and plenty o f water; good elim ination; and m eticulous
care o f the mouth.
Clothing should be adapted to the season, and each day
time should be s e t asid e fo r r e s t and recreation .
Care o f the Hands*
should be kept short*
Hands should be fr e e from abrasions and the n a ils
Frequent washing of the hands and the use of a hand­
brush may cause d erm atitis u n less th e g rea test care i s ex ercised .
lo tio n Should be used often*
Hand
Whan handling sa fe ty -p in s, the nurse should
guard against p in -p rick s, sin ce on t h i s service v iru len t organisms may e a s ily
gain entrance through even the sm allest opening and, i f n eglected , seriou s
consequences may resu lt*
Hands should be kept away from the fa ce, a s th e
m ajority o f in fe c tiv e b a cteria enter the body througi the mouth and respira­
tory tr a c t.
Care o f th e E yes.
I t i s important to avoid touching the ey es, sin ce in ­
fe c tio n o f th e eyes may be serio u s.
Care of the Hair.
The hair should be dressed c lo se to th e head, and a
net should be worn to prevent contamination o f stray locks*
The Nursef s Uniform* A short-sleeved uniform
twelve inches from
the flo o r should be worn.
with the s k ir t
Some
at
le a s t
h o sp ita ls require aspe­
c i a l type o f uniform to be worn on the wards*
Care o f the Nurse in I ll n e s s * The s lig h t e s t in fe c tio n or cold may r e su lt
in serious resp iratory com plications.
Therefore, fo r the p a tien t* s protection
as w e ll as her own, the nurse who contracts a cold should be ordered o f f duty
and to bed a t once.
No delay should occur in the proper reporting of sore
th roat, coryza, or symptoms o f any il ln e s s whatsoever*
18
The highest incidence o f illn e s s among nurses i s on the p ed iatric and
communicable d isea se se r v ic e s, according to a survey made by the Department
1
o f Studies of the National League of Nursing Education, and the nurse’s sus­
c e p t ib ilit y is shown in a study of the p o lio m y e litis epidemic at the Los
Angeles H osp ital, in 1935-1936.
Out of approximately 250 employees who con­
tracted the d isea se, the study reveals, 150 were nurses and, on Februaiy 15,
1937, approximately 120 nurses were reported as s t i l l receiv in g compensation.
" . . . . fa tig u e," the report s ta te s , "was a v i t a l fa cto r in lessen in g r e s is ­
tance . . . new wards had to be opened up, and 278 new nurses as w e ll as
doctors, o r d e r lie s,
and attendants whohadnever been trained in medical
a sep tic technic . .
. were substituted for some of the
trained workers . . .
and q u ite n aturally d irect and in d irect exposures were taking place."
2
From
th is can be seen the importance of observing m eticulous a sep tic technic to
prevent c r o ss-in fe c tio n s on the ward and illn e s s among the nurses.
Every nurse should be fam iliar with the basic facts-con cern in g each com­
municable d isea se.
1.
2.
3.
4.
5.
6.
7.
8.
She should know:
The
The
The
The
Tie
The
causal organism and how i t i s transm itted.
p ortals of entry and e x it of the in fe c tiv e agent.
secretio n s which harbor the in fe c tiv e agent.
length of time the patient may transm it the d isea se.
p o s s ib ilit y of the patien t remaining a c a rrier.
method of protecting h e r s e lf and others from contracting
the d isea se.
Body defenses in r e sistin g d ise a se s.
The lo c a l iso la tio n and quarantine reg u la tio n s.
1.
Joint Committee on the Costs of Nursing Service and Nursing Education of
the American H ospital A ssociation, the N ational League of Nursing Edu­
ca tio n , and the American Nurses’ A ssociation , A Study o f the Incidence
and Costs of I lln e s s Among Nurses, 1938, pp. 18-20.
2.
R esults of P o lio m y elitis Among Nurses, American Journal of Nursing,
XOTII (June, 1937), p. 620.
19
The Nurse as Teacher of Health.
The teaching function o f the nurse on
the communicable disease service cannot be overemphasized; opportunities for
general health teaching here are numerous, and the nurse must know not only
what to do, but also the reason fo r doing i t .
She must constantly act as
teacher of both d isease prevention and co n tro l, and she should be an example
of her teaching.
Whether in p rivate p ractice or public health work, the re­
s p o n s ib ilit ie s o f the nurse sre the same.
Selected References
Committee on the Grading of Nursing Schools, P sy ch ia tric and Communicable
D isease Experience. American Journal o f Nursing, XXXIII (September,
1933), pp. 859-60.
Joint Committee on the Costs of Nursing Service and Nursing Education of
the American Hospital A ssociation, the National League of Nursing Edu­
ca tio n , and the American Nurses* A ssociation , A Study of the Incidence
and Costs of I lln e s s Among Nurses. New York: The American H ospital
A sso cia tio n , the National League of Nursing Education, and the American
Nurses' A ssociation , 1938. P. 36.
MacLennan, K. M., Teaching the Care of P a tien ts Suffering from Communicable
D iseases. Canadian Nurse, XXX (October, 1935), pp. 455-59.
Pool, M., In fectio u s Disease Training and I t s Value.
cine (London), XLV (May, 1937), pp. 294-97.
R esu lts o f P o lio m y elitis Among Nurses.
(June, 1937), p. 620.
Journal o f State Medi-
American Journal of Nursing, XXXVII
S ellew , Gladys, The Child in Nursing. 4th Edition R eset.
W. B. Saunders Company, 1938. P . 600.
Philadelphia:
Whitten, Mary S treet, and Whitten, Hope, Pastimes for Sick Children.
York: D. Appleton Company, 1926. P. x i i i + 92.
New
CHAPTER I I I
INFECTION AND RESISTANCE TO DISEASE
Communicable d ise a s e s , to which the terms " infectious" and "contagious"
are interchangeably a p p lied , are th ose in which t h e ir causative agents are
d ir e c tly or in d ir e c tly transm itted from h ost to host*
A contagious d isea se
s ig n if ie s one th at i s rea d ily tra n sm issib le, and i t i s commonly referred to
as "catching."
In fectio u s d isea ses are described a3 those caused by liv in g
transm issible agen ts, whatever the means o f transm ission; they include those
that are in sect-b orn e.
Presence o f In fe c tio n .
An in fe c tio n i s present whan pathogenic organisms
invade the tis s u e s and m u ltip ly.
The body in which the in fe c tiv e agent has
gained a foothold i s c a lle d the "host."
In fectiv e Agents*
B acteria, protozoa, p a r a site s, sp iroch etes, and f i l t e r ­
able viru ses are the agents which cause In fe c tio n .
They may be the casual
agents o f communicable d ise a s e s . V iruses cause some of the most dangerous
diseases*
Sources o f In fe c tio n .
d ise a se s.
Man and animals are the sources of communicable
Man con tracts in fe c tio n from anim als, as rabies from dogs, but he
him self i s the main source o f human communicable d isease in fe c tio n .
in fec tio n source, he may be:
As the
a recognized ca se, an unrecognized or missed
case, an a ty p ic a l ca se, a la te n t ca se, or a carrier*
The recognized case i s immediately reported to a health o f fic e r and is
iso la te d ; thus the danger of t h is case spreading the in fec tio n is r e la tiv e ly
sm all.
Missed cases include those persons who have a mild form of a d isease
(2 0 )
21
but who do not f e e l s ic k enough to seek m edical advice, as w ell as persons
whose i l l n e s s i s not c o r r e c tly diagnosed*
A la te n t case may be a person who,
apparently, has recovered from a communicable d isea se but in whose system
organisms remain in a ctiv e u n t il the resista n c e of the host i s lowered; then
they become a c t iv e .
l o s i s and gonorrhea.
Examples o f la te n t case in fe c tio n are found in tubercu­
Carriers are persons who harbor disease-producing organ­
isms in th e ir bodies y e t have no symptoms of the d ise a se .
They are important
in the spread o f such d isea ses as epidemic m en in gitis, typhoid fev er, and amebic
and b a c illa r y dysentery.
Frequently, they are unrecognized.
P r a c tic a lly a l l
health departments have laws fo r the con trol of ca rriers.
P ortals o f Entry o f In fe c tiv e Agents.
The sk in , the respiratory tr a c t,
the genito-urinary t r a c t , and, before b ir th , the placenta are the four common
channels through which in fe c tiv e agents en ter the body.
The mere presence of
pathogenic micro-organisms on skin su rfa ces, however, i s not s u ffic ie n t to
cause in fec tio n ; they must invade and grow in the deeper t is s u e s .
About 90
per cent of the in fe c tiv e agents which cause communicable d isea ses enter
through the resp ira to ry t r a c t .
Factors Influencing the Occurrence o f In fectio n .
The occurrence of in fe c ­
tio n depends upon the p ortal of entry, the virulence and number o f in fe c tiv e
a gen ts, and the d efen sive powers o f the h ost, most organisms having d e fin ite
channels o f entrance and f a ilin g to produce d isease when introduced in to the
body by some other rou te.
Fpr example, when streptococci are rubbed on an
abraded sk in , they produce inflammation, but they are without e f fe c t when
swallowed.
I f only a few m icro-organisns enter the body, they usu ally are
overcome by the lo c a l d efen ses, but, i f large numbers of them en ter, they can
overcome the d efen sive h ost; th e ir a b ilit y to do th is being known as v iru len ce.
Generally organisms are most v iru len t in fresh body discharges.
22
Means of Disease Production.
The invading organisms cause disease
through s p e c ific p ro p erties, p a rticu la rly toxin s and b a cteria l s p lit proteins.
B acterial toxins are poisons produced by b acteria $ s ;’they grow in liv in g
tissu e or in a r t i f i c i a l culture media.
endotoxins.
They are of two types:
exotoxins and
Exotoxins are secreted by the b a cteria l c e l l , w hile endotoxins
are lib erated only when the b a cteria l c e l l i s destroyed.
For example, in
diphtheria the b a c i l l i grow lo c a lly and produce l i t t l e e f f e c t , but the exo­
toxin s are absorbed into the body and a ffe c t the nerves and heart t is s u e .
B acterial s p lit p rotein s are the r esu lt of the d isin teg ra tio n of the
b acteria within the blood stream or body t is s u e s .
various poisonous substances are set fr e e .
In th is s p lit tin g process
For example, disintegrated typhoid
b a c illi produce one s e t of symptoms, whereas the protein products of the tub ercle b a c illi bring about d ifferen t tis s u e changes.
Body Reactions to In fec tiv e Agents.
e f fe c t s of b a cteria l in fe c tio n i s fev er.
One of the most important general
The degree of fever may indicate
the sev erity of the in fa c tio n except in such toxemias as diphtheria, in which
there may be no elev a tio n o f temperature.
A change in the number o f leucocytes and in the r e la tiv e proportion of
the d ifferen t kinds of these c e l l s i s a lso a common resu lt of in fe c tio n .
For
th is reason, leucocyte and d iff e r e n t ia l counts are important in diagnosis and
prognosis.
Usually the leucocyte count i s increased markedly, but in m easles,
influenza, tu b ercu lo sis, typhoid fe v e r , and undulant fever there i s only a
s lig h t Increase in the
polymorphonuclear leu cocytes.
quently present in th ese d is e a s e s .
Lsucopenia a lso i s fr e ­
Anemia may r e su lt from prolonged in fe c tio n s.
Another important r e s u lt of in fe c tio n is the production of s p e c ific a n ti­
bodies which often protect the host from subsequent sim ilar in fe c tio n s.
For
23
example, a person who has recovered from smallpox w ill not contract the
d isease when again exposed to I t .
Incubation Period.
When disease-producing agents enter the body they
or th e ir toxins must combine chem ically with body c e l l s .
Hius, a variable
length o f time elapses before m anifestations of the disease appear.
This is
known as the incubation period,
the length of
whichdepends upon the follow ­
ing factors:
the in fe c tiv e
agent(fo r example, the incu­
(1) the nature of
bation period of sc a r le t fev er i s shorter than that of mumps);
lence o f the organisms;
(3) the r esista n ce of the host;
from the portal of entry to the a ffected part;
(2) the v iru ­
(4) the d istance
(5) the number of in fe c tiv e
agents entering the body.
P ortals of E xit of Organisms.
the body through various excreta.
The organisms which cause disease leave
For example:
(1) organisms causing ty ­
phoid fever and undulant fever leave through feces and urine;
(2) organisms
which cause tuberculosis and pneumonia and th e viru ses of smallpox and rabies
leave through the discharges from a
(3) stap h lycocci, stre p to c o cc i,
p a tie n t's
mouthand respiratory tr a c t;
and the spore
formers of tetanus and gas
gangrene* leave through wound discharges.
Transmission of Communicable D isea ses.
The causative agents of communi­
cable d isea ses are frequently transm itted by d irect and in direct contact;
also they may be transm itted through in se c ts as intermediary hosts and as a
means o f mechanical tra n sfer.
By d irect contact i s meant the spreading of in fec tio n d ir e c tly from
person to person, but th is does not n e c e ssa r ily imply actual body con ta ct.
1.
Charles F. Carter, Microbiology and Pathology. p. 206.
24
An. example of d irect contact is droplet In fectio n , which i s the tr a n sfe r of
in fe c tiv e agents c a st o f f in the spray during coughing or ta lk in g .
D irect
transm ission of in fe c tio n may a lso take place through the placenta, as in
s y p h ilis .
In d irect contact r e fe r s to the transm ission of the causative agent of
a d isease by contaminated hands, inanimate ob jects or fom ites, water, and food.
Typhoid fe v er , ch olera, sep tic sore th ro a t, and sc a r le t fever are included in
diseases transm itted in t h is way.
Personal c le a n lin e ss , e sp e c ia lly in th e care
of hands, i s a fa cto r which cannot be overemphasized in rela tio n to the spread
o f d isease by in d irect con tact.
B io lo g ic a l and mechanical tra n sfer of in fe c tio n are accomplished by in s e c ts .
In b io lo g ic a l tr a n sfe r , the in se c t b ite s a person or animal i l l with a d ise a se ,
or even a c a r r ie r , and in g e sts the in fected blood, then carries the harbored
organisn. to i t s v ic tim s.
M alaria, yellow fev er, and typhus fever are some of
the d isea ses tran sferred in th is way.
In mechanical tra n sfer, the in fe c tiv e
agents may adhere to parts of an in s e c t ’s body and thus be carried from place
to p lace.
Period o f Communicabllity of I n fe c tiv e Agents.
This is the period during
which the in fe c tiv e agent may be passed from one host to another; i t v a r ie s in
each d ise a se .
Immunity♦ Immunity i s the resista n ce of the body to d isea se.
I t i s the
defensive mechanism which p rotects the individual against constant invasion of
pathogenic micro-organisms.
Body defenses are external and in te r n a l.
Those c la s s ifie d as extern al
are the unbroken akin and mucous membranes and, in th e ir anatomical stru ctu re,
the upper resp iratory passages and the vagina.
25
The in tern al d efen ses are n on sp ecific and s p e c if ic .
s p e c ific defenses include:
The internal non­
the phagocytic action of the leucocytes and c e r ­
ta in tis s u e c e l l s , which en gu lf and destroy b acteria; the body f lu id s , blood
serum, g a s tr ic j u ic e s , s a liv a , and vagin al s e c r e tio n s, which p ossess an tisep ­
t i c p roperties; the lymph nodes, which f i l t e r micro-organisms from th e blood
and destroy them.
The s p e c if ic defenses comprise the follow in g antibodies:
(1) a g g lu tin in s, which may cause clumping or agglu tin ation of b a c illi ;
(2) p r e c ip itin s , which cause certain micro-organisms to p recip ita te and thus
become in a ctiv e; (3) b a c te r io ly s in s , which combine with bacteria and cause
them to d isso lv e ; (4) opsonins, which prepare b acteria fo r phagocytosis;
(5) a n tito x in s, which n e u tra liz e solu ble to x in s .
Types o f Immunity.
There are two types of immunity, natural and acquired.
Natural immunity may be r a c ia l.
For in sta n ce, the Negro and American Indian
react more sev erely to m easles and tu bercu losis than the white man, w hile the
white man i s l e s s to le r a n t o f yellow fever than the Negro.
These r a c ia l d i f ­
ferences are due, i t i s sa id , to the length o f previous exposure fo r genera­
tio n s .
Natural Immunity may a lso be rela te d to sp e c ie s.
For example, cold­
blooded animals are immune to th e la rg est doses o f bacteria pathogenic to
mammals; in man, in d ivid u al d ifferen ces in s u s c e p tib ility are marked, some
persons reactin g to sm aller doses then o th ers.
Acquired immunity may be a c tiv e or p assive.
in three ways:
measles
A ctive immunity is acquired
(1) by a previous attach o f certain communicable d is e a s e s , as
chickenpox; (2) by repeated exposure, as in urban cen ters where peo­
p le are con stan tly exposed to c a rriers generally; (3) by in jec tio n s of bacter­
i a l products into the body, as in ocu lation s against r a b ies, smallpox, typhoid,
p e r tu ss is, d ip h th eria, and other d is e a s e s .
The three types of b io lo g ic a l
26
products used in th is a r t i f i c i a l method of acquired immunity are:
(1) Virus
weakened or attenuated by passage through animals, as the Pasteur inocula­
tio n s used against rabies and the vaccine viru s against smallpox.
(2) Prep­
arations o f k ille d b a cteria , as the vaccines used in typhoid and p e r tu ssis.
(3) Toxin*’ as used in sc a r le t fever; toxin modified or attenuated by heat
and chem icals, as in diphtheria toxoid; toxin modified by the ad d ition of
a n tito x in , as in diphtheria to x ln -a n tlto x ln .
At the present time undenatured
antigens are being used fo r vaccination against p e r tu ssis.
To obtain these
an tigen s, liv e b a cteria are smashed in suspension by the impact of metal b a lls .
Thus they are fragmented but not otherwise damaged.*
Passive immunity i s conferred by in je c tio n of ready-made an tib od ies pro­
duced by some other person (or animal) who has acquired an a ctiv e immunity to
the same d ise a se .
Thus the newborn infant is immune to many communioable d is ­
eases for the f i r s t four to s ix months o f l i f e , the antibodies being supplied
in utero d ir e c tly from the blood stream of the mother, provided she i s immune
to the d ise a se .
I f a mother i s immune to measles and d iph theria, th is temporary
congenital immunity i s present in the c h ild .
There i s no such immunity to per­
t u s s is , smallpox, or tu b e r cu lo sis.
A ntitoxin in jec te d in to susceptible
exposed individuals affords immunity
as long as i t i s present in the c ircu la tio n , two weeks being the approximate
length of time.
n ity in m easles.
Convalescents' serum i s recommended to confer passive immu­
I t is used a lso in p o lio m y elitis, strep tococcic in fe c tio n s ,
and other communicable d ise a s e s , apparently with encouraging r e s u lt s .
Placen­
t a l ex tra cts a lso are used to produce passive Immunity.
1.
Eugene C. P ie tte and Jean Martin White, Microbiology and Nursing, p . 162.
27
E ssen tia l Points to Remember:
1 . A ctive immunity can be esta b lish ed only by having had the d isease or
having been vaccinated against i t .
The body must work to produce th is
immunity.
2. P assive immunity is borrowed immunity and i s of very short duration.
I t is used when there is immediate
danger of contracting a d isea se.
S elected References
Broadhurst, Jean, and Given, L e ila I . , Microbiology Applied to Nursing.
4th Edition Revised. Philadelphia: J . B. Lippincott Company, 1939.
P. x ix -f 654.
Carter, Charles F .. Microbiology and Pathology.
The C. V, Mosby Company, 1939. P. 756.
2nd E dition.
S t. Louis:
Park, William H ., and W illiams, Anna W., Pathogenic Microorganisms. 11th
Edition Revised. Philadelphia: Lea and Febiger, 1939. P. 1056.
P ie t t e , Eugene C ., and White, Jean Martin, Microbiology and Nursing.
delphia: F. A. Davis Company, 1940. P. v i i i +- 332.
Rosenau, Milton J«, Preventive Medicine and Hygiene. 6th E dition.
York: D. Appleton-Centuxy Company, 1935. P . xxv -f- 1482.
Phila­
New
CHAPTER IV
PREVENTION AND CONTROL OF COMMUNICABIE DISEASES
Protection of th e in d ividu al against communicable d iseases i s today
afforded by organized a c t i v it i e s of the government and private agencies.
Federal, s ta te , and lo c a l h ealth organizations have expanded th e ir programs
and are e f fe c tiv e ly operating in a l l parts of the United S tates in an e ffo r t
to prevent and control communicable d ise a se s.
Federal Health A gencies.
The United S ta tes Public Health S ervice, estab ­
lish ed in 1798, and now a d iv isio n o f the Federal Security Agency, aims to
prevent disease by studying i t s cause, i t s mode of spread, and i t s character­
is tic s .
I ts function in r e la tio n to communicable disease control i s summarized
as follow s:
1.
1
The protection o f the United S ta tes from the introduction of disease from
without.
2.
The medical examination and in sp ection of a l l arriving a lie n s and prospec­
tiv e immigrants.
3.
The prevention o f in te r s ta te spread of d isease and the supression of ep i­
demics, including the sup ervision of water supply and health conditions of
in te r sta te ca rr ie rs, such as train s and steamers.
4.
Cooperation w ith s ta te and lo c a l a u th o r itie s of health in public health
matters.
1.
Public Health Reports. XLVI,No. 1447. Washington, D.G.), United States
Government P rin tin g O ffic e , February 6, 1931, p. 271.
(28)
29
5.
Investigation of the d isea ses of man.
6.
The supervision and con trol o f b io lo g ic products.
7.
Public health education and the dissem ination of health information.
The Surgeon General of the United S tates Public Health Service issu es
a yearly report which contains information concerning a l l the accomplishments
in disease control o f the current year.
Other departments of the fed era l government which carry on public health
work include:
The Children’s Bureau of the Department of Labor;
Bureau of the Department o f Commerce;
the Census
the Bureaus of Animal Industry, Chem­
i s t r y , and P athological Survey of the Department of Agriculture;
o f Mines of the Departn&nt of the In terio r;
the Bureau
and the O ffice o f Education and
the S ocial Security Board of the Federal Security Agency.
L egislation fo r H ealth.
The Jones-Parker B i l l , which was passed in 1930,
aimed to consolidate the many fed eral h ealth a c t i v it i e s .
This was accomplished
when, in 1939, th e functions o f the United S tates Public Health Service and
those of the s o c ia l secu rity and w elfare bureaus were incorporated under the
Federal Security Agency.1
In January, 1940, the Wagnar-George B il l providing
an appropriation o f $10,000,000 fo r the establishment of small h osp itals in
rural d is t r ic t s was introduced in Congress.
These h osp itals w ill o ffe r com­
p le te f a c i l i t i e s fo r the community health programs.
State Agencies fo r D isease Control.
partment located in the s ta te c a p ito l.
embodied in a Sanitary Code.
of communicable d isea ses e x is t
1,
Each state has i t s own health de­
The regulations of th is department are
Wide discrepancies in regulations for the control
in the various s ta te s , however, Indicating a
Public Health Reports, LIF. Weshing^oh, DiQ..: United S tates Government
M inting O ffic e , June 30, 1939, pp. 1133-li43.
30
need fo r some ce n tr a liz a tio n of public health control of preventive measures.
Tor example, in two s ta t e s gaseous d isin fe c tio n is required fo r p o lio m y e litis.
Haven Emerson has c a lle d a tten tio n to the wide d iscrepan cies in communicable
1
d isea se con trol in the various s ta te s .
The S tate Health Department issu es b u lle tin s and pamphlets on communi­
cable d isea ses which contain information fo r ph ysicians, n urses, and lay per­
sons about the prevention of d isea ses as w e ll as about the care of p atien ts
during i l l n e s s .
I t is the function of th is department a lso to provide hospi­
t a ls for the care o f tu b e r cu lo sis.
Municipal Health A gencies.
The Municipal Health Department’s a c t i v it i e s
in the con trol o f communicable diseases are among i t s most important ones.
Special h o sp ita ls are provided fo r the care of communicable d isea ses in many
large c i t i e s , or cooperation w ith voluntary h o sp ita ls is esta b lish ed to assure
the necessary care of in fec ted persons.
In communities where there are no
s p e c ia l h o sp ita ls, the m unicipality compensates the voluntary general h o sp ita ls
fo r the care o f indigent p a tien ts with communicable d is e a s e s .
Many c i t i e s have esta b lish ed h ealth centers, to coordinate the a c t i v it i e s
o f lo c a l h ealth agen cies and to bring the necessary h ealth se r v ic e s c lo s e r to
the p u b lic.
These h ealth centers may include sp e cia l c lin ic s for d iagn osis,
prevention, and treatment of d ise a se s.
They a lso may provide opportunities
for study by the students in medical sch ools.
County Health U n its.
rural communities.
County health u n its have been esta b lish ed in many
A minimum health u n it's personnel would be:
a public
health o f f ic e r , a sa n ita ria n , a laboratory tech n ician , and a public health
1.
Haven Bnerson, S ta te Procedures for Communicable D isease Control, American
Journal of Public H ealth. XXIX (July, 1939), pp. 701-708.
31
nurse.
Throughout the United S tates th ere are more than 1,370 f u il- t in e
county h ealth u n it s .1
U n o fficia l Health Agencies.
in p u b lic health work are:
Among the many p rivate agencies th a t a s s is t
the American Public Health A ssociation , the
National Tuberculosis A ssociation , the American S o cia l Hygiene A ssociation ,
the American Red Cross, the National Organization for Public Health Nursing,
the National Committee on Malaria, and many other organ ization s.
L ife in ­
surance companies also aid in the work of public h ealth co n tro l.
These com­
panies are p a rtic u la r ly u sefu l in supplying lite r a tu r e and dissem inating in ­
formation through s t a t i s t i c a l research and health education, and in preparing
valuable s t a t i s t i c a l rep orts, pamphlets, ch a rts, and motion p ictu re s.
Regulations o f the United S ta tes Public Health Service on Communicable
D isease Control.
Important public health f a c ts concerning communicable d is ­
e a s e s, together with compiled l i s t s o f sixty-tw o d isea ses in th is c la s s if ic a ­
tio n (see Appendix B ), are found in a report prepared by the Subcommittee on
Communicable D isease Control of the Committee on Research and Standards of the
American Public Health A ssociation .
This report was o f f i c i a l l y approved by the
United S ta tes Public Health Service and was published in Public Health Reports
in 1935.
2
L ist A contains the d iseases for which n o tific a tio n i s usuallydre-
quired in the United S ta te s .
L ist B contains d isea ses or in fe s ta tio n s in the
United S ta tes and in su lar possessions for which n o tific a tio n is le s s uniformly
required.
L ist C includes three d iseases which o cca sio n a lly occur in epidemics
and which are of in te r e st to the health o f f ic e r , but which are not communicable
in the usual sense of the tern .
1.
World Almanac. 1940, p. 834i.
2.
Public H ealth Reports, L, Reprint No. 1697, Washington, D.C.; United S ta tes
Grovernment M in tin g O ffice, August 9, 1935, p . 2 .
32
Items which are presented by the committee as important, concerning the
con trol of each d ise a s e , include the follow ing:
A.
B.
C.
The in fected in d iv id u al, co n ta cts, and environment
1. Recognition o f the d isease and reporting
2 . Iso la tio n
3 . Concurrent d isin fe c tio n
4 . Terminal d isin fe c tio n
5 . Quarantine
6. Immunization
7. In v estig a tio n of sources of in fe c tio n
General measures
Epidemic measures
The Infected Ind ivid u al, Contacts, and Environment.
In the public health
regu lation s regarding the person in fected w ith a communicable d isea se, measures
are employed in r ela tio n to h is care and to the in v e stig a tio n of persons with
whom he has been in con tact, to prevent the transm ission of the d isease to
oth ers.
Recognition of the D isease and Reporting.
c lin ic a l pictu re and laboratory d ia g n o sis.
by the c l i n i c a l p icture;
A d isease is recognized by the
For example, measles is recognized
meningococcus m en in g itis, by both the c lin ic a l p ic­
ture and the laboratory examination.
The ro le o f the nurse in the recognition of communicable d isease symptoms
i s an important one, sin ce by immediately n o tify in g th e physician of her ob­
servation s she may prevent the spread of the d ise a s e .
In the wards and c lin ic s
there i s a d e f in it e opportunity for her to have a part in d isease con trol.
Recognition i s complete only when the physician has made the diagnosis and has
n o tifie d the health a u th o r itie s.
I s o la tio n .
Iso la tio n means the lim ita tio n of movement of the person having
a communicable d ise a se , or of a carrier who harbors an in fe c tiv e agent.
methods o f is o la tio n may be employed:
Three
(1) individual precautions in the open
ward o f a general h o sp ita l; (2) the patien t unit system; (3) the disease unit
33
system.
As provision i s u su ally made only in large c i t ie s for the care of
communicable d isea ses in h o sp ita ls, p a tien ts w ith th ese d iseases liv in g in
sm aller communities must, of n e c e s sity , regain a t home.
In the home, the
lo c a l h ealth regulations fo r is o la tio n are observed.
D isin fe ctio n .
tio n as fo llo w s:
The United S tates Public Health Service defines d isin fe c ­
"By the term d isin fe c tio n is meant the destroying of the
v i t a l i t y of pathogenic micro-organisms by chemical or physical means.
This presupposes a knowledge of the focus from which the disease organism
lea v es the body, the v i t a l i t y o f the organism, and the agents used in i t s
d estru ction .
D isin fectio n i s accomplished, as noted above, by chemical or
physical means;
s t e r iliz a t io n , by mechanical means.
S te r iliz a tio n is a
mechanical control measure, the autoclave being considered the best method
of mechanical s t e r iliz a t io n .
The action of a chemical d isin fecta n t depends upon the nature of the d is ­
in fec ta n t, the m aterial to be d isin fecte d (that i s , whether the bacteria are
in veg eta tiv e or spore form), and the manner of app lication of the d isin fe c ­
ta n t.
The concentration of the d isin fecta n t and the amount used are important
fa c to r s, sin c e a chemical in a solu tion of one strength may be a d isin fecta n t
w h ile, in a weaker so lu tio n , i t may a ct as an a n tis e p tic .
The time req iired
to destroy organisms i s important a ls o , and s p e c ia l a tten tio n should be given
to the d isin fe c tio n of wouhd discharges containing spore-farming organisms,
as tetanus and gas gangrene b a c i l l i .
D isin fectio n by physical means includes su n ligh t and heat.
D irect sun­
lig h t k i l l s most organisms in a few hours, but i t must reach them d ir e c tly to
34
be e f f e c t iv e .
When sun i s projected through ordinary window g la s s , most of
i t s rays are cut o f f and th e ir power to destroy the pathogenic organisms is
lessen ed .
The x-ray and u ltra v io le t ray a lso are d isin fe c ta n ts .
Concurrent D is in fe c tio n .
This refers to the immediate d estru ction o f
in fec tiv e agen ts as they leave the body, the d isin fection measures being
carried out continuously during the course of a p atien t's i l l n e s s .
The re­
s p o n s ib ility of concurrent d isin fe c tio n f a l l s particularly upon the nurse,
and When done w ith care c ro ss-in fectio n s due to exposure in the h o sp ita l are
minimized.
The nurse must see th a t a l l who come in contact with the p atien t
take adequate precautions.
Tem inal D is in fe c tio n .
the d isease has ended.
This refers to cleaning and d is in fe c tio n when
Since in only twenty-nine of the six ty -tw o communi­
cable d isea ses l is t e d by the United S tates Public Health Service term inal
d isin fe c tio n i s required, the value of concurrent d isin fectio n measures o f
d isease con trol may be seen.
Fumigation as a con trol measure is required for terminal d is in f e c tio n
in only three d ise a s e s :
Quarantine.
plague, m alaria, and yellow fever.
The term "quarantine" is defined by the United S ta tes Public
Health S ervice a s "the lim ita tio n of freedom of movement of persons (or animals)
who have been exposed to communicable d ise a se s for a period of time equal to
the lon gest usual incubation period of -the disease to which th ey have been ex­
posed."^"
The exposed persons are examined by the physician to determine whether
they are su scep tib le to the d isease or have become carriers of th e pathogenic
organisms.
The terms quarantine and is o la tio n are used interchangeably, no
clea r d iffe r e n tia tio n seeming to e x is t between them.
I s o la tio n , however, is
35
used more in reference to the i l l patient or c a r r ie r , while quarantine i s
used now to r e fe r to the period of time during which public health regu lation s
are enforced.
Immunization.
The increasing of the a b ilit y of the individual to r e s i s t
s p e c if ic in fe c tio n s i s c e ile d "immunization."
A r t if ic ia l immunization may be
acquired only in those d isea ses for which s p e c ific va ccin es, to x in prepara­
t io n s , a n tis e r a , and a n tito x in s have been developed.
I n v e stig a tio n of Source of In fectio n .
When a communicable d isea se such
as typhoid fe v e r i s reported to th e health a u th o r itie s, immediate step s are
taken to d isco v er the source of the in fe c tio n .
In v estig a tio n s are made of the
food, m ilk , and water su p p lie s, and a search is made for unrecognized cases
and c a r r ie r s .
Other p o ssib le sources of in fe c tio n , such as the insanitary
d isp o sa l of w aste, a lso are in vestigated .
General Measures.
General measures of disease control include:
control
of water supply, p a steu rization of m ilk, supervision of food and food handlers,
examination and supervision of animals, and, e sp e c ia lly , education of the pub­
l i c in personal hygiene and d isease prevention measures.
Epidemic Measures.
to d isc o v er i t s source.
In attempting to control an epidemic the f i r s t ste p is
Epidemics may be con trolled by destroying th e immediate
h o s ts , safeguarding the food and water su p p lies, or immunizing the population.
Other measures include proper iso la tio n of the patient or ca rrier and quarantine
of th ose who have been exposed.
A study o f m ortality s t a t i s t i c s and morbidity rates and of th e ir graphic
p resen ta tio n w i l l be h elp fu l in givin g the student nurse a b etter understanding
of her importance in the communicable disease control f i e l d .
Such s t a t i s t i c s
are a v a ila b le from the Bureau of Census, the United S ta tes Public Health S ervice,
36
sta te and c ity h ealth departments, and insurance companies.
E sp ecia lly
recommended are the weekly reports of th e United S ta te s Public Health S ervice,
which contain information o f disease conditions in other countries as w ell as
in our own.
These rep orts and other inform ative m aterial on recent develop­
ments in the communicable d isease fie ld may be used with p r o fit in t h is course.
Valuable a lso t o the student nurse in her understanding o f, and in te r e st in ,
the vast scope o f communicable disease control e f f o r t s , would be her own com­
p ila tio n of a l i s t o f the men o f genius who died prematurely from preventable
d ise a s e s .
To read about the fin d ings o f research workers and the d if f i c u l t i e s
that have had to be overcome thus fa r , as w ell as of th e large f ie ld which yet
remains unexplored, g iv es great stimulus to those who are continuing the work.
A ll measures for the control of d isease, whether in the h o sp ita l, home,
or school, aim to preserve th e health o f the public; the nurse’ s ro le in them
i s th at o f teacher.
essa ry .
I f r e s u lts are to be achieved, public cooperation is nec­
Through education, in stru ction w ill supplant coercion, and th e public
w i l l eventually r e a liz e that the happiness and progress o f a nation are depen­
dent upon the h ealth o f i t s people.
S elected References
Emerson, Haven, S tate Procedures fo r Communicable D isease Control.
Journal o f Public H ealth. XXIX (July, 1939), pp. 701-8.
H iscock, Ira V ., Ways to Community Health Organization.
York: The Commonwealth Fund, 1939. P. xvi ♦ 318.
Mustard, Harry S ., An Introduction to Public H ealth.
Company, 1938. P. x i ■* S50.
American
3rd E d ition .
New York:
New
The Macmillan
P ie t t e , Eugene C ., and White, Jean Martin, Microbiology and Nursing.
delphia: E. A. Davis Company, 1940. P. v i i i ♦ 332.
P hila­
37
S m illie , Wilson G ., Public Health Administration in the United S ta te s *
New York: The Macmillan Company, 1936. P. xvi 4 458.
The Control o f Communicable D iseases, Public Health Reports, L (August 9,
1935). Washington, D.C.: United S ta tes Government P rin ting O ffice.
The World Almanac.
New York: New York World-Telegram, 1940, p. 834.
Turner, C. E ., Personal and Community H ealth.
The C. V. Mosby Company, 1939. P. 652.
5th E d itio n .
S t. Louis:
CHAPTER V
VACCINES, IMMUNE SERA, AND SEKOM REACTIONS
V accines,
Vaccines are antigens (b acteria, v ir u se s , to x in s ), modified
to the degree th at they are Incapable of producing d ise a s e s , but they do
p ossess th e a b ilit y to stim ulate the production o f a n tib o d ies.
always produce a ctiv e immunity.
Vaccines
They d if f e r from immune sera in the type of
immunity produced and in th e ir b a sic p r in c ip le s.
Preparation of Vaccines.
A b a c te r ia l vaccine i s a suspension of k ille d
or attenuated organisms in sa lin e s o lu tio n .
Stock vaccines are made from
cu ltu res kept in the laboratory, whereas autogenous vaccines are made from
cu ltu res from the in fected lesio n s of the in d iv id u a l.
The cowpox viru s i s taken from th e v e s ic le s o f c a t t le i l l with th e d is ­
ease and inoculated into ca lv e s.
The liv in g vaccine viru s thus produced is
a s e p tic a lly prepared in g ly ce rin e, and i s used in the in ocu lation of human
beings against smallpox.
Rabies v ir u s, obtained from the spin al cords o f rabbits dead from the
d ise a se , i s attenuated by drying, or by treatment with carbolic a c id .
Toxins are produced by growing organisms in broth; exotoxins are found
in the broth f i l t r a t e .
concerned.
The u nit o f measure v a ries according to the d isea se
For example, in d ip h theria, a unit o f to x in i s defined as a m ini­
mum le th a l dose (M.L.D.), the sm allest amount o f to x in which, when in jected
in to a 250-gram guinea p ig , w i l l cause death in fou r days; in s c a r le t fe v e r ,
(38)
39
a u n it of toxin i s the skin t e s t dose (S .T .D .), the sm allest amount of scar­
la t in a l strep tococcic toxin which, when in jected intracutaneously, w ill pro­
duce a skin reaction in a susceptible person.
Diphtheria to x in -a n tito x in is a mixture of diphtheria to x in and a n tito x in ,
with a s lig h t excess of the to x in .
Diphtheria toxoid i s diphtheria toxin which
has been treated with form alin, thereby reducing i t s t o x ic it y , but allowing i t s
a n tigen ic properties to remain.
Uses of V accines.
ta in d ise a se s.
Vaccines are used e f f e c t iv e ly fo r immunization in cer­
For example:
(1) in typhoid fe v e r , the k ille d typhoid b a c i lli
suspended in sa lin e so lu tio n are used;
(2) in d ip hth eria, minute q u an tities
o f diphtheria toxin serve as antigens in to x in -a n tito x in or toxoid;
(3) in
sc a r le t fe v e r , graded dose3 of unmodified sc a r la tin a l streptococcic toxin are
used;
(4) in smallpox, the cowpox viru s i s used;
(5) in rab ies, the attenu­
ated or k ille d rabies v iru s i s used.
As immunizing agents against tetanus and staphylococcic in fe c tio n s, toxoids
are being used;
toxin s may be used f o r diagnostic t e s t s (such as the Dick and
Schick t e s t s ) and f o r in je c tio n into animals to produce an tito x in .
Trmmme Sera.
The serum of an animal or human being,immunized against a
s p e c ific disease and p ossessing corresponding an tib od ies s p e c ific far th at d is ­
ea se , is known as immune serum.
A n tib acterial serum i s that immume serum which
contains protective substances again st b a cteria l antigens; an titoxin s are immune
sera prepared against exotoxin s.
peysons
Convalescents' serum co n sists of the serum of
recently recovered from a d ise a s e , whose blood contains an tib od ies.
Preparation o f Sera.
doses of to x in .
A ntitoxin is produced by in jectin g an animal with graded
When the a n tito x ic production i s at i t s height, the animal is
bled and the a n tito x ic strength of the blood determined.
The an titoxin i s then
40
refin ed , p u rified fo r u se , and standardized in units*
A unit of sc a r le t fever
an tito x in s ig n if ie s th a t amount which w ill n eu tra lize 50 skin t e s t doses
(S.T.D .) o f s c a r la tin a l streptococcus toxin*
A unit of diphtheria a n tito x in
i s that amount o f a n tito x in which w i l l n eu tra lize 100 minimum le th a l doses
(M.L.D.) o f diphtheria toxin*
Ant ib a c t e r ia l sera are sim ila rly prepared,
using increasing doses o f a n tigen .
Both rabbits and horses are used in the
production of th ese sera*
Uses o f Immune Serum.
Immune sera are used with great value in the tr e a t­
ment o f certa in d isea ses and as a prophylactic measure against in fe c tio n .
In
the various types o f pneumococcic pneumonia, the horse and rabbit sera are
used; in sc a r le t fever and d ip h th eria, s p e c ific an tito x in s are used; in meningococcic m en in g itis, the polyvalent sera have been e ffe c tiv e in reducing the
m ortality r a te .
The serum o f convalescent p atien ts may be used in supplying
s p e c ific a n tib od ies.
When used as a prophylaxis measure, the immune sera confer a passive im­
munity to su scep tib le co n ta c ts.
A small c h ild , fo r example, who is su scep tib le
to diphtheria and who has been exposed to the disease would be given a prophy­
la c t ic dose o f diphtheria a n tito x in ; a person with a deep wound from a rusty
n a il would be given prophylactic treatment (tetanus
an titoxin ) to prevent
serious r esu ltin g in fectio n *
Supervision o f B io lo g ic Products.
Supervision of control o f b io lo g ic prod­
ucts means th at a l l v ir u se s , v a ccin es, therapeutic sera, to x in s, a n tito x in s,
and analagous products ap p licab le to the prevention and cure of d isea ses of
man are te ste d by the United S ta tes Public Health Service fo r purity and potency.
Serum R eactions.
Unusual m anifestations may be caused by in je c tio n s of
the sera in to certa in in d iv id u a ls who are h ypersensitive to some foreign p ro tein s.
41
Various types of rea ctio n s are: anaphylaxis; thermal or protein reaction ;
serum sick n ess*
When anaphylaxis occurs, i t may be w ithin a few minutes a fte r the serum
i s administered.
The symptoms are th ose of complete co lla p se , and u n less
epinephrine and other supportive treatments are given Immediately death may
follo w .
A thermal or p rotein reaction may appear w ithin one h alf to s ix hours
a fte r adm inistration of th e serum.
The symptoms may be:
a c h i l l followed by
elevation of temperature, abdominal pain s, and sometimes vom iting.
serious symptom i s resp iratory d is t r e s s .
The most
For the c h i l l , external heat should
be immediately applied by means o f blankets and hot water b o t tle s , and hot
flu id s should be given i f the p atien t is conscious.
For elevated temperature,
a cold colonic flu sh in g may be resorted to and an ice-bag placed on the head.
For respiratory d is t r e s s , epinephrine, amyl n i t r i t e , and atropin may be used.
A hypodermic o f epinephrine always should be in readiness when sera are admin­
iste r e d .
The third type o f serum rea ctio n , serum sick n ess, may occur between the
six th and ten th days follow ing an in je c tio n of a foreign protein; i t is charac­
terized by an eruption, u su a lly u r t ic a r ia l.
Other m anifestations are: vom iting,
elev a tio n of temperature, enlarged p ain fu l glands, and sometimes p ainful jo in t s .
For the marked ir r it a tio n of the sk in , sodium bicarbonate sponges are
given and calamine lo tio n with phenol ap plied .
The lo tio n , which is c h ille d in
a bowl o f i c e , should be applied lib e r a lly by p a ttin g , the patient being more
comfortable i f kept between sh eets during the treatment.
I f t h is treatment is
not e f fe c t iv e , and no r e l i e f i s obtained, epinephrine may be prescribed, or
42
intravenous in je c tio n s o f calcium gluconate given by th e p hysician .
Potassium
s a lts and histam inase are recent recommended treatments for the r e l i e f of serum
sickness.
For p ainful glands, ice-ca p s may give r e l i e f .
The symptoms of th is th ird type of reaction rarely la s t more than twentyfour to fo r ty -e ig h t hours, but during th a t time the patient su ffers in te n se ly .
Patience and ingenuity on th e part o f the nurse are required to provide tem­
porary r e l i e f fo r persons who experience serum r e a ctio n s. Thereseems
to be
no permanent r e l i e f u n til the eruption has run i t s course.
S elected References
Broadhurst, Jean, and Given, L eila I . , Bacteriology Applied to Nursing.
E d ition . Philadelphia: J . B. Lippinoott Company, 1939. P. 654.
Carter, Charles F ., Microbiology and Pathology.
The C. V. Mosby Company, 1939. P. 756.
2nd E d ition .
4th
S t . Louis:
Park, William H., and W illiam s, Anna W., Pathogenic Microorganisms. 11th
Edition R evised. Philadelphia: Lea and Febiger, 1939. P. 1056.
Zinsser, Hans, and Bayne-Jones, Stanhope, A Textbook o f B acteriology.
Edition R evised. New York: D. Appleton-Century Company, 1939.
P. x x v iii * 990.
8th
CHAPTER VI
MEDICAL ASEPSIS
Medical a se p sis refers to a method of procedure used in the care of com­
municable d ise a se s and known as medical a sep tic tech n ic .
The nurse who i s car­
ing fo r p a tien ts with communicable d isea ses has a fourfold duty:
nursing care to her p a tien ts;
(2) to protect others;
in fe c tio n s (frequently c r o s s-in fe c tio n s);
(1) to give
(3) to prevent secondary
(4) to avoid contracting th ese d is ­
eases h e r s e lf.
The nurse must understand that medical a sep sis is based upon certa in funda­
mental concepts o f m icrobiology, one of which is th a t d isea ses are spread c h ie fly
by d ir e c t or in d irect con tact.
They a lso may be air-borne, a s demonstrated in
1936 by Wells and Wells of Harvard.
These in v estig a to r s found that when broth
cu ltu res o f many pharyngeal organisms were projected into the a ir in a fin e spray
the organisms remained a liv e , suspended in a ir , fo r as long as two or three days.1
The aim of medical a sep sis i s to prevent the tran sfer of in fe c tio n to oth ers.
Anyone who comes in contact w ith the p atien t becomes contaminated because a pa­
t ie n t w ith a communicable d isea se i s the source of in fe c tio n .
Cough droplets may
tra n sfer micro-organisms fiv e or s ix fe e t; therefore a d istan ce of a t le a s t s ix
f e e t should separate beds o f d ifferen t u n its.
Experience in su rgical asepsis w i ll help the nurse to master the tech nics
o f m edical a s e p s is .
1.
In medical asep sis the patient represents the contaminated
M. W. Wells and W. F. W ells, Air-Borne I n fe c tio n s. Journal of the American
Medical A sso cia tio n . CVII (November 21, 1936), p. 1698.
(43)
44
f ie ld ;
in surgical asep sis the p atien t represents the s t e r ile f ie ld .
In carry­
ing oyt the tech n ics, medical a sep sis should be adhered to as s t r i c t ly as surgi­
c a l a se p sis.
V ariation in Method.
A ll nurses should understand the underlying p rin cip les
o f bacteriology so that they themselves can judge the comparative value of v a ri­
ous te c h n ic s.
Methods must be adapted to conditions as they e x is t , as ru les which
are j u s t ifia b le in one h o sp ita l may be inadequate in another.
Personnel, equip­
ment, physical set-up of wards in a h o sp ita l, and varying conditions in the home
determine the method to be used.
The fundamental p rin cip le of medical asep sis
i s c le a n lin e ss, and the nurse who keeps t h is in mind can e a s ily apply to any
situ a tio n the technics learned on the communicable d isease s e r v ic e .
C ro ss-in fectio n .
A c r o ss-in fe c tio n i s an in fe c tio n superimposed upon a
p a tien t i l l with another communicable d is e a s e .
For example, a patient w ith scar­
l e t fever may develop measles as the r e su lt of a break in medical a sep tic technic .
One
of the most important measures in the prevention o f c ro ss-in fectio n s is the
p a tie n t’s h isto r y , which should be thoroughly in vestigated to determine recent
exposure to communicable d ise a se s.
The r e s p o n sib ility for securing the p a tie n t’s
h isto ry l i e s upon the ambulance nurse who removes the p atien t from the home/and
upon the admitting physician in the h o s p ita l.
A p atien t who i s incubating a
second communicable disease when admitted to the h osp ital may be the cause of a
s e r ie s of c r o ss-in fe ctio n s in the h o sp ita l ward.
For example, a patient with
measles may be incubating chickenpox, and thus be responsible fo r an outbreak
o f chickenpox on the measles ward.
When p a tien ts from child-caring and other
in s titu tio n s are admitted to the h o sp ita l, they should be iso la te d in rooms for
observation.
45
Medical asep tic technic i s a lso d irected toward preventing c r o ss-in fe c tio n
in the follow ing ways:
(1) in stru ctio n of the e n tir e ward personnel in the
underlying p rin cip les o f a se p sis;
(2) thorough hand cleansing and gown technic?
(3) enforcement of the regu lation forbidding those w ith colds to remain on duty;
(4) concurrent and terminal d is in fe c tio n .
Hand Cleansing.
Hand cleansing i s a very important measure in preventing
the spread o f in fe c tio n .
The practice of chemical d isin fe c tio n has been discarded in favor of warm
r u n n in g
water, soap, and a brush.
longer used.
In some general h o sp ita ls the brush i s no
On communicable d isease se r v ic e s where the danger of cro ss-in fectio n
is great, the use o f a brush provides an ad d ition al safeguard fo r th e protection
of the p a tien t.
The water supply of a scrub sink should be controlled by a foot pedal, i f
p o ssib le.
When hand or elbow fa u cets are used, they are turned with paper squares
or with the back of a brush.
A soap dispenser with foot pedal i s the most d e sir ­
able method of transferring powdered or liq u id soap to the hands.
The type which
d istrib u tes the soap by pressure o f fin g er or palm of hand, or by tip p in g , should
never be used.
A cake of bland soap in a dry container frequently is used.
The
hands are scrubbed for one to two m inutes, a revolving sand-glass in d icatin g the
length of time.
The n a ils are cleaned with an orangewood s tic k a fte r which the
hands are rinsed under cold water and dried with a paper tow el.
Hand lo tio n
should then be used.
When there is an adequate supply of hand-brushes, they are discarded immedi­
a te ly a fte r use and dropped into a container provided for the purpose.
After the
brushes and container are b oiled for ten minutes, the brushes are replaced in a
clean basin without so lu tio n , and the container i s returned to the scrub sin k .
46
Whan the supply of brushes i s lim ited , they are kept in 0.25 per cent creso l
solu tion when not in u se, and are replaced in th is solu tion a fte r u se.
solu tion i s changed freq u en tly.
The
The brushes are b oiled for ten m inutes, or
autoclaved, tw ice during the twenty-four hours.
Terminology in Medical A sep sis.
Certain terms which are used in r e la tio n
to medical asep sis should be c le a r ly understood.
The follow in g are important:
Contaminated r e fe r s to the presence of pathogenic organisms on the su rfa ce.
(Example, a book which a p atien t has handled is contaminated.)
freedom from known contamination w ith pathogenic organisms.
which th e nurse ca rries to the patient is c le a n .)
sence of a l l organisms.
Clean s ig n if ie s
(Example, a tray
S te r ile in d ica tes the ab­
(Example, dressings which have been autoclaved are
s te r ile .)
A p atien t unit i s a contaminated area with complete equipment for
his care.
(Example, a room, a cu b icle, or a space s e t asid e in a ward i s a
patient u n it.)
u n it .
The word "unit" when used in th is tex t refers to th e p a tien t
A d isease unit i s an area in which two or more p a tien ts known to have
the same d isea se are cared fo r .
for the same d ise a s e .)
(Example, a room or ward may comprise a unit
D isin fe c tio n is the destruction of pathogenic organisms.
Concurrent d isin fe c tio n r e fe r s to the d isin fe c tio n of a r t ic le s immediately f o l ­
lowing contamination.
Terminal d isin fe c tio n s ig n if ie s d isin fe c tio n of the unit
and of a l l a r t ic le s used by the p atient at the term ination o f the d ise a se .
Cleaning r e fe rs to the removal of organic matter containing pathogenic organisms
by scrubbing or washing with hot water and soap.
Fumigation i s the use of gas­
eous agents fo r the d estru ction of in se c ts and rodents.
Renovation means the
treatment necessaxy to put a room or a house in sa tisfa c to r y sanitary con d ition.
47
Medical Aseptic Technic In th e H ospital
On th e communicable d isea se serv ice the in stru ctio n o f nurses, internes,
tech n icia n s, and ward helpers presents as great a problem as does the adequate
care and is o la tio n of the p a tien t.
Clean and Contaminated Areas.
In communicable d isease wards
a l l flo o rs
are considered contaminated because of the presence of bacteria-laden dust,
and of contact w ith contaminated a r t ic le s , such as toys or the so le s of shoes
o f persons entering the ward.
contaminated areas.
Cubicles and rooms which are occupied also are
Other areas are clea n , except such as are temporarily
designated "contaminated" in the carrying out of d is in fe c tio n .
Scrub Stands.
With the excep tion
of the in sid e o f the bowl,the scrub
stand, including the fau cets, i s always considered clean .
Individual Equipment.
Each person admitted to the h o sp ita l is placed in
a p a tien t u n it unless otherwise s p e c ifie d .
Each un it has the follow ing a r t ic le s
o f equipment:
Bed or crib
Bedside stand:
Face basin
Soap dish
Emesls basin
Mouthwash cup
Toothbrush
Fine comb
Orangewood stick
B ottle with
)
rubbing alcohol )
if
Container with
) necessary
powder
Face towel
Bath towel
Face cloth
S h elf:
Thermometer (r e c ta l)
Thermometer jar with 5 per cent
phenol, or 1:1000 bichloride
o f mercury
Tube of lubricant
Jar with cotton
Two rubber bands on hook (for
the gown)
48
Gowna .
The most su ita b le type o f gown i s of cotton t w i l l , is b e lte d , has
long or Short s le e v e s , and buttons at the neckband and c u ffs.
A gown is worn to p rotect th e uniform when in contact with the p a tie n t,
and should e n tir e ly cover the clo th in g .
The nurse wears a gown in any procedure
which involves contact with the p a tie n t.
The physician wears a clean gown for
each patient he examines.
GownB are not worn by the adm inistrative personnel
when making rounds.
The most s a tis fa c to r y tech n ic is to put on a clean gown a t every contact
with a patient and to
discard i t in to a hamper bag for autoclaving; o r, i f the
gown becomes s o ile d , to place i t in the
laundry bag.
This i s
ca lled the discard
technic and, when used fo r
an acu tely i l l p a tien t, may require as many as 25
gowns during a twelve-hour
p eriod .
I f the supply of
gowns i s lim ite d , a gown is hung in the
and the nurse employs
a sp e c ia l technic each time i t is worn.
Gown Technic: P utting on th e Gown.
p a tie n t's u n it,
The gown i s kept hanging by the arm­
holes on a hook, folded rig h t sid e out, with the l e f t side of the gown toward
the side of the cu b icle.
The nurse en ters the u n it and faces the patient when putting on th e gown.
With palms together, touching only the inner surfaces, she separates the sid es
of the gown, grasps the shoulder seams and removes the gown from the hook.
nurse then grasps both shoulder seams
p u lls on the l e f t s le e v e .
near the neckband with the righ t hand and
The righ t shoulder seam i s next held by th e l e f t hand
in sid e the gown, and the righ t slee v e is pulled on.
bands, are buttoned.
The
The hands are now contaminated.
The neckband, then the w rist­
Rubber bands are removed
from a hook in the cu b icle and used to keep the cu ffs of the gown c lo se to the
w r is ts .
49
The gpwn i s closed by fold in g the rig h t sid e over th e l e f t sid e .
The
rig h t sid e i s f i r s t brought forward by holding th e seam w ith th e l e f t hand
and grasping the righ t outer edge w ith th e rig h t hand.
The righ t fla p i s then
brought across the m idline o f the back, where i t i s transferred to th e l e f t
hand.
I t is now brought to the seam on the l e f t sid e and the b e lt is securely
t ie d .
Removing the Govm.
Before leaving the c u b ic le , the nurse u n ties one loop
of the knot in the b e lt , tucking the ends under the b e lt to keep the gown from
opening.
She removes the rubber bands, unbuttons the c u ffs , and tucks up the
slee v e s u n til they are s lig h t ly below the elbow.
She then proceeds to the
nearest scrub stand.
The nurse grasps one and of th e hand-brush, removes i t from the cresol
so lu tio n b asin , turns on the faucet with the back of the brush, which she then
rin ses w e ll under th e running water to remove the c r e s o l.
w e ll, r in se s o f f the soap and returns i t to the d ish .
She soaps the brush
Using the back of the
brush, she turns the two-minute sand-glass and scrubs one hand fo r one h a lf
minute, beginning with the w rist and back of the hand.
She then grasps the
clean end of the brush with the clean hand and scrubs the other hand fo r 4>he
h a lf minute.
P articu lar atten tion i s paid to scrubbing between the fin gers
and under the n a ils .
At the completion of the procedure, she rin ses the brush,
replaces i t in the solu tion basin, and washes the soap from her hands.
She
turns o f f the faucet with a clean paper tow el, d r ie s her hands, and wipes o ff
the top of th e scrub stand.
She then returns to the cu b icle.
With clean hands, the nurse unbuttons the heckband, p u lls the slee v es over
her hands by grasping the in sid e of th e l e f t sleev e with her clean right hand,
then the outside of the righ t sleeve w ith the covered l e f t hand.
She unfastens
50
the b e lt with both hands protected by the s le e v e s.
She s lid e s her hands
through the sle e v e s, and grasps a shoulder seam in each band.
She then trans­
fe r s the shoulder seams to the right hand, a fte r which she grasps the ends of
the neckband with the l e f t hand.
Holding the gown below the yoke and gather­
ing i t to the shoulder seams, she hangs the armholes over the hook, with the
l e f t sid e of the gown toward the w all o f the room or cu b ic le .
to keep the neckband upright.
Care i s taken
The gown i s hung with the open edges away from
the p a tien t.
The nurse's hands are again contaminated.
She returns to the nearest scrub
stand, and for two minutes scrubs her hands.
Masks.
When the nurse i s caring for a diphtheria patient who is coughing,
or fo r an irresponsible p a tien t with a profuse respiratory tra ct discharge, a
mask affords protection;
but a mask which is not changed frequently becomes
contaminated from each s id e , and thus provides a warm, m oist medium fo r the
growth of b a cteria .
Therefore, the value o f a mask i s questionable, as i t s e l ­
dom does more than to impart to th e wearer a fa lse fe e lin g o f secu rity .
If it
i s imperative that a mask be worn, i t should be discarded immediately a fte r
caring fo r a p a tien t.
The m aterials used for masks are, u su a lly , muslin and gauze.
A gauze mask
i s made by folding six or more layers into su itab le s iz e , or using a f i l l e r of
flan n el between ttoo la y e r s.
Care o f Clothing and V aluables.
A r tic le s o f clothin g and leather goods
are d isin fec te d by a irin g for at le a s t s ix hours.
A fter proper a irin g , the
a r t ic le s are labeled and placed in lo ck ers.
A ll valuables are d isin fec te d before being placed in an envelope.
(paper and coin) and jewelry are washed with soap and w ater.
are autoclaved or treated with dry heat.
Money
Valuable papers
51
Taking the Temperature, P u lse, and R espiration.
when taking the temperature, p u lse, and resp ir a tio n .
The nurse wears a gown
Before donning the gown,
she places her watch on a clean paper square on the p a tien t’s bedside t a b le .
The thermometer i s removed from the d isin fecta n t so lu tio n , dried thorou^aly with
cotton p led gets, and then lu b rica ted .
While the temperature i s being taken, the
nurse takes the pulse and resp ir a tio n without contaminating her watch.
At com­
p le tio n , the thermometer i s wiped with a wet cotton sponge, dried, and returned
to the thermometer jar in th e u n it.
gown in the usual manner;
The nurse scrubs her hands and removes her
a fte r scrubbing her hands a second tim e, she returns
to the cu b icle, picks up her watch, and discards the paper square.
The tempera­
ture, p u lse, and resp ira tio n are recorded on a s lip of paper on the ward desk
and la te r on the p a tie n t’s c lin ic a l record.
This procedure should be planned to
coincide as nearly as p o ssib le with the nursing procedures, such as morning,
afternoon, and evening care, or sp e cia l treatm ents.
Disposal of Linen.
S o iled lin en i s removed from the unit in a folded sheet
or in a p illow case and emptied d ir e c tly into hamper bags fastened in metal
frames.
Before the bags are com pletely f i l l e d , they are tie d t i g i t l y at the top
and removed by th e ward p orter.
Small a r t ic le s such as dusters or washcloths are placed in a mesh bag in
the u t i l i t y room.
Each day the bag is removed and placed in the s o ile d lin en
hamper bag.
A small metal refu se can in which a canvas bag i s fastened i s provided for
diapers.
S oiled diapers are washed at the hopper.
The diaper bag is tie d at
the top before i t i s q uite f u l l , removed from the container, and i s then placed
in the so iled lin e n hamper bag.
The hamper bags o f s o ile d lin en are placed in a designated area and co l­
lected by the laundry p o rter.
52
Methods of D isin fectio n and S t e r iliz a t io n .
Exposure to sunshine and fresh
a ir , the use o f soap and w ater, b o ilin g , the use of chem icals, autoclaving, and,
i f necessary, in cin era tio n are methods of d isin fe c tio n and s t e r iliz a t io n em­
ployed in communicable disease h o sp ita ls.
A ll a r t ic le s contaminated by spore-
forming organisms are autoclaved under f if t e e n pounds pressure for twenty to
th ir ty minutes.
Organisms in the vegetative form are destroyed by b o ilin g for
f iv e to ten minutes.
A iring outdoors in the sunshine for s ix hours i s su ita b le f o r such a r t ic le s
as exten sion lig h t cords and e le c t r ic p la tes;
bags;
cloth or rubber-covered sand­
cleaning u t e n s ils , as brooms, brushes, and mops;
s lip p e r s for ward use;
m attresses and p illo w s.
p a tie n ts' clothing;
The m attresses are hung on
lin e s by heavy canvas ta,bs or placed on racks, and the p illow s are fastened to
c lo t h e s - lin e s .
Rubber sh eets are f i r s t washed with soap and water and then
aired for s ix hours.
two hours.
C lin ica l records which become contaminated are aired fo r
H osp itals should provide sp ecia l porches or roofs fo r exposure to
su n lig h t.
Washing with soap and water is a method of d isin fe c tin g many a r t ic le s fo r
in dividual use of th e p a tie n t, such as combs, orangewood s t ic k s , rubber bands,
s a fe ty p in s, tube o f lu b rican t, washable to y s, hot water bags, ice-ca p s, K elly
pads, the oxygen u n it with canopy, and the oxygen tank.
scopes are washed with soap and w ater.
Contaminated steth o­
A ll ward furnishings also are washed
with soap and water.
B o ilin g or exposure to steam for ten minutes i s a method o f d isin fe c tio n
frequently employed.
Hand-brushes are b oiled in a sp e cia l container,
cloth
masks, before being b o iled for ten m inutes, are washed with soap and water.
Such a r t ic le s as face b a sin s, emesis b a sin s, mouthwash cups, soap d ish es,
53
solu tion bowls, ir r ig a tin g cans, enamel graduates, metal p itc h e r s, metal sputum
cups, thermometer ja r s , cotton ja r s, and flow er vases are b o iled in th e utenfcil
s t e r i l i z e r fo r ten m inutes.
D ishes, g la ss drinking tubes, silverw are, and medi­
cine g la sse s are exposed to liv e steam in the dish s t e r i l i z e r fo r ten m inutes.
Nursing b o ttle s and n ip p le s, a fte r being washed, are b oiled fo r f iv e minutes
in a su ita b le con tain er.
Medicine droppers are f i r s t washed c a r e fu lly , and are
b oiled alone fo r f iv e m inutes.
Ear specula and syringes are washed in cold
water, then in a hot soapy so lu tio n , and boiled in the instrument s t e r i l i z e r
for ten m inutes.
Instruments are cared for sim ila rly , with the exception of
sc isso r s and k n ives.
Rubber goods, such a s nasal ca th eters, rubber bulb syr­
in g es, and gavage and lavage s e ts are washed thoroughly and b oiled fo r f iv e
minutes in an enamel container.
R ectal tubes and catheters or other rubber
tubing, a fte r being washed, are wrapped in gauze and b oiled for ten minutes in
the bedpan s t e r i l i z e r .
Such u te n s ils as bedpans, u rin a ls, and the p a il fo r cor
lonic Irr ig a tio n s are b o iled in the bedpan s t e r iliz e r for ten m inutes.
D isin fe ctio n by chemical means i s lim ited in communicable d ise a se h o s p ita ls .
C lin ica l thermometers are s a tis fa c t o r ily d isin fected in b ich lo rid e o f mercury
1:2000, or phenol 5 per cen t.
Ecker found that c lin ic a l thermometers immersed
1
in b ich lorid e of mercury 1 :JDOO required only half a minute for d is in fe c tio n .
Sharp instrum ents, such as s c a lp e ls , s c is s o r s , and myringotomy knives are washed,
g
then immersed in metaphen 1:2500 for ten minutes, or in merphenyl 1:1500«,
b oilin g in a 2 per cent sodium carbonate solu tion for f if t e e n minutes also is 'e ffe c ­
t iv e .
Brushes for use a t the hopper are d isin fected by continuous immersion in
1.
E. E. Ecker and Ruth Smith, D isin fectin g C lin ical Thermometers.
H o sp ita l, XLVIII (A pril, 1937), p. 86.
2.
1 . E. ,Ecke£ and Ruth Smith, S t e r iliz in g Surgical Instruments.
H o sp ita l, XLVIII (March, 1937), p. 96.
The Modern
The Modern
54
a 2k per cen t c r e so l so lu tio n .
Postcards which the p a tie n ts may w rite and
d iagn ostician s* cards which have become contaminated are dipped in to a bowl
o f 2k per cent c r e so l so lu tio n , then allowed to dry.
A r tic le s which cannot
be b o iled or immersed in a d isin fecta n t solu tion such as head m irrors, oto­
scop es, f la s h - lig h t s , the oxygen tank gauge, and su ctio n apparatus are wiped
o f f thoroughly w ith a clo th saturated with 70 per cent a lc o h o l.
The otoscope
and f la s h - lig h t are protected from contamination w ith a paper tow el in so fa r
as i s p o s s ib le .
Autoclaving under f if t e e n pounds pressure fo r twenty to t h ir t y minutes i s
the method o f d is in fe c tio n used fo r contaminated books or valuable papers.
In cin eration i s used for burnable refuse of a l l kin ds, magazines, papers,
and nonwashable t o y s .
D isposal o f D ischarges.
Dressings s o ile d with wound discharges are taken
to the u t i l i t y room in a dressing basin, and are c a r e fu lly wrapped in newspaper
before being discarded in to the refuse can fo r subsequent in cin era tio n .
Riper t is s u e s so ile d with upper respiratory tr a c t discharges are discarded
in to th e paper bags at the patients* bed sid es.
cans fo r burning.
These bags are placed in refuse
I f paper sputum cups are n ecessary, a sm all amount o f sawdust
i s added to each cup to absorb the moisture, and th e cup i s then wrapped in
sev era l la y ers o f newspaper before being discarded into the refuse can s.
The
m etal holders are b o iled fo r ten minutes.
In d ise a s e s in which the p ortal o f e x it i s the alim entary can al, excreta
are d isin fe c te d before being discarded.
A large covered galvanized p a il con­
ta in in g a 10 per cent so lu tio n o f chloride o f lime i s kept in th e u t i l i t y room.
A s u ffic ie n t amount o f d isin fecta n t to h alf f i l l the p a il i s prepared and the le v
e l in d icated on th e o u tsid e. The contents o f bedpans or u rin a ls are emptied into
55
the galvanized p a il, together with the water used to rin se them.
of discharges added must not exceed the quantity of d isin fe c ta n t.
The quantity
Formed s to o ls
must be broken into small p a r tic le s w ith a stic k in order that the d isin fecta n t
may penetrate the fe c a l m aterial.
creso l so lu tio n .
sary.
The s t ic k is cleaned and kept in a 2^ per cent
Exposure fo r one hour in the chloride of lime solu tion is neces­
Excreta may be d isin fe cte d in the bedpan with the addition of powdered
chloride of lime or 5 per cent c r e so l so lu tio n , but th is is not recommended on
account of the offen sive odors.
Ward Kitchen Technic.
Trays for the p a tien ts are prepared in the ward
kitchen in an uncontaminated area;
they are placed on bedside ta b les by the
nurse who does not become contaminated.
The nurse wears a gown i f it i s neces­
sary to feed the p a tien t.
The trays are c o lle c te d , one at a tim e.
contaminated sh e lf in the k itch en .
Dishes and trays are placed on the
The kitchen maid, who wears a gown w ith elbow-
length s le e v e s, places the garbage can cover on the flo o r with the handle-side
uppermost;
remnants of food are put into the garbage can.
The dishes are then
stacked on the contaminated s h e lf .
Fluids are poured into a sp ecial recep ta cle,
and la te r emptied into the hopper.
Paper tray-cloth s and napkins are put into
the waste-basket, and the trays are stacked on the contaminated sh e lf.
The
maid replaces the cover of the garbage can by grasping the handle with a paper
square.
The maid places the dishes in the dishwashing machine, scrubs her hands fo r
two minutes, then clo ses and operates the machine.
The dishes are rinsed in the
machine, s te r iliz e d by steam for ten minutes, and then are removed to a clean
sh e lf;
they are la te r washed, d ried , and placed in the cupboards.
s te r iliz e d in a sim ilar manner.
Trays are
56
P o rter’s Technic.
The ward porter in performing h is d u ties wears a gown
with elhow-length s le e v e s .
I f the gown becomes contaminated, he discards i t ,
scrubs h is hands, and puts on a clean gown.
Care o f Contaminated Mattresses and P illo w s.
When contaminated m attresses
and p illow s are ready to be a ired , the porter brings a stretch er draped with a
large sheet to the cu b icle or room.
stretch er.
The mattress and p illow s are placed on the
The porter discards h is gown, scrubs his hands, and puts on a clean
gown.
He then covers the m attress and pillow s with a sheet and proceeds to the
roof.
He e ith e r hangs the m attress on a lin e or places i t on a rack;
the p i l ­
lows are hung on a l i n e .
The porter fo ld s the sheets and places them on the str e tc h e r .
He removes
his gown and fo ld s i t w ith the clean sid e out, then p laces i t over h is r i^ it
aim and hand and, guiding the stretch er with his l e f t hand, he returns to the
ward.
The porter may open doors or press the elevator button with h is covered
righ t hand.
The contaminated sheets and gown are put in to the hamper bag.
The
porter then scrubs h is hands, puts on a clean gown, washes the s tr e tc h e r , and
cleans the u n it.
A fter the m attresses and pillow s have aired for at le a s t s ix hours, they
are brought to the ward by the porter.
In inclement weather, m attresses and
p illow s are aired fo r twenty-four hours on a porch or in a room.
Fumigating
rooms are provided in general h osp itals where roofs and porches are not a v a il­
a b le.
Contaminated m attresses and pillow s are suspended on hooks and are ex ­
posed to formaldehyde.
Care of Contaminated Rooms and Cubicles.
A ll fu rn ish in gs are scrubbed
with soap and w ater, and the w alls and floors of the cu b icle or room a lso are
washed w ith soap and water.
57
D isposal of Refuse.
Refuse i s put into cans which are taken to the in ­
cin erator by the p orter, and the contents are burned.
Empty cans are exposed
to l i v e steam and washed, a fte r whichnthey are returned to the wards.
Care of F lo o rs.
On communicable d isease wards the flo o r s should be of
m aterial which is easy to keep clean .
Before being swept, they should be
covered with a chem ically-treated sawdust, which a c ts as a dust-down;
sweeping, they should be washed with soap and water.
a fte r
Mops, a fter u se, are
thoroughly washed with soap and water, and are b o iled d a ily .
V is itin g R egulations.
ing the ward.
seam less cape;
slip p e d .
Each v is it o r must be properly gowned before enter­
The v i s i t o r ’s gown i s made of a cotton fa b r ic , and resembles a
i t has an opening at the top through which the head may be
The hands are thus completely covered during the v i s i t .
When the
v i s i t o r le a v e s, h is gown i s removed by the nurse and placed in th e so ile d linen
or s t e r iliz in g room bag.
In th e cubicled wards, a v is it o r observes the p a tien t through the g la ss at
the back of the c u b icle.
The window in the cu b icle i s kept closed , to prevent
contact with the p a tie n t.
I f there is no passageway behind the cu b ic le , the
v i s i t o r stands in front of the cubicle at le a s t s ix f e e t from the p a tie n t.
When th e p atien t i s iso la ted in a room, the v is it o r observes him from the
corrid or.
When a p a tien t i s c r it ic a lly i l l , a v is it o r wearing a nurse’s gown
may enter h is room, i f a nurse remains in attendance during the S ntire v i s i t .
A v is it o r is permitted to bring only small rubber to y s, magazines, inex­
pensive books, and t o i l e t a r t ic le s , which are l e f t with the nurse in charge.
A ll toys are washed before they are given to p a tie n ts.
by p a tien ts may not be taken from the h o sp ita l.
Books or a r t ic le s used
58
C lin ica l Records.
C lin ical records are kept in the nurses* s ta tio n .
When
a c lin ic a l record i s taken to a p a tie n t's u n it on ward rounds, i t is carried by
eith e r a nurse or a doctor who remains clean .
Records which a ccid en ta lly become
contaminated are aired for two hours.
Signing of Documents.
The p atien t may sig n a le g a l document and other
papers without contaminating them.
A clean paper towel i s placed on the bedside
ta b le , and the paper to be signed i s la id upon i t by the nurse.
With the excep­
tio n of the space for the sign ature, the document i s covered with paper tow els.
While the nurse holds the tow els and the document in p la ce, the p atien t sign s
h is name, and the nurse then removes the document.
The paper towels are d is ­
carded and the penholder i s washed with soap and water.
Medical A septic Technic in a General H o sp ita l.
Communicable disease pa­
t ie n t s may be cared for in a general h o sp ita l where there is no provision for
an is o la tio n s e r v ic e .
R equisites fo r a p p lica tio n of medical asepsis include:
correct d ia g n o sis, a ctiv e immunization o f the h o sp ita l personnel, running water,
gowns, and f a c i l i t i e s for d isin fe c tio n and s t e r iliz a t io n .
In placing p a tien ts in an open ward, a tten tio n must be given to grouping.
For example, a sc a r le t fever patient must not be placed beside a patient with an
open wound.
Beds must be at le a s t s ix fe e t apart so th at droplets from coughing
or sneezing do not reach the adjoining bed.
I f necessary, screens may be placed
between beds.
The members of the medical and nursing s t a f f s at the Western Reserve Uni­
v e r sity H ospital have prepared an o u tlin e o f transm issible d ise a se s, have c l a s s i ­
fie d them according to type, and have advised the degree of precaution that needs
to be taken to avoid c r o s s-in fe c tio n .
These tech n ics have been su c cessfu lly
practiced on the medical serv ice since 1937.1
1.
A lice Rothfus, A Sane A septic Technic for Nurses,
LI (December, 1938), pp. 59-60.
The Modem H osp ital,
59
The open wards o f the modern h osp ital are equipped with adequate f a c i l ­
i t i e s fo r th e care of p a tien ts with communicable d isea ses, such as provision
for sun ligh t and fresh a ir , for hand cleansin g, and for d isin fe c tio n and
s t e r iliz a t io n .
In homes and in h o sp ita ls where f a c i l i t i e s are lim ited , the
nurse should be able to adapt the technic to the s itu a tio n .
In such ca ses,
in te llig e n c e i s more important than equipment.
E ssen tia l P oints to Remember;
1.
Everyone who enters the ward should understand and comply with the d e ta ils
of tech n ic.
2.
The lo y a lty of the patient is necessary.
3.
By p rotectin g h e r se lf the nurse protects her p a tie n ts.
S elected References
Carter, Charles F . , Microbiology snd Pathology.
The C. V. Mosby Company, 1939. P. 756.
2nd E d ition .
St. Louis:
Ecker, E. E ., and Smith, Ruth, D isin fectin g C lin ic a l Thermometers.
Modern H o sp ita l, XLVTII (A p ril, 1937), p. 86.
__________ S te r iliz in g Surgical Instruments.
(March, 1937), p. 96.
The
The Modern H osp ital, XLVIII
Harmer, Bertha, and Henderson, V irgin ia, Textbook o f the P r in cip les and
P ractice of Nursing. 4th Edition Revised. New York: The Macmillan
Company, 1939. P. x + 1048.
MacChesney, Emma, Nursing I so la tio n Procedures.
XL (A p ril, 1940), pp. 378-82.
American Journal of Nursing,
McCulloeh, Ernest C», D isin fectio n and S t e r iliz a t io n .
and Febiger, 1936. P. 526
Philadelphia:
Lea
60
Park, William H ., and Williams, Anna W., Pathoganic Microorganisms. 11th
Edition Revised. Philadelphia: Lea and Febiger, 1939. P. 1056.
Rosenau, Milton J . , Preventive Medicine and Hygiene. 6th E dition .
York: D. Appleton-Century Company, 1935. P. xxv •+- 1482.
New
Rothfus, A lic e , A Sane Aseptic Technic fo r Nurses.
LI (December, 1938), pp. 59-60.
The Modern H osp ital,
Tracy, Margaret A ., Nursing. An Art and a S cien ce.
Mosby Company, 1938. P. 560.
S t. Louis:
The C. V.
W ells, M. W., and W ells, W. F ., Air-Borne I n fe c tio n s. Journal of the Amerl
can Medical A ssociation , CVII (November 21, 1936), p. 1698.
W illard Parker H osp ital, Manual o f Medical A septic Technic.
Willard Parker H ospital, 1939. P. iv 4 102.
New York:
Z in sser, Hans, and Bayne-Jones, Stanhope, A Textbook of B acteriology.
E dition Revised. New York: D. Appleton-Century Company, 1939.
P. x x v iii-f 990.
8th
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P ig . 1. Drawing o f s a g i t t a l se c tio n through th e head. Arrows
in d ic a te the p o r ta l o f e n try o f many organians Which cause'communicable
d is e a s e s . (Drawing by J u le s G raubard.)
CHAPTER
V II
MEASLES
D e fin itio n .
Measles is an acu te, h igh ly tran sm issib le d isease charac­
te r iz e d by fe v e r , catarrhal symptoms (c o n ju n c tiv itis , coryza, cough), Koplik's
sp o ts, and a c h a r a cter istic maculopapular eruption.
Synonyms: M o rib illi;
Rubeola.
H istory.
Measles has ex isted in Europe and Asia in epidemic fbim since
early C hristian tim es.
Ahrun, an Alexandrian p hysician of the seventh century,
described th e d isea se; Rhazes of Bagdad described the symptoms; Thomas Sydenham
d iffe r e n tia te d measles from sc a rlet fever in the seventeenth century; and
Withering, in 1792, separated i t from sm allpox.
Prevalence.
d ise a se s.
Measles is the most w idely d istrib u ted of a l l communicable
I t i s most common during the la te w inter and spring months, although
clim ate does not in fluence i t s occurrence.
Epidemic outbreaks of the disease
occur every few years, more frequently in urban centers than in rural d is t r ic t s .
Each outbreak appears to attack a l l su scep tib le in d ivid u als exposed and leaves
the ch ild population fairly immune u n til there i s a new group of susceptible
ch ild ren .
Measles i s e sp e c ia lly v iru len t in p rim itive races.
E tio lo g y .
The organism; causing m easles i s unknown, but probably i s a
f ilt e r a b le v ir u s.
Records in d icate that the f i r s t in ocu lation for measles was
made by Francis Home of Edinburgh.
He did t h is by applying cotton saturated
with measles blood to sc a r ifie d wounds o f su scep tib le ch ild ren .
(61)
His resu lts
62
were uncertain.
In 1852 Mayer caused measles in human subjects by using buccal
and nasal se cr etio n s.
In 1905 Hektoen in jected subcutaneously small q u an tities
o f blood taken from measles p a tien ts a t th e height of the d isease and
i t in human su b jects.
produced
In 1911 Anderson and Goldberger, using human blood, suc­
ceeded in producing measles in rhesus monkeys; Park showed that rabbits develop
a rash and temperature when inoculated with throat secretion s o f early cases of
m easles.
In 1917 Ruth T u n n icliff described a small Gram-positive coccus, oc­
curring in pairs and short ch ains, which she found almost constantly present
in the blood in the preeruptive and eruptive sta g e s,
la t e r , stu dies of the or­
ganism and animal experimentation led T u n n icliff to think i t had a d e fin ite
e t io lo g ic a l rela tio n sh ip to m easles.
In 1926 Ferry and F isher, of the Parke,
Davis Laboratory in D etro it, published stu d ies on the measles v ir u s, and des­
cribed a small Gram-positive ooccus sim ila r to the T u n n icliff organism:*.
In
1938 Broadhurst reported the presence of in clu sion bodies in the nasal membrane
three to four days before the exanthem appears.
These bodies are abundant even
on the fourteenth day o f the d ise a s e , and for t h is reason carriers may play a
part in measles tra n sfer.
The search fo r the causative agent is s t i l l being carried on, but the
much needed production o f an immune animal serum or a n tito x in of therapeutic
value has not been accomplished.
Sources of In fe c tio n .
The b u ccal, n a sa l, and lacrim al secretion s of an
in fected individual have been found to contain the measles v iru s.
Mode of Transmission.
Measles i s transm itted by d irect contact in most
ca ses, but sin ce the v iru s i s present in the nosb and th roat, i t may be spread
by cough d rop lets.
As the viru s i s s h o r t-liv e d , the intervening time of trans­
m ission must be short i f conveyed by a third person or fom ites.
is not transmitted by the s c a le s from the skin.
The disease
63
S u s c e p ti b i l i t y .
S u s c e p tib ility to measles i s p r a c tic a lly u n iv e r s a l.
An
in fa n t is immune from th e d ise a se fo r the f i r s t few months of l i f e provided
the mother has had th e in f e c tio n , but c h ild re n a re h ig h ly s u s c e p tib le , 90 per
cent of th e cases o ccu rrin g by the ten th year.
Both sexes are e q u a lly a ffe c te d .
One a tta c k of m easles u s u a lly produces immunity f o r l i f e .
In a stu d y o f 14,744 cases of measles in P rovidence, Rhode Is la n d , Chapin
found 698 p a tie n ts who had p rev io u sly had the d ise a se ; o f t th ese , fo rty -o n e had
1
had i t more than once.
In urban c e n te rs ad u lts from eighteen to tw en ty -fiv e
years of age fre q u e n tly c o n tra c t th e d ise a se .
This is explained by the fa c t
th a t th e se in d iv id u a ls come from r u ra l communities where they never had been
exposed.
Severe outb reak s occurred in the tra in in g camps of the U nited S ta te s
Army d uring the World War where r e c r u its came from remote d i s t r i c t s and were
not p ro te c te d by childhood a tta c k s .
H isto ry in d ic a te s t h a t when measles i s introduced in to a community where
i t has not e x is te d f o r s e v e ra l g en eratio n s a l l ages are a tta c k e d .
Fanum de->* -
scribed an epidemic which occurred in th e Faroe Is la n d s , in 1846, where th e re
had been no m easles sin c e 1781; in a population of 7,800, approxim ately 6,000
persons of a l l ages were a tta c k e d w ith in a few months.
In the F i j i Isla n d s ,
in 1875, out of a p o p u latio n of 150,000 attacked by m easles a f t e r the a r r i v a l
of a B r itis h s h ip , 40,000 d eath s occurred, probably due to lack of c a re .
P athology.
E arly in th e in cubation period the blood shows a mild lympho­
c y to sis or le u c o c y to s is , which is followed by the c h a r a c te r is tic leucopenia.
A decided
polym orphonuclear
ca te s a co m p licatio n .
1.
leu co cy to sis a f t e r th e p erio d of in v asio n in d i­
The c h a r a c te r is tic pathology of uncom plicated m easles
C harles Chapin, M easles in P rovidence, Rhode Is la n d , 1858-1923, American
Jo u rn al of N u rsin g , XXV (September, 1925), p . 635.
64
c o n sists of the inflammatory changes in the skin.
Incubation Period.
Most a u th o r itie s give the sh ortest incubation period
as eig h t days and the longest as seventeen;
u su ally, however, it is twelve to
fourteen days, and frequently only ten days.
During the incubation period the
p a tien t usually presents no symptoms.
Course of the D isease: Period of Invasion.
The period of invasion is
important because the d iagn osis i s uncertain and i t i s a time in i&ich the
d isea se i s rea d ily transm itted to others through droplet in fec tio n .
There
are three d is tin c t stages of the d isea se during t h is period: the f e b r ile ,
catarrh al, and enanthem (an eruption on the mucous membrane).
The course of
the fever is varia b le, but there i s always some elevation of temperature.
This may be the e a r lie s t sig n of the d ise a s e .
The fever i s followed by con­
g estio n or inflammation of the conjunctiva with a watery or mueo-purulent d is ­
charge, when the patient shuns the lig h t .
The e y e lid s are congested and may
be sw ollen, coryza i s p resen t, and a brassy cougi develops.
n e ss, due to involvement of the larynx.
There i s hoarse­
The mucous membrane of the mouth i s
congested, and a spotted m ottling o f the p alate (the enanthem) which occurs
la t e r resembles the rash on the idcin.
appear before the rash d evelop s.
The spots described by Koplik in 1896
These are minute b luish white spots, usually
surrounded by a red a reo la , which appear on the buccal mucosa opposite the molar
te e th and spread quickly over the whole lin in g o f the cheeks and inside of the
lip s .
They resemble grains o f s a lt sprinkled on a red background.
As the sta g e
of invasion progresses, congestion of the mucous membrane increases and the
spots gradually fade.
E oplik’ s spots occur in no other d isea se, so they are an
important aid in the ea rly diagn osis of m easles.
to recognize the spots.
Bright daylight is e s s e n tia l
The ”m easles l i n e , ” described by Stimson as a d e fin ite
65
lin e of con gestion , may appear on the conjunctiva of the lower e y e lid s one
or two days before K bplik's spots appear.
Period of Eruption.
The ch a ra cteristic measles rash (the exanthem)
appears a fte r th ree or four days of catarrh and fev er.
I t i s f i r s t observed
behind and below the ears, on the fa c e , at the roots of the h a ir, and about
the mouth and chin as fin e pink macules which rapidly in crea se, becoming darker
and papular.
In twenty-four to fo rty -eig h t hours they have spread downward
over the trunk and then to the extrem ities.
When completed the eruption is
dusky red, m ottled , and s lig h t ly elevated .
As the rash appears the patien t
becomes sick er and sic k e r and the catarrhal symptoms become more in ten se.
His appearance i s c h a r a c te r istic : the face blotchy, the eyes In jected and
sec re tin g , and the nose discharging a secretion which reddens and excoriates
the nares and upper l i p .
fa c ie s."
His expression is woe-begone and fo r lo r n , a ’♦measly
The fe v e r a t i t s height i s 102° - 105°
rash begins to fa d e.
cates a com plication.
but i t subsides as the
A continued elevation or la te r r is e in temperature in d i­
The rash fades in three or four days, leavin g a brownish
sta in which is gradually absorbed.
Desquamation, the fin e and branny scalin g
which takes p la c e , i s most marked on the fa ce, but sometimes i s b arely percep­
t ib le .
In severe cases the rash becomes hemorrhagic, the area
assuming a pur­
p lish hue which causes the condition to be described as "black m easles."
This
i s a grave p rognostic sig n .
Period o f Convalescence.
The patient may convalesce
very r a p id ly , though
frequently the cough i s prolonged.
Complications and Sequelae.
Complications rarely occur except in severe
attacks of m easles, the most common being broncho-pneumonia and o t i t i s media.
L aryn gitis, c e r v ic a l a d e n itis , c o n ju n c tiv itis, and, o cca sio n a lly , diarrhea are
66
o th e r co m p licatio n s.
I f noma, a gangrenous c o n d itio n of the ti s s u e s , o ccu rs,
th e r e s u l t s in v a ria b ly are f a t a l .
The sequel of tu b e rc u lo s is , which may be
caused by the lig h tin g up of a l a t e n t tu b e rc u lo s is in fe c tio n of the lungs when
i*esisteiD6 is lowered by an a tta c k of m easles, a ls o is s e rio u s .
P erio d of Communlcability.
The d is e a s e is h ig h ly communicable from about
fo u r days b efo re u n t i l fiv e days a f t e r the appearance of th e r a s h .
P ro g n o sis.
The prognosis depends upon s e v e ra l f a c to r s :
the age and p h y si­
c a l c o n d itio n of the p a tie n t; to some e x ten t upon the season and c h a ra c te r of
the epidemic; and la rg e ly upon th e care which the p a tie n t re c e iv e s .
The presence
of com plications always renders i t le s s fa v o ra b le .
M o rta lity .
The m o rta lity r a te among o ld e r c h ild re n is very low, which
probably accounts f o r the erroneous view taken by many of th e l a i t y t h a t the
d ise a se is of minor im portance.
M easles is one of the c h ie f causes of death
between the ages of one and th re e y e a rs .
The m o rta lity is p a r tic u la r ly high
among m alnourished c h ild re n or when th e d ise a se is com plicated by o th e r d is eases.
1
P ro p h y lax is:
C onvalescents’ Serum.
The use of intram uscular in je c tio n s
of m easles serum o f fe r s a defense
a g a in s t t h i s d is e a s e .
Blood is secured from
convalescent p a tie n ts from one to
th re e months a f t e r the a tta c k .
The donor
must be in good co n d itio n and f r e e from any in f e c tio n , p a r tic u la r ly tu b e rc u lo sis
and s y p h il i s .
Whan t h i s serum is
ad m in istered in tram u scu larly w ith in f iv e days
a f t e r th e exposure, no d isease develops in th e
m ajo rity of c a se s.
In c h ild re n
under fiv e years and in d e b ilita te d c h ild re n of any age, complete p ro te c tio n
from th e d isea se should always be attem p ted .
C onvalescents’ serum i s u se fu l
in lim itin g epidemics in an i n s t i t u t i o n .
1.
Emma MacChesney, What i s Communicable D isease Nursing?
of N ursing, XL (March, 1940), p . 266.
American Jo u rn al
67
7/hen th e serum is given s ix to seven days a fte r exposure, measles usually
i s lim ited to a modified form of the d isea se.
This m odification w ith the im­
munity th a t follow s i s considered a more desirable e f f e c t in healthy children
over fiv e years who have been exposed to the d isea se than complete protection .
I f a m ild, modified form o f measles i s d esired , the ezposed ch ild should re­
ceiv e e ith e r £>,.5 c c . from the f i f t h day a fte r exposure, or the f u l l dose from
the s ix th to seventh days a f te r .
The dosage recommended by the New York City
Department of Health for prevention is as follow s:
.
Infants and children under fiv e y ea rs...................... 5 cc.
Children over f iv e years (dose for each y e a r )
1 cc.
Adolescents and a d u lts..............................................15-20
cc.
When the serum i s given eig h t or more days a fte r exposure th ere is no a s ­
surance of prevention or m odification of m easles.
The attack which follow s an
in fe c tio n of serum i s of decreased in te n sity when not altogeth er prevented.
Parental serum.
When convalescents’ measles serum
is not a v a ila b le, some
p rotection may be afforded by the blood of a d u lts who have had measles in c h ild ­
hood.
The whole blood or separated serum is used, the dosage being 30 to 40 cc.
of the blood, or 15 to 20 cc. of the serum.
P lacental Extract (Immune G lobulin).
to modify an attack of m easles.
Treatment.
In jectio n s are made intram uscularly.
Human p lacen tal ex tra ct a lso is used
Pooled glob u lin i s obtained from human placentas.
Small doses o f aspirin or pyraraidon may be ordered to r e lie v e
headache and general discom fort.
Small doses of codeine may be ordered to sup­
press th e nonproductive cough.
Steam in h a la tio n s, w ith or without tin ctu re of benzoin, may be used to
a lle v ia te la r y n g itis .
Whisky, one teaspoon to one ounce o f water, w e ll sweet­
ened, may be prescribed to quiet the p a tie n t.
I t is reported that in the pre­
e m p tiv e stage a large dose of convalescents' serum may modify the d isease.
68
Methods of Control: Recognition and Reporting.
by the c lin ic a l symptoms.
o f f ic e r .
Cases should be immediately reported to the health
In many communities the house is placarded.
I so la tio n .
c a b ility .
Measles i s recognized
The p a tien t should be iso la te d during the period of communi-
The exclusion o f v is it o r s reduces the exposure o f the p atien t to
secondary in fe c tio n s, to which he i s very su scep tib le at t h is tim e.
Quarantine.
The United S ta te s Public Health Service s ta te s th a t, i f the
date of exposure i s reasonably c e r ta in , an exposed susceptible ch ild may be
allowed to attend school for the f i r s t seven days of the incubation p erio d .1
When a case of measles develops in a h o sp ita l ward or ch ild -carin g in ­
s tit u t io n , p rotective doses o f con valescen ts’ serum, parental blood, or placen­
t a l extract should be given to exposed children who have not had m easles, and
s t r i c t quarantine should be in s titu te d .
Immunization.
The two types of immunization are called a ctiv e and p a ssiv e.
For passive immunization, convalescents' serum, parental blood, or p lacen tal
extract are used to protect the su scep tib le individual and lessen the m ortality;
i t i s the more e ffe c tiv e typ e.
r e s u lt s .
A ctive immunity to measles has had l e s s certa in
The e ffo r ts to produce th is type of immunity are indeterminate and
unconfirmed, according to in v e stig a to r s.
Nursing Care
I s o la tio n .
Measles cannot be cared for in an open ward with other d ise a s e s .
A private room or ward where a l l p a tien ts have measles is necessary.
The p atien t
should be iso la ted u n til recovery, which is u n til the temperature is normal and
1.
Public Health Reports, L.[ Wqphlngtpn, D.;Q .: United S tates Government P rin tin g
O ffice, August 9, 1939, p. 23.
69
th e r a s h has faded .
Medical a s e p tic technic should be r i g i d l y observed.
V i s i t o r s should be excluded to reduce exposure of the p a tie n t to r e s p ir a to r y
i n f e c t i o n s , to which he is very s u s c e p tib le during the ac u te stage of the
d isea se.
Environment.
The room should be li g h t and a i r y .
Sunlight is d e s ir a b le ,
provided the p a t i e n t ’s eyes are screened from d i r e c t o r too b r ig h t l i g h t .
o ld -fash io n ed p r a c tic e was to s e le c t a closed dark room.
An
The growth of organ­
isms commonly found asso ciated with m easles, p a r t i c u l a r l y the pneumococcus, is
o
i n h i b it e d by s u n lig h t. The temperature of the room should be about 70 F.
Cold a i r should be avoided, as inflammation of the upper a i r passages is charac­
t e r i s t i c of the e a r ly stag es of the d is e a s e .
Comfort of th e P a t i e n t .
Rest in bed i s e s s e n t i a l .
Delay in p u ttin g the
p a tie n t to bed a t the beginning of th e a tta c k is l i k e l y to increase i t s s e v e rity .
C lothing should be l i g h t in weight, warm, and not i r r i t a t i n g .
A co tto n s h i r t ,
warm nightgown, and stockings should be worn by in f a n ts and young ch ild re n .
For o ld e r c h ild re n pajamas w i l l be found b e st as a p r o te c tio n from c h i l l i n g .
'S leeping bags provide added p ro te c tio n during th e n ig h t.
P erso n al Hygiene:
Care of the Skin.
A warm sponge bath should be given
d a i l y , very l i t t l e soap being used, to avoid skin i r r i t a t i o n .
Itc h in g or burn­
ing of th e sic in may be re lie v e d by applying a 5 per c e n t s o lu tio n of sodium
b icarb o n ate o r calamine l o t i o n , or by rubbing with carb o lized v a s e lin e .
t e p id sponge may be ordered fo r high fe v e r or f o r r e s t l e s s n e s s .
A
Care must be
taken to avoid exposure, and the temperature should never be below 90° F.
Care of th e Eyes.
The eyes should be cleansed se v e ra l times d a ily with a
warm s o lu tio n of 2 per cent boric a c id , and v a s e lin e o r o i l should be applied
to th e l i d s .
I f th ere i s a profuse d isc h a rg e , th e i n s t i l l a t i o n of s i l v e r so lu ­
tio n s may be p rescribed by the p h y sician .
The head o f the bed should be placed
70
toward the window, so th a t th e l i g h t w i l l e n te r the room without d ire ctly s tr i k i n g the eyes of th e p a t i e n t .
I f the eyes are inflamed o r i f excessive
discharge is p r e s e n t, a screen may be placed between th e bed and th e window,
or th e p a tie n t may wear an eye-3hade.
Care of th e Nose,
Gold compresses may be found soothing.
As a profuse nasal disch arg e accompanies m easles, the
nose should be cleansed fre q u e n tly with co tto n swabs.
M ineral o i l w i l l so ften
c r u s ts t h a t may have formed, and hydrogen peroxide and w a te r, equal p a r t s , w i l l
remove them,
When the discharge i s extreme, g e n tle suction may be orderedo
The c a t h e t e r used f o r su ctio n should have a closed t i p and a small opening a t
the s id e .
The nares and upper l i p should be p ro te c te d v:ith ointm ent, such as
cold cream or zinc oxide.
Older ch ildren should be provided with paper hand­
k e rc h ie fs and in s tr u c te d to keep the nose c le a n .
A paper bag fo r s o ile d hand­
k e rc h ie fs may be attached to the bedside ta b le w ith scotch ta p e .
Care of the Mouth,
The mouth req u ires co n stan t c a re , bo th f o r the comfort
of th e p a tie n t and to avoid in fe c tio n of the ea rs and throato
Older c h ild re n
should use a mouth-wash and should gargle b efo re and a f t e r nourishm ent.
For
young c h ild r e n , s o f t cotto n swabs should be used to cleanse th e mucous membranes.
D ilute hydrogen peroxide, sodium bicarbonate, or any a lk a lin e a n t i s e p t i c s o lu ­
tio n may be used.
I f hydrogen peroxide i s used, the mouth should be r in s e d
with water d i r e c t l y a fte rw a rd .
A l u b r ic a n t, such as v a s e l in e , b o ric ointm ent,
or m ineral o i l , should be ap plied to th e l i p s .
A coated tongue may be swabbed
with lemon ju ic e and m ineral o i l .
Care of the E a rs.
The ears should be examined every day by the physician*
or when th e re is an otherw ise unexplained r i s e in tem perature; they should be
cleansed twice d a ily with cotton swabs.
cian may ord er dry wipes o r i r r i g a t i o n s .
I f a discharge i s p r e s e n t, th e physi­
Vaseline o r zin c oxide ointment should
71
be applied to the external ear to prevent ir r it a tio n from the discharge*
It
may be necessary to restra in the arms of a small child*
E lim ination.
A mild la x a tiv e , a s m ilk o f magnesia, or an enema may be
ordered, i f necessary, to reg u late elim in ation .
D ie t.
The d ie t should be su ited to th e age of the p a tien t.
be liq u id during the acute stage and should be given regu larly.
I t should
Milk, f r u it
ju ic e s , broth, cerea ls, and ice-cream c o n s titu te the d ie t fo r a c h ild .
Some­
tim es, when there i s much mucus secretio n in th e mouth, milk i s d if f ic u lt to
take*
I f the mouth i s rinsed with a sodium bicarbonate so lu tio n to cut the
mucus, the milk i s w ell to le r a te d .
d ie t may be given to an a d u lt.
Purees, c e r e a ls , t o a s t , and a more lib e r a l
Water should be offered frequently.
As the
symptoms subside the d ie t may be gradually increased to a s o f t , then la te r to
a regular high c a lo r ic , d ie t .
In infancy, th e feeding requires sp e c ia l care
to avoid d ig e stiv e disturbances and diarrhea.
the t o t a l quantity being m aintained.
Complications: O titis Media.
Frequent small feedings should be given.
Complications generally may in many cases
be prevented by d ilig e n t nursing care.
any unusual sign or symptom.
The formula may be d ilu te d ,
The nurse should be a le r t to n otice
A continuous fev er or r is e in temperature a fte r
the rash begins to fade i s almost in variab ly the f i r s t symptom of a secondary
in fe c tio n .
In addition, each com plication g iv es other sig n ific a n t warnings*
O titis media, usually staphylococcus or streptococcus in o rig in , i s a common
com plication of m easles, going on to suppuration and, sometimes, to mastoid
involvement.
This condition i s most frequent when the r h in itis is sev ere, or
when the adenoids and t o n s ils are enlarged.
The f i r s t sign o f o t i t i s media in young children may be the r o llin g o f the
head, placing of the hand over the a ffe c te d area, or p ulling of the ear; redness
M B A vS L E S
Bed No.
A d m itte d
------- -------------------------------------------------
N a m e ......._ M a lS ____________________________
M onth.
Age........_____________________ Caee No.
January
D a y o f M onth.
23
24
o
D a y o f Illn ess.
25
10
26
11
27
12
28
13
29
14
H o u r of D a y .
R esp. P
ulse t e m p
170
108
160
107
150
106'
140
105'
130
104'
120
103'
110
102 '
100
101
TEM P.
.
100 '
2 i i ;£i
ii si
F ig . 2 . Temperature chart o f a p atien t w ith m easles and broncho­
pneumonia. (See1page 7 2 .)
72
and sw ellin g of th e ear-drum and purulent discharge a lso are ea rly symptoms. I t
may be necessary fo r th e physician to perform a myringotomy.
Irrig a tio n s of
an a n tise p tic so lu tio n , as 2 per cent boric acid , may be ordered.
and canal should be dried thoroughly with cotton p led gets.
never be l e f t in the ea r unless ordered by the physician.
The a u ricle
Cotton should
Zinc oxide ointment
may be used on th e a u ricle and around the ear to prevent ex co ria tio n .
I t may
he necessary to r e str a in the arms of a small ch ild .
Broncho-pneumonia.
U sually there is a b ron ch itis with m easles, but the
most frequent of th e seriou s com plications, and the p rin cip al cause of death,
i s broncho-pneumonia.
The symptoms o f pneumonia most often appear when the
rash is at i t s height or beginning to fade from the fa ce, and they are in ­
dicated by continued r is e in temperature, rapid, labored breathing, d ila ta tio n
o f nares, rapid p u lse, a severe cough, and prostration . The pneumonia may run
i t s course in a week or ten days; more often i t i s three or four weeks.
P leu risy and empyema sometimes occur.
The nursing care o f pneumonia should include frequent changing of the
p a tie n t's p o s itio n , frequent mouth care, tepid sponges to reduce temperature
and a lla y r e s tle s s n e s s , and forcin g f lu id s , e sp e c ia lly f r u it ju ic e s and water.
Abdominal d iste n tio n is a danger s ig n a l, fo r which d a ily cleansin g
enemata may be ordered as a preventive measure.
I f t h is condition p e r s is t s ,
milk and m olasses enemata, turpentine stupes, and the in sertio n o f a r e c ta l
tube are measures used to a lle v ia te i t .
I f resp iration s are rapid and labored,
the p a tien t may be placed in an oxygen te n t.
C ervical A d e n itis.
Sw elling of th e lymph glands, e s p e c ia lly in the cer­
v ic a l group, i s frequent, but the glands seldom suppurate.
An ic e - c o lla r may
be prescribed to r e lie v e pain and sw ellin g in th is con d ition.
/
\
73
L a ry n g itis .
A c a ta r r h a l inflammation of the lary n x, u s u a lly of s tr e p to ­
coccus o r ig i n , fre q u e n tly accompanies m easles, and may p e r s i s t throughout the
d is e a s e .
The swelling of the mucous membrane i s o fte n s u f f i c i e n t to produce
p a r t i a l o b s tru c tio n , e s p e c ia lly in in f a n ts , and to cause croup.
should watch f o r symptoms of hoarseness and noisy b re a th in g .
The nurse
A p atien t with
croup re q u ire s constant watchfulness because of th e p o s s i b i l i t y of su ffocation .
P a t i e n ts s u ffe rin g from la r y n g itis may be put in a croup t e n t .
I f surgical
in te rf e r e n c e is necessary and an in tu b a tio n or a tracheotomy i s performed,
the prognosis u s u a lly i s poor.
D iarrh ea.
Diarrhea may be prevented i f the d i e t is c a r e f u l l y watched
and t h e p a tie n t guarded against c h i l l i n g .
Qonvalescence.
Convalescence u s u a lly i s un eventful in uncomplicated cases.
S everal days a f t e r the rash has faded, th e p a tie n t may be allowed out of bed
f o r g ra d u a lly in creasing in te r v a ls .
taken to avoid c h i l l i n g .
Children should be warmly dressed and care
I f a troublesome cough p e r s i s t s , the physician w il l
p re sc rib e s u ita b le medication.
P rovision should be made f o r th e entertainment
o f convalescent c h ild re n .
D i s in f e c t io n : Concurrent.
Discharges from the nose, t h r o a t , and eyes,
and handkerchiefs and dressings s o ile d with these d ischarges should be burned.
In th e home, lin e n should be boiled f o r t h i r t y minutes before being washed.
Pood waste should be securely wrapped and burned.
A ll u t e n s i l s and di3hes
should be s t e r i l i z e d .
Terminal.
A cleansing bath and shampoo are given to the p a ti e n t , a f t e r
which he i s tr a n s f e rr e d to a clean u n i t .
Tub b ath s are not advisable u n t i l
the p a tie n t has completely convalesced, as c h i l l i n g may r e s u l t in pneumonia,,
74
E ssential Points to Remember:
1.
Measles is a very dangerous d isea se for children under four years of age.
It is not dangerous a fte r n in e.
2.
The disease u su ally is transm itted during the prodromal p eriod , vhen coryza
and a mild fever are the usual symptoms before the rash appears.
3.
The nurse should be a le r t fo r symptoms o f complications because secondary
infections are resp on sib le fo r the high m ortality ra te.
4.
The patient must always be kept warm.
Home Care
Nursing In stru ctio n s.
The p atien t with measles should be kept in one room
and in bed; other persons should not be allowed in the room.
Symptoms and com­
p lica tio n s should be watched f o r , e sp e c ia lly when the rash fad es, and understanding
care should be given during convalescence.
Community P rotection
The public should be acquainted with the fa c t that measles i s a seriou s
disease in young ch ild ren ,
p u b lic ity campaigns may be organized to acquaint
parents with the important fa c ts concerning m easles, as the c y c le s are f a ir ly
predictable.
Schools should not be closed or c la sse s discontinued where d a ily
observation by a physician or nurse i s provided.
children should be kept at home.
During an epidemic, preiechool
At the f i r s t sig n of a cold, the nonimmune
ch ild should be kept home from school and put to bed, and a physician should be
c a lle d .
Nonimmune in fa n ts and children under f iv e years of age should be kept
apart from older nonimmune ch ild ren , i f p o ssib le .
The importance of the use of
convalescents' serum or whole blood as preventive measures should be understood.
Selected References
Broadhurst, Jean, MacLean, M. E ., and Saurino, Vincent, Inclusion Bodies
in M easles. Journal o f In fectiou s D isea ses, LXI (September, 1937),
p. 201.
Degwitz, R ., The E tiology o f Measles.
(October, 1927), p, 304.
Journal of In fectio u s D iseases, XLI
Emerson, Haven, Measles and Whooping Cough - Incidence, F a ta lity , and Death
Rates - 1924-1933. Report prepared fo r the subcommittee on the evalua­
tio n of Administration P ra ctice, American Public Health A ssociation .
New York: American Public Health A ssociation , 1937.
Kohn, J. L ., Fischer, A. E ., and Resch, N, V ., Treatment of Measles with
Parental Whole Blood. Journal of P e d ia tr ic s, XIV (A p ril, 1939), pp. 502-5.
Kohn, J. L ., and Koiransky, Henry, R elation of Measles and Tuberculosis in
Young Children. American Journal o f D iseases in Children, XLIV (December,
1932), p. 1187.
Park, William H ., and W illiams, Anna W., Pathogenic Microorganisms. 11th
E dition Revised. Philadelphia: Lea and Febiger, 1939. P. 1056.
Penruddock, E ., and Levinson, S. 0 ., Human Convalescents' Serum.
Journal o f Nursing, XXXVI (February, 1936), pp. 121-23.
Rosenau, Milton J . , Preventive Medicine and Hygiene. 6th E dition .
D. Appleton-Century Company, 1935. P. xxv + 1482.
American
New York:
CHAPTER VIII
RUBELLA
D e fin itio n .
Rubella i s a m ild communicable d isease characterized by
slig h t catarrhal symptoms and a fin e ly m ottled eruption resembling m easles
or sca r le t fe v e r , or both.
Any term for ru b ella which includes the word
measles is not d esirab le because of the general tendency to confuse t h is
disease with m easles.
H istory.
Synonyms; German Measles; Roseola; ROtheln.
The nane ru b ella was proposed in 1866 by Veala.
"Rubeola,”
the term used in Germany to designate th is d isease, could not be adopted by
English-speaking physicians as i t already had been applied by them to
"measles."
They adopted th e word "rfltheln" for a time but, f in a lly , unable
to adopt unqualifiedly e ith e r o f th ese terms, the medical profession h it up­
on the term "German m easles," under which ru b ella i s generally recognized.^
Prevalence.
Rubella u su ally occurs in epidem ics, more frequently in
c i t i e s than in rural d i s t r i c t s .
While rub ella occurs mostly in ch ild ren , i t
i s contracted by more a d u lts than i s m easles.
The disease commonly occurs in
the la te winter and spring months.
E tio lo g y .
The cause o f th e d isease i s not known.
I t may be a f ilt e r a b le
v iru s.
Source of In fe ctio n .
S ecretion s o f the nose and throat o f in fected
persons harbor the organisms.
Mode o f Transmission.
The d isea se is spread by d irect contact with the pa­
tie n t and in d irectly by contact with a r t ic le s fresh ly s o ile d with the discharges
1.
I . E. Atkinson, Rubella (ROtheln).
VI (January, 1887), pp. 17-34.
(76)
American Journal of Medical D isea ses,
Bed No.
A d tn itte d ___________________ ______________________
Mary Smith
Name.
M onth.
Age
7 years
Case No..
534
March
D a y o f M onth.
D a y o f Illn ess.
A!.M
A.M P.M A.M P.M A.M P.M A.M P.M A.M P.M A.M P.M
H ou r o f D a y.
610
6 LC2
6 LC
LC2.6LC
TEM P.
R e s p. P u l s e T em p.
170
108 '
160
107'
150
106 '
140
105 '
130
104 '
120
103 '
110
102'
100
101
100'
EfcU
1 .&
l e g . n s .to .i^scTa. .
F ig . 3.
Temperature chart o f a patient with r u b e lla .
(See page 77.)
77
from the nose and throat o f th e p a tie n t.
There is no information a s to
c a rr ie rs.
S u s c e p tib ility .
S u s c e p tib ility is general among children and a d u lts.
One attack usu ally confers immunity.
Infants appear to have a natural im­
munity .
Incubation Period.
twenty-one days.
The incubation period usually is from fourteen to
During th is period there are no symptoms.
Course of the D isease:
dromal period.
Period of Invasion.
There i s p r a c tic a lly no pro­
Twelve to twenty-four hours before the rash appears there may
be s lig h t m alaise, fever below 101° P ., mild catarrhal symptoms, or sore th roat.
Swelling and tenderness of the s u b -o c c ip ita l, p ost-au ricu lar, and p o st-c e r v ic a l
glands may be noticed before the rash appears.
Frequently the patient does not
f e e l sick enough to remain in bed.
Period of Eruption.
The rash appears f i r s t on the fa ce, then spreads
rapidly over the body w ithin twenty-four hours.
On the f ir s t day i t i s charac­
te r iz e d by fin e pink macules which gradually blend on the second day and become
a d iffu se erythema resembling sc a rlet fev er.
The eruption d iffe r s from th a t of
measles in that i t does not f e e l " velvety” or papular, does not appear pigmented,
and fades w ith in fo rty -eig h t to seventy-two hours.
Occasionally a fin e brownish
desquamation may follow the rash.
In addition to the eruption, two sign s are suggestive of the d isease:
pain or s t if f n e s s in the back of the neck (due to enlargement of the lymph
nodes of th is region) and a mild sore th roat.
Complications.
Complications are rare.
Period of Communicability.
The period during which the in fe c tio n may be
communicated to others i s undetermined, but i t is believed to la s t as long as
78
any symptoms are p resen t.
This would be about four days from the onset of
the catarrhal symptoms.
P rognosis.
P atien ts with rubella recover in a few days.
Methods of C ontrol:
Recognition and Reporting.
nized by the c lin ic a l p ic tu re .
The d isea se is recog­
It i s n o tifia b le because i t may be confused
with s c a r le t fever or m easles.
I s o la tio n .
The patient should be separated from nonimmune ind ividu als
u n til the disappearance of the rash.
from school for seven days.
Quarantine.
In New York City children are excluded
Exposed children may continue at sch o o l.
There i s no quarantine.
Immunization.
No vaccines or an tisera have been developed.
Nursing Care
There i s no s p e c ific treatment fo r rub ella.
Rest in bed u su a lly i s pre­
scribed during the period of eruption and u n til the temperature returns to
normal.
As the d isea se i s s l i ^ i t l y communicable, the p atien t should be is o ­
la te d , and medical a sep tic technic observed.
Personal Hygiene:
Care o f the Skin.
A warn bath should be given dal l y .
The itc h in g may be reliev ed by sponging the skin with a so lu tio n of sodium
bicarbonate.
Care o f the Eyes, Nose, and Throat.
gargle w i l l a lle v ia te the discom fort.
with a warm 2
If the throat i s inflam ed, a warm
I f necessary, the eyes may be washed
per cent boric acid solu tion, and nasal a n tis e p tic s may be
ordered.
D ie t.
quently.
A regular d ie t usually i s ordered.
Fluids should be given fr e ­
79
D is in fe c tio n :
Concurrent.
A rtic le s s o ile d by discharges from th e nose
and throat should be burned.
Terminal.
The unit diould be thoroughly cleaned and aired.
E sse n tia l P oints to Remember:
1.
Rubella may be confhsed with sca rlet fever or m easles during th e early
sta g es.
2.
Tenderness in the back o f the neck from enlarged lymph nodes u su ally i s
p resen t.
Community P rotection
This d isease should be reported because o f the p o s s ib ilit y of confusing
i t w ith s c a r le t fever or m easles.
Selected References
Atkinson, I . E ., Rubella (ROtheln).
¥1 (January, 1887), pp. 17-34.
American Journal of Medical D iseases,
Emerson, Charles P ., and Brown, N e llie G ., E sse n tia ls o f Medicine. 12th
E dition R evised. Philadelphia: J. B. Lippincott Company, 1936. P. xxi * 608.
Graham, J . R ., R ubella.
1932), p . 1368.
New York State Journal o f M edicine, XXXII (November,
S ellew , Gladys. The Child in Nursing.
Saunders Company, 1938. P. 600.
4th E d itio n .
Philadelphia:
W. B.
CHAPTER IX
CHICK3HP0X
D e f in itio n * Chickenpox is an a c u te , high ly tra n sm iss ib le d ise a se , charac­
te r iz e d by an exanthem of papules and v e s ic le s which appear in successive crops,
and by mild c o n s titu tio n a l symptoms.
H is to ry .
cen tury .
Synonymi
V aricella.
This d isease was d i f f e r e n t i a t e d from smallpox in the s ix te e n th
The name chickenpox o r ig in a te d in Sngland; v a r i c e l l a ( l i t t l e v a r io la )
by which name i t is a lso known, was f i r s t used by Vogel, in 1765.
P revalence.
Chickenpox i s p re v a le n t throughout the world.
I t u s u a lly is
endemic in urban c e n te r s , but o c c a sio n a lly i t occurs in epidemic form.
As th is
d isea se u su ally i s con tracted on f i r s t exposure, th e m ajority of p a tie n ts are
under f i f t e e n years of age.
Host fre q u e n tly i t occurs in the w in ter and sp rin g
months.
Sources of I n f e c ti o n .
The le s io n s of th e skin and mucous membrane of in­
fe c te d in d iv id u als are the sources of i n f e c t io n .
Mode of Transmission.
The d isea se is spread d i r e c t l y from person to person,
o r i n d i r e c t l y through in fe cted a r t i c l e s and by a t h i r d person.
S u sc e p tib ility .
S u s c e p ti b il i t y
i s p r a c t i c a l l y u n iv e r s a l.
Chickenpox is
the c r o s s - in f e c tio n most d i f f i c u l t to prevent in communicable disease h o s p ita ls
and c h ild -c a rin g i n s t i t u t i o n s .
Pathology.
The le sio n s of t h i s
theliu m , the f lu i d being confined in
d isea se occupy the ou ter la y e r
one compartment (u n ilo c u la r ) . The red a reo la
which surrounds th e pock is formed by d isten ded c a p i l l a r i e s .
(8 0 )
of the ep i­
As the pock is
81
absorbed, a scab form s, which l a t e r is e a s i ly detached.
I f the pocks a re
scratched o ff too soon, th e process extends deep in to the skin and leaves a
s c a r which becomes w hite, and which may.remain f o r .years.
Period of In c u b a tio n .
The incubation period is from about eleven to
tw enty-four days,- u su ally t h i r t e e n to s ix te e n days.
Course of th e Disease:
Period of In v asio n .
sion i s not n o tic e a b le in young c h ild re n .
U sually the p eriod of inva­
Older c h ild re n and a d u lts may have
f e v e r, headache, m alaise, and aching in the back and legs f o r one to th re e days
b efo re the skin le sio n s appear.
The lesio n s of the mucous membrane appear e a r ly ,
and they rupture as soon as the v e s ic le s form.
Period of E ruption.
The exanthem of chickenpox f i r s t appears as a small
papule surrounded by an a re o la o f pink d i s c o l o r a t i o n .
This changes in a few
hours to a round watery b l i s t e r o r v e s ic le , the contents of which have a milky
appearance w ith in th ree or four days.
These v e s ic le s form c r u s ts which gradu­
a l l y dry in to hard scales and soon f a l l o f f , r a r e l y leaving a s c a r unless
scratched o r i n f e c t e d .
The f i r s t le s io n s may be seen on the c h e s t, back, th ig h , or in the scalp .
In e ig h t to tw enty-four hours another s e t of them ap p ears, and fre s h crops con­
tin u e to appear f o r several days,
so th a t papules,
v e s ic le s , c r u s t s , and scabs
are found on s e v e ra l areas of the
body a t th e same
tim e. This i s an important
d ia g n o stic point in d i f f e r e n t i a t i n g the d isease from smallpox.
eru p tio n u su a lly i s of one sta g e .
the tem perature i s s l i g h t l y above
severe cases.
During the heig ht o f a
normal, although
In smallpox the
case of chickenpox
i t may r i s e to 103° p . in
Within a week a f t e r th e onset th e le sio n s are crusted and scabbed.
The scabs d isap pear gradually w ithin two to th r e e weeks.
Period o f Convalescence.
Convalescence is uneventfu l in most in sta n c e s.
82
Complications and Sequelae.
The c h ie f cause of complications i s secondary
in fec tio n of skin le s io n s .
The in fe c tio n u su ally remains lo c a l, but i t may r e ­
s u lt in abscess formation;
e ry sip e la s a lso may ensue.
i s present during the acute sta g e .
C onjunctivitis frequently
Rare com plications include la r y n g itis , en­
c e p h a litis , and gangrene o f the ex trem ities.
Chickenpox frequently com plicates
another disease as a resu lt of c r o s s -in fe c tio n .
Period of Communicability.
The period of in f e c t iv it y extends from twenty-
four hours before the eruption appears u n til seven to ten days a fter the appear­
ance o f the f i r s t crop o f v e s ic le s .
Prognosis.
The prognosis is e x c e lle n t in uncomplicated cases.
Treatment.
The treatment includes r e s t , lig h t d ie t , and the ap p lication
of ointments (to a lla y itc h in g );
Methods of Control:
by the c lin ic a l symptoms.
otherw ise, i t is e n tir e ly symptomatic.
Recognition and Reporting.
The disease i s recognized
Sporadic and doubtful cases should be seen by a phy­
s ic ia n , to esta b lish the c e r ta in ty th at the d isease i s not smallpox.
In order
to ru le out smallpox, a l l persons over f if t e e n years of age, esp ecia lly those
who have not been vaccinated a t a l l or w ithin fiv e years, should be examined by
a health o ffic e r .
I so la tio n .
The patient should be iso la te d during the in fectiou s period,
which is approximately two weeks.
Q,uarantine.
Quarantine is not compulsory, and usually is not practiced.
Children are excluded from school u n til primary scabs have disappeared.
Prophylaxis.
Convalescents’ serum has been used, but i t s value has not
been d e fin ite ly esta b lish ed .
Children who have been exposed to chickenpox
when i l l from another communicable d isease may be given convalescents’ serum.
83
Nursing Care
I s o la t io n * As chickenpox i s the most highly tran sm issib le o f a l l com­
municable d ise a se s, th e p atien t in the h o sp ita l should be iso la te d in a private
room.
Comfort o f th e P a tie n t.
The p atien t should be kept in bed during any e le ­
vation o f temperature, and for twenty-four hours a fte r the temperature has re­
turned to normal.
him contented.
As he i s not very i l l , playthings should be provided to keep
Care should be taken to prevent the patient from scratching the
le s io n s , as secondary in fe c tio n may r e s u lt .
short.
The fin g e r -n a ils should be kept
I f necessary, s p lin ts may be applied to the arms and stockings used to
cover the hands.
Care should be taken to avoid c h illin g .
Special care should
be exercised in combing the hair, as le sio n s usually are found in the scalp.
Personal Hygiene;
Care o f the Skin.
A warm bath should be given d a ily ,
care being taken to pat rather than rub the skin dry, to avoid loosen in g the
scabs.
Ammoniated mercury ointment may be applied to open le s io n s .
baths w ith a 2 per cent sodium bicarbonate solu tion are sooth in g.
Sponge
The itching
may be r e lie v e d by applying cslamine lo tio n with phenol; carbolated vaselin e
also may be used.
The le sio n s should be covered with an ointm ent, as t h is helps
to keep the scabs adherent.
B oils are treated su r g ic a lly .
Care o f th e Mucous Membranes.
I f lesio n s appear on th e conjunctiva or in
the mouth, warm b o ric acid ir r ig a tio n s w ill r e lie v e the ir r it a t io n .
D ie t.
A regular d iet usually i s ordered, care being taken t o preserve the
alk a lin e balance.
D is in fe c tio n :
F lu id s, e s p e c ia lly fr u it ju ic e s , should be offered frequently.
Concurrent.
should be properly cared fo r .
A r tic le s so ile d by discharges from le sio n s
84
Terminal.
The p atien t should be given a tub bath, shampoo, and clea n
clo th in g , then removed to a clean u n it.
The unit used during the illn e s s
should be thoroughly cleaned and a ired .
E ssen tia l Points to Remember:
1.
Chickenpox usually i s not a serious d ise a se .
2.
Scratching a le sio n may cause serious in fe c tio n .
3.
Scratched scabs are lik e ly to leave scars.
Home Care
Nursing In stru ctio n s.
Keep the ch ild from scratching the le s io n s , as
in fe c tio n s may r e s u lt .
Bathe the child d a ily , using a warm 2 per cent so lu tio n
of sodium bicarbonate.
Apply va selin e a fte r cru sts are formed, to soften the
cru sts and to f a c i l i t a t e th e ir dropping o f f .
Community P rotection
In v e stig a tio n .
In v estig a tio n is important because of p ossible confusion
with smallpox, e s p e c ia lly in persons over f if t e e n years of age.
For t h is
reason, the American Public Health A ssociation recommends that cases thought
to be chickenpox in those over f if t e e n be in v estig a ted , to elim inate the p o ssi­
b i l i t y of smallpox.
85
Selected References
Bower, A lbert, and P ila n t, Editft, Conmunlcable D iseases for Nurses.
E d itio n . Philadelphia: W. B. Saunders Company, 1939. P. 550.
Bullowa, J . C. M. and Wishik, S. M., Complications of V a r ic e lla .
Journal o f D iseases of Children, XLIX (A pril, 1935), p . 923.
4th
American
Laidlaw, F. W., Smallpox snd Chickenpox - The D iffe r e n tia l D iagnosis.
York S ta te Journal o f Medicine, XXVTII (A pril, 1928), p. 310.
New
Shuman, H. H ., V aricella in the Newborn. American Journal of D iseases of
C hildren, LVIII (A pril, 1939), p. 564.
Stimson, P h ilip M., Common Contagious D isea ses.
Lea and Febiger, 1940. P. 466.
3rd E d itio n , Philadelphia:
C H A PT E R
X
SMALLPOX
D e f in itio n * Smallpox i s an a c u te , h ig h ly tra n sm issib le d isea se, ch a ra c ­
t e r iz e d by sudden onset and severe c o n s t i t u t i o n a l symptoms, and by a macular
erup tion which appears about the t h i r d day of th e d isease, and which passes
through the stages of papule, v e s i c l e , p u s tu le , and c r u s t .
Hist o r y .
Smallpox i s a very old d ise a se .
e a r ly as 1200 B.C.
Synonym;
V ario la.
I t was prevalent in China as
The f i r s t a c c u ra te d e s c rip tio n of th e disease was made by
Hhazes, the famous Arabian p h y s ic ia n , in the te n th century.
The o ld e st Japanese
medical book (982 A.D.) records t h e ex isten c e of is o la tio n houses f o r smallpox
p a tie n ts.
Epidemics of smallpox swept over Europe fo r c e n tu r ie s , decimating
the population.
P r a c t ic a l l y everyone was a f f e c t e d .
The disease reached England
in the th ir te e n th century and f o r fiv e hundred years was a r e a l scourge.
I t was
brought to Mexico by the Spaniards in the s ix te e n th century, and in a few years
caused over 3,000,000 d e a th s .
I t was hig hly d e stru c tiv e to the American Indians.
Thousands of cases of smallpox occurred in the United S tates annually u n t i l
1934, when in ten siv e educational campaigns re s u lte d in the vaccination of most
c h ild re n .
In seven s t a t e s , a l l west of the M ississip p i River, compulsory vac­
c in a tio n i s opposed by the p o p u la tio n .
Three of these s ta t e s a c tu a lly p ro h ib it
v accin atio n by s ta t u to r y regulation."*"
The occurrence of smallpox in a c i v il i z e d
1.
M etropolitan Life Insurance Company. S t a t i s t i c a l B u lle tin , XIX* New ..York: ,
Mptrppolitan Life Insurance Company, May, 1938, p. 3.
(86)
87
country i s a n ational disgrace as of a l l the communicable d iseases i t is the
most completely preventable by public h ealth measures.
Prevalence.
In 1938 the la rg est number o f smallpox cases was reported
in th e United S tates and India, 15,011 of them occurring tflethe United S ta te s.
This d isease i s most prevalent in the w inter months.
E tio lo g y .
A f ilt e r a b le virus i s b eliev ed to be the cause of the d isea se.
The Paul reaction t e s t , which is made by rubbing the m aterial from a v e s ic le or
pustule on the sc a r ifie d cornea of a rab b it, i s used fo r the diagnosis of sm all­
pox.
I f smallpox i s present, the h is to lo g ic a l examination of the le sio n may
reveal G uarnieri's b od ies, discovered in 1892.
The complement fix a tio n t e s t
devised by Parker and Muckenfuss may prove to be valuable in diagnosis in the
ea rly stages of the d ise a se .
Source of In fe c tio n .
The lesion s of the skin and the mucous membranes of
in fected persons harbor the v ir u s.
Mode of Transmission.
Smallpox is transm itted d ir e c tly by contact with an
in fected person, or in d ir e c tly by contact with a r t ic le s s o ile d with body d is ­
charges.
F lie s or animals also may spread the d isease in d ir e c tly .
S u s c e p tib ility .
Pathology.
A ll ages and a l l races are su scep tib le to the d isease.
The le sio n s of the skin and mucous membrane show degeneration
of th e upper layers of the skin, with i n i t i a l edema;
la tio n , and frequently u lceration occur.
la te r , v esic u la tio n , pustu-
Changes in the bone marrow usually are
present, and the liv e r , kidney, spleen, and lymph nodes show evidence of sw ellin g .
Incubation Period.
The incubation pe riod is from eigh t to sixteen days,
although longer or shorter periods have been reported.
period may be headache and general m alaise.
The symptoms during th is
S MALLP OX
A d m itte d .
Name...
M ale
-A ge
Month.
Ji„
Case No..
A p r il
D a y o f M onth.
11
10
12
14
13
15
A
D a y o f Illn ess.
H our of D a y .
R e s p . PU L S i T
170
tem p.
em p.
108 °
42°
160
107 ° _
150
106° _
140
105 ° _
130
104 ° _
120
103 °
110
102°_
100
101° _
90
100 °
41‘
.40°
39c
■ fa8 °
80
99° _
70
98 ° _
60
97
50
96°
37°
36°
: .y \
70
60
40
95 °
Lo
s: .<
m
P X i t a.
a
ir a de y
ir t . i o;r
' b £] &
,x<’
T ’Jt Snfl ISt h
cla
lilll
:<i ;
50
40
30
20
F ig . 4 .
Temperature chart of a smallpox p a tie n t.
(See page 88.)
(S m a llp o x
-
c o n tin u e d )
A d m itte d
___________________ __ ________ ________
Name______________
Age........ ........... 3 ...»__________ Case No...
M onth.
D a y o f M onth.
April
17
18
D a y o f Illn ess.
19
10
20
11
21
12
13
23
14
H o u r o f D a y.
R esp. P
ulse
170
TEM P.
TEM P.
108° _
42°
160
107° _
150
106 ° _
140
105° _
130
104° _
120
103° _
110
102 °
100
101° _
90
100°
41'
.40°
39°
38°
t
80
70
70
98°
60
97°
50
96°
40
95 °
36°
V ii s'il 32! d;?
60
50
40
30
20
37°
13t
3.4 d3i
3r:r
88
Course of the D isease: Period of Invasion.
The onset of smallpox i s
abrupt and severe, with backache, sudden elevation of temperature, and vom iting.
The p atien t u su ally complains o f severe backache.
O ccasionally a rash resem­
b lin g sc a r le t fever appears on the ex trem ities and the abdomen.
Period of Eruption.
On the th ird or fourth day a macular rash appears on
the fa c e , forearms, and w r is ts , and spreads rapidly over the en tire boc^y.
In
a short time the rash becomes papular, and when touched f e e ls lik e p ieces of
sh o t.
The patient a t t h is time f e e l s b etter and the temperature drops.
In
three or four days the papules change to v e s ic le s , which a t f i r s t resemble
b lis t e r s ; then umbilicate and change to p u stu les.
and form brown or yellow c r u s ts .
The pustules la te r coalesce
The le s io n s are more numerous on th e exposed
parts o f the body, face,and e x tr em ities, than on the trunk.
The temperature, which is se p tic in character, r is e s with the onset of the
pustular sta g e.
The face i s sw ollen.
The le s io n s appear in the mouth and th roat,
and a c h a r a c te r istic musty odor is p resen t.
The le sio n s are p ainful during the
pustular stage; during the crusting stage the itching is annoying.
The duration of the d isease u su ally is s ix to eigh t weeks,the acute stage
la s t in g about three weeks.
ca st o f f .
I t takes from four to fiv e weeks for the cru sts to
P its often seen on the face resu lt from deep le s io n s .
Crusts on the
s o le s of the fe e t may adhere a long tim e.
Convalescence.
Convalescence in uncomplicated cases i s uneventful;
itc h ­
ing may continue to be troublesome.
Types of the D isease.
There are fo u r recognized types of smallpox:
(1) d isc r e te , sometimas termed "alastrim ," characterized by mild symptoms, which
appears in unvaccinated persons;
toms and exten sive eruption;
(2) confluen t, characterized by severe symp­
(3) v a r io lo id , which i s a f a ir ly mild form appearing
69
in persons vaccinated years before the attack ;
(4) hemmorrhagic, character­
ised by hemorrhagic rash and b leed in g from a l l mucous membranes.
Complications and Sequelae.
The com plications of smallpox may include
c o n ju n c tiv itis , in fectio n s of the sk in , broncho-pneumonia, septicem ia, and
o cca sio n a lly psychoses.
Period o f Communieability.
The d isea se i s communicable from the appear­
ance of the f i r s t symptoms to th e disappearance of a l l scabs and c r u sts.
Prognosis* The prognosis in mild cases i s very good, but poor in severe
cases among in fan ts and small ch ild ren .
M ortality.
The m ortality rate is from 10 to 20 per cent of the c a s e s, but
v a r ie s with epidemics and l o c a l i t i e s .
The rate in young children, aged persons,
and prim itive peoples is high.
Treatment.
There is no s p e c if ic treatment fo r smallpox.
the eruptive stage are comforting.
The ap p lica tio n of calamine lo tio n with
phenol or of boric acid ointment w i l l r e lie v e itc h in g .
r e lie v e backache.
has been used.
Wam baths during
Heat may be applied to
Iodine applied to th e le sio n s may be ordered.
Sulfanilam ide
Other treatment is symptomatic.
Methods o f Control:
R ecognition and Reporting.
The disease is recognized
by the c lin ic a l picture and should be reported immediately to the health o f f ic e r .
H isto lo g ic a l examination o f the pock may confirm th e diagnosis.
I so la tio n .
The patient should be iso la te d in a hosp ital in a screened
room u n til the period of i n f e c t iv it y is p ast.
I f h o sp ita liza tio n is not p o ssib le ,
he should be iso la te d in a room in h is home.
Quarantine.
A ll persons who have had contact with the patient should be
iso la te d u n til vaccinated with viru s of f u l l potency.
Daily observation of the
contacts should be made u n til the h eigh t of the reaction is past, i f vaccination
90
was performed within, twenty-four hours of the f i r s t exposure; otherwise, for
six te e n days from the la st exposure.^
Education.
Enlightenment of the public and a determined e ffo r t to apply
th e recognized preventive measures against anallpox in the western s ta te s would
erad icate th e d isea se from that sectio n of th e country as has been done in the
e a s t.
Nursing Care
I s o la tio n .
The smallpox patient should be cared fo r in a private room.
V is ito r s must be excluded.
m ission of the d is e a s e .
Special precautions are necessary to prevent trans­
The disease is rep u lsive and d if f ic u lt to manage.
Paper handkerchiefs containing nose and throat secretio n s or cru sts should be
dropped into a paper bag at th e p a tie n t's bedside.
This bag should be dropped
in to a larger bag held by a "clean" nurse before being removed from the room.
The p illo w case containing the so iled bed cloth in g should be dropped into a
clean pillow case held by a "clean" nurse.
As a means o f preventing spread of tie in fe c tio n , the u te n sils used for
clean in g the p a tie n t's room should be kept sep arate.
A wet mop is used to
prevent the accumulation of scales on the flo o r in severe ca ses, and a cloth
saturated w ith a 2 per cent phenol solu tion should be used to thoroughly wipe
o f f the outside o f any a r tic le s before carrying them from the room.
The room
should be w ell screened to prevent the spread o f in fe c tio n through f l i e s ; i t
should be w ell v e n tila te d and kept at a temperature of 68° F.
The nurse should
wear a clo se p rotectin g cap over her h a ir.
1.
Public Health Reports, L* Washington, D.C,.: .Unit.ed S ta tes Government P rinting O ffice, August §, 1935, p. 35.
91
Nurses who care fo r p a tien ts with smallpox should be vaccinated, even
though known to be immune.
Personal Hygiene:
given d a ily .
itch in g .
Care o f the Skin.
A warm cleansing bath should be
Sodium bicarbonate solu tion or calamine lo tio n a lle v ia te s the
Potassium permanganate packs may be ordered to r e lie v e the itching
and reduce th e odor ch a ra cteristic of th i3 d isea se.
ordered by the ph ysician .
An ointment is frequently
Scratching should be prevented in order to avoid
extension and secondary in fe c tio n of the le s io n s .
Air m attresses and cradles
over the painful parts w i l l add to the p a tien t’ s comfort.
Care of the Mouth.
mouth
S pecial a tten tio n should be given to the care of the
before and a fte r nourishment.
Potassium chlorate mouthwash is frequently
ordered when the le s io n s appear on the mucous membrane.
Hot throat irrig a tio n s
are soothing.
Care of the Eyes.
The eyes are frequently inflamed and sw ollen .
be protected from d ir e c t lig h t .
Warm boric acid ir r ig a tio n s should be given fr e ­
quently, and o i l applied to the l i d s .
D ie t.
d a ily .
They should
Compresses may be ordered.
F luids should be offered frequently, t o ta llin g a t le a s t 4,000 cc.
A bland nourishing d ie t is indicated.
Lesions in the pharynx may cause
painful swallowing, and patience on the part of the nurse is required to persuade
the patient to take s u ffic ie n t nourishment. During convalescence, the d iet should
be directed toward combatting the secondaiy anemia.
Com plications;
C o n ju n ctiv itis.
and may r e su lt in lo ss o f s ig h t.
Lesions in the eyes cause co n ju n c tiv itis
S p ecific treatment w i l l be ordered by the
physician.
In fection s of the Skin.
c e l l u l i t i s and gangrene.
the physician.
These include fu ru n cles, a b scesses, and occasionally
Nursing procedures in these conditions are ordered by
92
Septicem ia.
In severe cases general sep sis is frequently p resen t.
The
nurse should watch for symptoms in d icative o f th is con d ition .
Psychoses.
The nurse should immediately report symptoms of th is condition
to th e physician.
Broncho-pneumonia.
(For nursing care, see page 72.)
Care in Convalescence.
Convalescence is usually uneventful.
Calamine
lo tio n with phenol may be applied to the skin i f the itch in g remains trouble­
some .
D isin fe c tio n :
Concurrent.
A ll discharges must be d isin fe c te d or burned.
No a r tic le should leave the p a tie n t’s room without f i r s t being b oiled or d is in ­
fe cted .
S p ecial a tte n tio n should be given to the lin en .
Terminal.
A cleansing bath and shampoo should be given to the p a tien t.
The m attresses and p illow s should be aired , dried, and sunned f o r twelve hours,
or s te r iliz e d in an au toclave.
The unit should be washed with soap and water,
sunned and aired fo r tw enty-four hours.
In the home, chlorinated lime or ly s o l
may be added to the water used in cleaning the room.
E ssential Points to Remember:
1.
Smallpox is communicable u n til the la s t pock has disappeared and the skin
has healed.
2.
The danger of transm itting the d isease through a r t ic le s so ile d by d is ­
charges is greater than in any other d isease.
3.
The same precautions should be observed for a mild as fo r a severe case.
4.
Protection is given to a person who has been vaccinated as soon a s there
is a "take."
V accination, even as long as four days a fte r exposure, may
prevent th e d ise a s e .
93
5.
Vaccine virus should be stored a t a temperature below 40
s t a b ilit y is not high.
o
F ., as i t s
The date o f expiration (which i s stamped on the
la b e l) should be ca refu lly noted.
Home Care
Nursing In stru ctio n s.
The p a tien t should be kept in bed, and a l l in stru c­
tio n s concerning th is in fe c tio n c a r e fu lly observed.
No one except the doctor
and the nurse should be allowed to en ter the room.
Community P rotection
A ll in fa n ts should be vaccinated and a l l children entering school should
be re-vaccinated.
A ll persons should be vaccinated once in every fiv e to ten
years, or whenever exposure is suspected.
Vaccination against Smallpox
D e fin itio n .
Vaccination is the introduction of vaccine virus in to the skin,
with the object of producing cowpox (vaccina) in order to prevent smallpox.
H isto ry .
Inoculation for smallpox was introduced into England in 1718 by
Lady Mary Wortley Montagu^, the w ife of the B r itish Ambassador to Turkey.
The
Turks, lik e the Chinese, induced immunization against smallpox by inoculating
the skin of su scep tib le persons with m aterial obtained from the pustule of a
smallpox p a tie n t.
This would u su ally cause a mild attack of the disease in the
inoculated person.
However, i f a su scep tib le person came in contact with t h is
in d iv id u a l, he might develop a severe a tta ck .
94
The introduction o f vaccination by Edward Jenner, an English physician,
i s a landmark in medical h isto ry .
Jenner noticed that dairy maids frequently
got pustules on th e ir hands from scratches that became in fected from the udders
o f cows with cowpox.
These individuals never contracted smallpox.
He secured
some m aterial from the pustules o f a dairy maid who had cowpox and inoculated
a c h ild , obtaining a vaccination le s io n .
When the le s io n healed, he inoculated
the ch ild with smallpox, and proved h is theory.
"vaccination" (vacca, cow),
o f th is d iscovery.
Jenner c a lle d th is method
fie received many honors and awards in recognition
England passed a law in 1851 making vaccin ation compulsory.
Jenner’s method of vaccination was f i r s t
used in America in 1800 by
Waterhouse, a Boston physician who inooulated h is own sons.
Thomas Jefferson
was in flu e n tia l in spreading the doctrine of vaccination in the United S ta te s.
C h aracteristics of the V irus.
The rela tio n sh ip of cowpox (a d isease of
cattle)an d smallpox (a d isease of man) is not c lea rly understood.
A uthorities
claim, however, that smallpox i s converted in to cowpox by passage through the
tis s u e s o f c a t t l e . ’*'
Preparation o f Vaccine T lru s.
The abdomen of a healthy young h eife r is
shaved, s t e r iliz e d , and a s e r ie s of p a ra llel scratches made, into which the "seed
virus" is rubbed.
A fter four days the area i s covered with a cowpox eruption.
This m aterial i s removed and preserved in 50 per cent glycerin e containing 1 per
cent carbolic a cid .
At the end o f one month, a reduction in i t s b a cte r ia l count
i s brought about by the carbolized
g ly cerin e, and i t is ready fo r u se.
autopsy i s performed on the c a lf to assure freedom from the d ise a se .
c a lf i s d iseased , the vaccine i s discarded.
1.
An
I f the
The vaccine is tested for anaerobic
W. H. Park and A. W. W illiams, Pathogenic Microorganisms, p. 724.
95
organisms such as tetanus b a c i l l i before i t is sealed in ca p illa ry tubes and
released from the laboratory.
As calves are immune to s y p h ilis , t h is d isease
cannot be contracted through vaccin ation today, as was the case when m aterial
from human smallpox p u stu les was used to vaccinate another in d iv id u a l.
Recently, chicken embryo has been employed in making smallpox vaccine, and
th is viru s is in je c ted in to the sk in .
D irections fo r the care o f the v ia ls of viru s issued by the New York City
Bureau of Laboratories are as fo llow s:
v ir u s.
’’This product i s a suspension of liv in g
To keep the viru s a liv e and potent, i t is ab solu tely necessary th at i t
be stored cold , below 41
Procedure.
o
F .”
1
Vaccination i s performed on the arm over the in se r tio n of the
l e f t d elto id muscle.
Leg vaccinations are objectionable as they are exposed to
moisture and str e e t d u st, and frequently resu lt in la rg e, slow ly healing u lcer­
a tio n s.
The s i t e of the vaccination is cleaned with soap and water, sponged with
acetone or a lco h o l, and thoroughly d ried .
I f scratching i s employed, a sin g le
scratch one-eighth inch long is made with a s te r ile needle a fte r which the virus
is applied and rubbed in with the side of the needle; or the scratch i s made
through the vaccine already applied to the sk in .
to dry.
The vaccine is then allowed
The s i t e of the vaccin ation should be kept cool and dry so a s to permit
rapid fonnation o f a cru st.
never be used.
No dressing should be applied, and sh ie ld s should
The stim u latin g action which the development of the vaccinal
y e s ic l’e tends to exert on b acteria which are present on the skin needs to be
combatted by the natural drying and aerating process which goes on in the
1.
Bureau of L aboratories, Department of Health, City of New York* 1940.
96
uncovered sk in .
I f necessary to prevent s o ilin g of the clo th in g , clean gauze
or lin en may be attached to the sle e v e , not to the skin.
I f no reaction to smallpox vaccination appears, the person should be re­
vaccinated as probably the vaccine was not p oten t, or the technic was not
co rrect.
Course of Eruption of Vaccination:
F ir s t Vaccination (primary "take**).
A fter three to f iv e days a papule appears which develops into a v e sic le ;
is follow ed by a pustule which d r ie s , c r u s ts , and rap id ly h e a ls.
m alaise may be present about the seventh day.
run3 about three weeks.
th is
Symptoms of
The course of the vaccination
At the end of th is time the crust f a l l s o f f , exposing
a c le a r , reddish scar which becomes i/foite and p itte d .
Second Vaccination (modified "take").
ty p es, accelerated and immune.
Secondary vaccin ation i s of two
In th e former a papule appears on the third or
fourth day; on the six th day v esic u la tio n takes place and the process then sub­
s id e s .
In the inrmufifl reaction the papule appears in about two days and disap­
pears without a v e s ic le .
Recording the Vaccination.
I t i s always advisable to keep a record of the
name of the manufacturer of the vaccin e, the lo t number, and expiration date
found on the package.
Vaccination c e r t if ic a t e s should be accurately kept,
showing the d ate, the nature of the "take," and the name of the physician.
Complications of Vaccination:
Autovaccination.
A fter scratching the
vaccin ation , a ch ild may scratch another part of the body.
Autovaccinations
are o cca sio n a lly seen on the li p s , arms, and cheeks.
Secondary In fe ctio n .
The pustule may become in fected by a secondary in ­
vader, as the staphylococcus, and the reaction may become e x ten siv e.
E n cep h a litis.
Cases of en cep h alitis have been reported following vaccina­
tio n , but they are rare.
97
S elected References
Cones, w. P ., Washington’ s Campaign Against Smallpox in the Continental
Army. Northeastern Journal of Medicine, CCII (June 26, 1930), p. 1254.
Jordan, C. F ., Story o f Smallpox.
1938), pp. 4-19.
Iowa Public Health B u lle tin , LII (A p ril,
Leake, J. P ., Questions and Answers on Smallpox and V accination. Public
Health R eports, Reprint No. 1137 (Revised 1939). Washington, D.C.:
United S ta tes Government P rin tin g O ffice, 1939.
Manual of Communicable D iseases fo r Public Health Nurses.
York S tate Department o f H ealth, 1939.
Albany:
New
McCammon, W. 0 ., Sulfanilam ide in Treatment of Smallpox. Journal of the
American Medical A sso cia tio n , CXII (May 13, 1939), pp. 1936-37.
Park, William H ., and W illiam s, Anna W., Pathogenic Microorganisms.
E dition. P h ilad elp h ia: Lea and Febiger, 1939. P. 1056.
Schamberg, F. J . , and Kolmer, J . Ao, Acute In fectiou s D iseases.
Philadelphia: Lea and Febiger, 1928. P. v i i + 888.
11th
2nd E d ition.
CHAPTER XI
SCARLET FEVER
D e fin itio n .
S ca rlet fev er i s an a c u te , communicable d isease character­
ized by sudden onset o f fe v e r , sore th ro a t, vom iting, and by the appearance,
u su a lly on the second day, o f a punctate erythematous rash over the body and
ex trem itie s, followed by c h a r a c te r istic desquamation.
H istory.
Synonym: S ca rla tin a .
Although there i s reason to b eliev e th at sc a r le t fev er pre­
v a ile d in Europe fo r c e n tu r ie s, the d isea se was f i r s t c lea rly described by
Thomas Sydenham in 1675, when, as " feb ris sca rla tin a ," he d iffer e n tia te d i t
from other rashes.
Prevalence.
The d istr ib u tio n of th e d isease i s world-wide, but th e in ­
cidence in th e tro p ics i s low.
ters.
I t i s more common in urban than in ru ra l cen­
In c i t i e s , approximately Soper cent o f the cases occur in children under
te n , and 60 per cant in those under four years of age.
The disease is most
common in the winter and spring months.
S ca rlet fever appears every few years in epidemics o f greater or l e s s
s e v e r ity .
S ix ty years ago i t was the most dreaded of the common communicable
d ise a se s in England.
During the la s t twaaty years i t has become a much m ilder
d isea se in Great B r ita in , Soandanavia, France, Germany, and the United s t a t e s .
Since the viru len ce of in fe c tio u s d isea ses tr a v e ls in c y c le s , th e pres A t may
be a period o f low v iru len ce.
the public fo r many yea rs.
I so la tio n in h o sp ita ls and homes has protected
On th e other hand, m ilder oases, many o f which
are never recognized, spread a mild type of the d ise a se .
(98)
99
E tio lo g y .
The cause o f the d isease i s probably a hem olytic streptooocous
known a s the streptococcus sc a r la tin a s.
The b e lie f th a t t h is organism i s the
cause o f s c a r le t fewer i s due to the experiments of Drs . George and Gladys
Dick o f Chicago, in 1924.
They produced the d isea se in human su b jects by
swabbing th e ir th roats w ith a pure culture o f streptococcus hemolytious ob­
tained from a s c a r le t fewer p a tie n t.
These physicians were the f i r s t to s a t­
i s f y Koch's p o stu la tes by prowlng that a s p e c ific strep tococcu s hamolyticus
was the cause o f s c a r le t few er,
lfce streptococcus o f s c a r le t fewer i s iden­
t i c a l w ith other hem olytic strep tococci in morphologioal p ro p erties.
chocolate agar i s used as
When
culture m ed ia,its co lo n ies can e a s ily be d if f e r ­
en tia ted from those o f the streptococci of ery sip ela s and streptoooocus sore
th ro a t.
The theory adwanoed by Caxonia and others i s th a t the cause of the
d isea se i s a f ilt e r a b le w irus.
This theory has not been gen era lly accepted
in the United S ta te s .
Sources of In fe c tio n .
Discharges from the n ose, th ro a t, e a r s, ab scesses,
or wounds o f in fe c te d or eonwalescent p atien ts harbor the organisms
Carriers
a lso may be a source o f in fe c tio n .
Mode o f Transmission,
s c a r le t fewer i s transm itted by d ir e c t contact
with the in fe c te d person, by a r t ic le s fresh ly s o ile d w ith discharges of an
in fected person, and through contaminated m ilk or m ilk products.
Instances
have been reported o f to y s, books, and clothing carrying the d ise a s e .
r ie r s may transm it the d ise a s e .
Car­
Formerly the desquamation was bellowed to
be in fe c tio u s , but a u th o r itie s hawe disprowed th is theory.
S u s o e p tib lllty .
S u sc e p tib ility varies g r e a tly .
In fa n ts u su ally hawe
an in h erited immunity vfcioh la s t s eight months or more.
A fter the f i r s t year
of l i f e s u s c e p t ib ilit y r is e s and reaches i t s height a t the six th year,
gradu­
100
a lly decreasing to adult l i f e .
under ten years o f age.
Approximately 75 per cent of a l l cases occur
One attack of sc a r le t fever u sually produces l i f e ­
long immunity, although second attack s do occur.
urban cen ters, are immune.
Most a d u lts, e s p e c ia lly in
This immunity may be due to repeated s lig h t ex­
posure to the organisms causing the d isea se.
Pathology.
The outstanding p ath ological feature is the hyperemia of the
skin with p etech ial hemorrhages.
swollen and enlarged.
The lymph nodes, e sp e c ia lly o f the neck, are
The blood shows a d e fin ite leu co cy to sis during the f i r s t
stage o f the d isease; la te r , there may be a s lig h t e o sin o p h ilia .
Incubation Period.
The incubation period of sca rlet fever i s from two
to seven days, usu ally two to fo u r.
Course of the D isease:
Period of Invasion.
The onset u su ally is sudden,
and is characterized by fev e r, sore th roat, and vom iting.
symptoms are preceded by headache and m alaise.
O ccasionally th ese
In very young children the on­
s e t may be accompanied by convulsions.
The fev er r is e s rapidly to an average height of 102
o
o
- 104 F.
It f a lls
to normal w ithin three to seven days, depending upon th e severity of the d is ­
ease and the treatm ent.
The pulse is very rapid.
The throat usually i s d i f ­
fu sely red and, in severe c a se s, exudate may be present on the t o n s ils .
Vom­
itin g i s a very common symptom, and u su ally occurs during the f i r s t twelve
hours.
I f the cheeks are flu sh ed , circumoral p a llo r i s marked.
The tongue
i s th ic k ly coated.
Period o f Eruption.
From tw elve to twenty-four hours a fte r the onset o f
fever the rash appears on the neck and c h e st, spreading over the e n tir e body
in ten to tw enty-four hours.
The exanthem i s a d iffu s e , red erythema, with
superimposed punctate spots o f a deeper red co lo r .
Numerous tin y papules
101
are d istrib u ted uniformly over th e body, giv in g th e appearance of g o o se -fle sh .
The eruption fades on pressure exoept when hypo rplgmante d .
Hyperpigmentation
i s apt to ooeur in the fo ld s o f th e sk in , p a rtic u la rly a t th e elbow, giving
r is e to the appearance o f transverse lin e s (F a s tia 's s ig n ), which are q u ite
c h a r a c te r is tic .
When an area o f marked eruption i s stroked with a tongue
depressor, blanching (dermographia) i s seen in most ca ses.
A d ia g n o stic measure freq u ently employed i s th e Schultz-Cbarlton phenom­
enon, whioh c o n sists in the in je c tio n intracutaneously of convalescents' Scar­
l e t fev e r serum or d ilu ted s c a r la tin a l a n tito x in where the eruption i s marked,
u su a lly the abdomen.
Blanching a t the s i t e o f in je c tio n w i l l occur w ith in
e i& t to tw elve hours.
A p o sitiv e rea ctio n can rarely be obtained a fte r the
fourth day o f the rash.
The enanthem is seen on th e nruoous membrane o f the
p a la te .
The tongue in th e ea r ly stages becomes red at the edges, and enlarged
red p a p illa e protrude through the white coatin g.
strawberry tongue" which freq u en tly i s seen .
This i s the ty p ica l "white
Within two days the furring d is ­
appears, leaving a red tongue w ith elevated p a p illa e , which resembles a red
strawberry.
The oircumoral p a llo r p e r s is t s throughout the en tire eruptive
sta g e.
Period o f Desquamation.
A general desquamation, u su a lly beginning the
second week o f the d isea se, fo llo w s the exanthem, and i s not completed u n til
the fourth or f i f t h week.
This may be confined to a few fin e branny fla k e s
between the fin g ers and a t th e fin g er tip s along the n a il edges.
I t may ap­
pear in large patches o f fla k e s from the e n tir e body, and there any be th ic k
e a s ts from the hands and f e e t .
i s a c h a r a c te r istic featu re.
Desquamation o f the Skin o f the fin g er t ip s
102
Period o f Convalescence.
Convalescence Is u su a lly uneventful u n less
com plications occur as the r esu lt of secondary I n fe c tio n s.
R elapses may occur from three to s ix weeks a f t e r th e onset of the o r i­
g in a l attack In 1 to 5 per cent of the o a ses.
These a tta ck s may he due to
a new in fe o tio n .
Types o f the D isease:
Mild form.
The m ild type o f s c a r le t ferar i s
characterised by s lig h t i l l n e s s and a s i i g i t l y elevated temperature.
The
rash may be so f a in t , appearing on the chest only a few hours, that i t may
be m issed e n t ir e ly .
Typical desquamation, which fo llo w s some tims la t e r ,
I d e n tifie s the co n d itio n .
This type i s dangerous in th a t i t i s often over­
looked , thus i t spreads the d isease to oth ers.
A lso , th ese mild o a ses may
develop com plications from exposure.
S ep tic form.
In t h is type a l l symptoms are severe from th e o n se t.
The
lymph glands in the neck are enlarged and tender; the n a sa l discharge i s pro­
fu s e .
Albumin, c a s t s , and red blood oorpuseles are found in th e u rin e.
fever is very h igh .
Toxic form.
The
This form carries a high m o rta lity .
The onset of toxie sc a r le t fe v e r i s extrem ely sev ere, with
marked nervous symptoms.
The rash i s very heavy and sometimes hemorrhagic.
Death may occur in two to seven days.
Surgical form.
The focus o f in fectio n i s u su ally in operative wounds,
b u m s, and in th e puerperal u teru s.
The to x ic m an ifestation s o f sc a r le t fe v e r ,
which are fe v e r , vom iting, and a ty p ica l exanthem, may be p resen t.
This type
i s unusual.
Complications and Sequelae:
Septic Com plications.
s c a r le t fe v er may be c la s s if ie d as sep tic and t o x ic .
The com plications of
In s e p tic com plications
108
the organisms may circ u la te in the body, lodging in various parts and caus­
ing lo c a l in fe c tio n s, such a s c e r v ic a l a d e n itis , o t i t i s aed la, and sep ticem ia.
Toxic Complications.
These are l e s s freq u en tly observed, and Include
n e p h r itis , a r t h r itis , and degenerative changes in tha h eart.
The la tt e r may
occur as sequelae.
Serum sickness follow in g th e ad m inistration of sera i s a to x ic m anifesta­
t io n .
Period of Corcraunicability.
This period u su ally i s considered to be three
weeks from the onset of the d ise a s e , or u n t il a l l abnormal discharges have
ceased and a l l opea sores or wounds have h ealed .
Prognosis,
ttie prognosis depends upon the s e v e r ity o f the epidemic and
the type of the d isea se, the presence o f com plications, the proper adm inis­
tr a tio n o f s p e c ific treatm ent, and th e care which the p atien t rec e iv e s.
M ortality.
The m o rta lity v a ries in d iffe r e n t epidemics, averaging from
10 to SO per cent.
In in fa n ts and young child ren the m ortality i s high and
ranges from 25 to 30 per cen t.
Prophylaxis;
The Dick T est.
I t i s p o ssib le t o determine s u s c e p tib ility
to s c a r le t fev er by employing the Dick T e s t.
The t e s t i s made by the in je c tio n
intxacutaneously of 0 .1 e e . o f te ste d s c a r le t fe v e r toxin on the fle x o r surface
of th e forearm.
This represents one skin t e s t d ose.
In a suaoeptible in d iv id ­
ual a fa in t red usually appears a t the s i t e of in je c tio n in six to tw elve hours,
and a d is tin c t reaction i s evident in eigh teen hours.
To be considered p o s it iv e ,
the 8kin should be s lig h t ly Indurated, and the area of redness Should measure
1 - 3 cm. in diameter.
l e t fe v e r .
This in d ic a te s an absence of a n tito x ic immunity to scar­
At the Willard Parker H o sp ita l, a con trol t e s t con sistin g of 1 eo.
of heated sc a rla tin a l toxin i s used with the Dick Test.
104
A pseudo-reaction nay occur, due to a lo c a l hyperaensltiveness of the
c e l l s t o th e protein in the toxin d ilu tio n .
This pseudo-reaction, which i s
sore common in th e old er age group, cannot he d iffe r e n tia te d from the true
rea o tio n .
I f there i s doubt whether a reaction i s due to the toxin or to
the p r o te in , i t i s advisable to consider the reaotion a s p o s itiv e ,
A etive Immunization.
Temporary a c tiv e immunity i s produced by in jectio n s
o f a to x in prepared from sc a r le t fever s tr e p to c o c c i, th e dosage being expressed
in m u ltip les of the skin t e s t dose.
Five in je c tio n s u su a lly are given , the
In terv a l between doses varying from f iv e to seven days.
Some physicians rec­
ommand d ividing the dosage in to more than f i v e in je c tio n s , as th is seems to
reduce the discom fort.
A r e la tiv e ly rapid immunity develops w ithin two weeks
a fte r s ta r tin g the in je c tio n s .
The New York City Department of Health recom­
mends a c t iv e immunity as a general procedure during the preschool age.
The
s p e c ia l Committee on Prophylactic Procedures Against Communicable D iseases of
the American Academy o f P e d ia trics, a t i t s meeting in A p ril, 1935, reported:
"Active Immunization i s not recommended as a general h ealth procedure sin ce
rea ctio n s both lo c a l and general are frequent . . . and fo r the reason that
the degree and duration of the immunity have not been d e f in it e ly estab lish ed ," 1
Immunity may l a s t from one to two years.
The N ational I n s titu te of Health pre2
pared a toxoid fo r a c tiv e immunization, but t h is has not been w idely used.
P a ssiv e Immunity,
Human convalescents* serum, when a v a ila b le , has la rg ely
replaced s c a r le t fev er a n tito x in fo r immunizing co n ta cts.
P rotection is as e f ­
f e c t i v e , and anaphylaxis, serum rashes, and serum sick n ess are avoided.
The
1.
M. Cr« Peterman, immunization Against S carlet Fever,
D iseases o f Children. 1X7 (July, 1937), p. 89.
American Journal of
2,
Public Health Reports. XE7IXI. Veshihgt o h ,'li«Ci'i TMlted S ta tes Government
P rin tin g O ffic e, May 26, 1933, p . 549.
S C A fi L E T.
F E V E R
A d m itte d ..
..A*.....8_..yr:s .j
_Male_
Name...
...Case No..
M arch
M onth.
8
D a y o f M onth.
10
11
10
D a y o f Illness.
H ou r o f D a y.
RESP.
P
u lse
170
TEM P.
TEM P.
108° _
160
107° _
150
106 ° _
140
105 ° _
130
104° _
120
103° _
110
102 ° _
100
101 ° _
90
100° _
80
99 ° _
Goi a..£
v .h
3<* Till
42°
fctl
IPa,y
■41'
d
.40°
*
39°
#-
38°
&
• *
70
98 °
60
97
70
50
96 ° _
60
40
95 °
36°
50
40
30
37c
I
ini
20
F ig . 5 . Temperature chart of a scarlet fever patient a fte r the
in je c tio n o f convalescents' serum. (See page 105.)
106
dosage recommended i s 10 e c . for children under te n years of age and 20 cc.
fo r those over th is age.
S c a rla tin a l a n tito x in may produce p assive immunity la s tin g from one to
two weeks.
This method produces such a severe rea ctio n that physicians have
p r a c tic a lly abandoned i t .
Infants have congenital immunity la s tin g from s ix to twelve months i f
the mother is . immune.
Treatment.
Human convalescents * serum i s adm inistered intravenously
and produces ex c elle n t r e s u lts in moderately severe c a ses.
S ca r le t fe v e r a n tito x in i s administered immediately to to x ic p a tien ts.
I t am eliorates the course o f th e d ise a s e , and reduces the incidence of compli­
c a tio n s .
Serum reaction s re su ltin g from i t s use u su ally are sev ere, but with
a refin ed serum rea ctio n s are markedly reduced.
Sulfanilam ide is used in the treatment of s c a r le t fe v e r , e ffe c tiv e re­
s u lt s being reported by some a u th o r itie s, e s p e c ia lly in the treatment of com­
p lic a tio n s .
Methods of Control:
by the c l i n i c a l symptoms.
tic .
Recognition and Reporting. ScarletFever. is reoognized
Hie Schultz-Charlton t e s t , i f p o s itiv e , i s diagnos­
I t i s a reportable d isea se .
I s o la tio n .
A period of Iso la tio n Of twenty to th ir ty days has bean adopted
by h ealth a u th o r itie s in most communities.
In Mew York C ity , p atien ts are iso la te d twenty-one days from the onset of
the d ise a s e .
They are then released , provided th ere axe no com plications or
d isch arges.
P atien ts with a com plication are released a fte r th irty days, pro­
vided there are no discharges.
I f there i s a discharge from the nose, the ear,
or a gland, is o la tio n continues u n til the f o r t y - f i f t h day, when the patient may
be released i f oultures are n egative
tov hem olytic strep to co cci.
106
Quarantine.
Exposed su scep tib le in dividuals should be segregated for
seven days from exposure to a recognized ca se.
Immunization.
The house should be placarded.
A ctive immunity i s obtained by the use o f the to x in of
the streptococcus sc a r la tin a s.
Passive immunity i s obtained by the use of convalescents* sc a r le t fever
serum.
A ntitoxin i s not recommended fo r con tacts.
Nursing Care
Nurses caring fo r s c a r le t fever p a tien ts should be a c tiv e ly immunized
i f found su sc e p tib le .
I s o la tio n .
Medical a sep tic technic should be enforced.
The s c a r le t fever patient should be iso la te d fo r a peTiod
designated by the h ealth a u th o r itie s .
Comfort o f the P a tie n t.
Rest in bed (fo r children, about three weeks;
fo r a d u lts, two weeks) i s recommended.
The danger of allow ing p a tien ts to
become ambulatoxy too soon i s th a t convalescence may be delayed and compli­
cations may occur.
The temperature o f th e room should be maintained a t 68° - 70° F . , and
c h illin g of the p a tien t should be avoided.
Reduction o f Fever.
The fev er, which usu ally is high (101° - 103° F.
or h ig h er), may be reduced by tep id sponge baths.
Personal Hygienet
Care of the Skin.
A d a ily cleansing bath should
be given; sodium bicarbonate or magnesium sulphate added to the bath water
may a lle v ia te itc h in g .
O live o i l or cocoa bu tter applied to the skin con­
trib u tes to the p a tien t* s com fort, e s p e c ia lly during th e desquamation
period.
Alcohol should never be used during the eruptive sta g e, as i t i s
ir r ita tin g to the sk in .
107
Care o f the Nose, Mouth, and Throat.
P articu lar atten tion should be
given to the c lea n lin e ss o f th e n o se, mouth, and th roat, both f o r the com­
fo r t o f the patient and to avoid in fe c tio n of the surrounding area.
At th e onset of the d isea se when the throat i s very sore, ir r ig a tio n s
o f equal parts of sodium bicarbonate and sodium chloride (one teaspoon to a
quart o f water) may afford r e l i e f .
be used.
A 10 per cent glucose solu tion may a lso
The so lu tio n should be as hot as can be tolerated by the p atien t
(110° - 120° 7 .)
oomfort.
An ic e - o o lla r fasten ed snugly around the neck may afford
An a n tise p tic mouthwash should be used freq uently.
A so lu tio n o f
lemon ju ic e , g ly cerin e, and boric a c id , or a 50 per cent solu tion of hydrogen
peroxide w ill remove sord es.
A 5 per cent so lu tio n of sodium bicarbonate is
e ffe c tiv e in removing mucus from th e mouth.
Cold cream or mineral o i l should
be applied to the l i p s .
The nose should be clean sed frequ ently with cotton swabs, and mineral
o i l should be applied to th e mucous membrane.
Suction maybe ordered f o r a
profuse discharge.
Elim ination.
corded.
The urinary output should be accurately measured and r e ­
Specimens for u r in a ly s is are frequ ently ordered to determine kidney
fu n ction .
D ie t.
Laxatives and enemata are ordered when necessary.
The d ie t should c o n s is t of m ilk , f r u it ju ic e s, and water during
the height o f the d ise a s e .
Glucose should be added to the liq u id s to in ­
crease the carbohydrate metabolism.
I f liq u id s cannot be tolerated by th e
swollen th roat, n asal gavage u su a lly i s ordered.
A f u l l d ie t should be given
as soon as f e a s ib le , as con valescen ts improve more rapidly on a generous d ie t .
Whether or not a low protein d ie t i s given to the patient depends upon th e
d iscre tio n o f the ph ysician .
In order to avoid the occurrence of n e p h r itis ,
108
sens physicians exclude meat, eggs, and other proteins from th e d ie t
three weeks;
tax
other physicians f e e l d iffe r e n tly , and do not r e s t r ic t them
u n less n e p h r itis occurs.
An accurate account of the f lu id intake should be
kept.
Com plications:
O tit is Media.
The f i r s t sig n s o f o t i t i s media in older
children and a d u lts u su a lly are sudden elev a tio n of temperature and r e s t ­
le s s n e s s .
A myringotomy may be indicated, so th at pus may be evacuated.
The discharge should be constantly wiped away, a f t e r which the contaminated
swabs should be c a r e fu lly dropped into a paper bag attached to the bed or
ta b le .
The p a tien t should be encouraged to l i e on th e a ffe c te d s id e .
amount and character o f th e discharge Should be recorded.
The
The ch ild should
not contaminate h is hands w ith the discharge; therefore i t may be necessary
to apply s p lin t s to h is arms.
end th e arms massaged.
These should be removed tw ice during the day
V aseline or zinc oxide ointment should be applied to
the outer ear to prevent excoriation of the Skin.
Heat should never be ap­
p lied without the p h y sicia n 's order.
M a sto id itis.
O t it is media may lead t o m a sto id itis.
u su ally i s s u r g ic a l.
The treatment
The patient is very I r r ita b le and req uires S k ilfu l
nursing ca re.
Cervical A d e n itis.
A sudden r is e in temperature may in d ica te in volve­
ment o f the c e r v ic a l glands.
An lc e -o o lla r may be ordered.
s c e ss formation su r g ic a l Interference is necessary.
In case of ab­
The care o f the d ress­
ings i s extrem ely important, as the discharge i s h igh ly in fe c tio u s .
The
s o ile d d ressin g s should be wrapped and burned.
A r th r itis .
About th e beginning of the second week the j o in t s , espec­
i a l l y of the w r ists and hands, may become swollen and very p a in fu l.
This
109
condition may la s t from f iv e to seven d ays.
p lie d , and the jo in ts wrapped in o o tto n .
may have to be immobilized.
O il o f wintergrean may be ap­
O ccasionally the a ffected parts
The patient should be kept warm and q u ie t, and
care should be exercised in moving him.
N ep h ritis.
P a llo r , p u ffin e ss of th e fa c e , or decrease in urine in d i­
cate the onset of n e p h r itis.
The laboratory reports show the presence o f
albumin, red blood
corp u scles, and c a s t s . The patient should be kept warm
and quiet in bed.
The d ie t i s s a lt f r e e , and may be r e s tr ic te d to milk and
f r u it ju io e s, or a lig h t d ie t may be ordered according to the d isc r e tio n of
the physician.
An accurate account o f Intake and output should be k ept.
The urine i s tested d a ily .
Cardiac Involvement.
As th e streptococcus toxin has an a f f in it y
the h eart, a toxic m yocarditis may fo llo w
longed r e s t is in d icated .
The
fo r
an attack of sc a r le t fe v e r , Pro­
ingenious nurse w i ll find many ways of pro­
viding entertainment fo r the p a tie n t, e s p e c ia lly the c h ild , who w i l l find
t h is enforced stay in bed irksome.
Convalescence.
During convalescence provision should be made fo r en­
tertainment adapted to the age of the p a tie n t.
I f no com plications develop,
the patient is allowed out o f bed a t the end of two to three weeks, or a
week a fte r the temperature has returned to normal.
The patient should be
warmly cloth ed , as he i s e a s ily c h ille d and is susceptible to r ein fectio n .
A ssistin g with the Adm inistration of Serum.
Serum Sickness.
D isin fe c tio n :
(See Appendix A .)
(See pages 41, 4 2 .)
Concurrent.
be d isin fe cte d or burned.
A ll m aterial so iled with secretio n s should
D ejecta are always contaminated, and in the home
should be d isin fecte d in a so lu tio n of 10 per cent chlorinated lim e.
110
Terminal.
The patient should be given a tub bath, shampoo, and clean
c lo th in g , and he then should be removed to a clean u n it.
The u n it should be thoroughly cleaned w ith soap and water and aired
fo r a t le a s t twenty-four hours.
Bedding should be exposed to the sunlight
fo r a t le a s t twenty-four hours.
Toys should be washed thoroughly with soap
and water, or destroyed.
In the h o sp ita l, books are autoclaved.
The New
York City Department o f Health requires the follow ing procedure fo r books
used by in fected Individuals:
Books must be opened and turned freq u en tly and exposed to
the sun and a ir fo r fo rty -eig h t hours. Public lib rary and school
books a f te r sunning and a irin g f o r fo r ty -e ig h t hours must be
wrapped in paper and returned to the lib rary or school with in ­
stru ctio n s that they have been in contact w ith a communicable
d ise a s e . The Department o f Health in stru ctio n s to lib r a r ie s and
school p rin cip a ls are that such books must be kept out o f circu ­
la tio n fo r three months.
E s se n tia l P oints to Remember:
1.
S c a rle t fev er usu ally ii'ff transm itted by d irect con tact, but i t may
be transm itted by fom ites.
2.
S ca rlet fev er is a serious d ise a s e , because com plications may develop
even a fte r a mild attack and a fte r acute symptoms have disappeared.
3.
A severe case o f sca r let fev er may be contracted from a very mild case,
even from one that has only a sore throat and a very lig h t rash.
4.
P a tien ts released from quarantine who have discharging ears or nasal
sin u ses may transm it the d isease to o th ers.
1.
New York City Department of H ealth, Bureau of Nursing, Manual of Com­
municable D isea ses, 1938, pp. 84-25.
I ll
Home Care
Nursing In str u c tio n s.
The patient should be kept in a room alone and
in bed, fo r as long as the physician orders.
com plications.
This i s important, to prevent
The p h y sicia n 's orders as to d iet and warmth should be follow ed,
1
and i f unusual symptoms, as earache or enlarged glands, develop, he should be
called immediately.
A specimen o f urine should be saved.
The return of a
patient to f u l l a c t iv it y should be gradual, even a fte r a mild a tta ck .
I f sore throat i s contracted by other members o f the fam ily, care should
be taken to prevent i t s spread, as even though th is may be the only symptom
of sc a rlet fev er in one in d iv id u al, in another a serious attack o f sca rlet
fever may r e s u lt .
Children who have recovered from the d isea se should not,
for at le a s t a period o f three weeks after being released from is o le t io n , be
permitted to sleep in the same bed with others who have not had i t .
During
th is period a l l a r t ic le s used at meals should be kept separate.
Community Protection
Suspicious cases should be reported to a physician or h ealth o ffic e r
immediately when sc a r le t fever i s prevalent in a community.
escapes n o tic e , e s p e c ia lly in mild cases.
The rash often •
Milk should be p esteu rized .
S elected References
Bureau o f Nursing, Manual - Communicable D iseases.
York Department o f H ealth, 1938. P. 38.
Carter, Charles P ., M icrobiology and Pathology.
The C. V. Mosby Company, 1939. P. 756.
New York: C ily of New
2nd E d ition .
S t . Louis:
112
Department o f Health, The Sanitary Code of the City o f New York.
Department of H ealth, 1939, P . 156.
New York:
Dick, G. 7 . , and Dick, G. H ., The Control o f S carlet Fever. American Journal
o f the D iseases o f Children, XXXVIII (November, 1929), p . 905.
Dick, G. H ., B rief Hiatory o f Sear l e t Fever. Journal o f the American Medical
A ssociation , CXIII (July 22, 1939), pp* 327-30.
F isch er, A. E ., and K o jis, F. G ., The Schultz-Charlton T est. American Journal
o f the D iseases o f Children, XLVI (Novenber, 1933), p. 1282.
Hoyne, A. L.,and Spalth, R ., The Ear Complications of S carlet Fever.
o f P e d ia tric s, XII (March, 1938), p. 287.
Journal
CHAPTER X II
DIPHTHERIA
D e fin itio n ,
Diphtheria i s an acute communicable d isease Characterized
by th e formation of a pseudo-(f a ls e ) membrane, u su a lly in the th ro a t, nose,
or laryn x, and by a general toxemia.
This d ise a se i s c la s s if ie d according
to the lo c a tio n of th e membrane.
H istory.
Diphtheria was f i r s t (dearly described by Aretaeus, a Greek
p h ysician , about 100 A .D ., although i t was known fo r oenturles under various
names.
I t was not d istin gu ish ed from other d isea ses
mation of the t o n s ils u n til the nineteenth century.
associated with inflam­
The name "diphtheria"
was f i r s t given to the d isea se in 1821 by Brentonneau,
The organism was
described by Klebs in 1883, but L o e ffle r , in 1884, f i r s t id e n tifie d i t as
the e x c itin g cause o f diphtheria.
For t h is reason i t i s c a lle d the Klebs-
L o effler b a c illu s .
In 1893 a n tito x in was su c c essfu lly used by von Behring.
duced in to the United S ta tes in 1894 by Park and B iggs.
I t was in tro­
Before the introduc­
tio n of th is treatm ent, diphtheria was attended by a high m ortality r a te,
averaging from 30 to 40 per cen t.
In laryngeal diphtheria (croup) the mor­
t a li t y ra te was almost 100 per cen t.
Within a short time the wide-spread
use o f a n tito x in reduced the m ortality to a very low fig u r e .
Schick devised
a t e s t fo r s u s c e p tib ility in 1913, and in 1914 Baxk perfected a method of
(113)
DI PHTHERIA
U se
of
A n t it o x in
on
Da y
of
D is e a s e
mm
PfPCFNT/IGF OF PFCOIS/M S
\p ffiC fm F f 0F/>F4r//j
t
F ig . 6. ‘ Graph showing a c tio n of a n tito x in on d i f f e r e n t days of
th e d is e a s e , showing how th e chances of recovery from d ip h th e ria are
in creased by e a r l y use o f a n t i t o x i n . (After Kblle and Hetch, P ublic
Health R e p o rts , Supplement No. 156.)
^
114
a c tiv e immunization.
Intensive immunization campaigns have been conducted
in the United S ta te s , and in many c i t i e s the disease has been p ra c tic a lly
wiped o u t.
Prevalence.
Diphtheria i s endemic in the temperate zone.
Many v io len t
epidemics occurred during the n in eteen th century, but the disease now ra rely
occurs in communities where a c tiv e immunization i s practiced .
The winter
months are the periods o f i t s h igh est in cid en ce.
E tio lo g y .
The cause of d iph th eria i s the K lebs-L oeffler b a c illu s .
i s a Gram -positive, nonspore-forming organism.
It
The b a c illi which are found
in the pseudo-membrane do not penetrate th e body, but lib e r a te a soluble
toxin w h ile growing.
The absorption o f t h is exotoxln in to the blood stream
produces the symptoms o f the d ise a s e .
The organism liv e s on necrotic t is s u e
o f the mucous membrane; when protected from d ir e c t sunlight i t r e s is t s both
drying and ordinary low temperature f o r weeks, but i t i s read ily k ille d by
b o ilin g , and w ill d ie in three minutes at 70° C.
Sources o f In fectio n .
The discharges from the nose, throat, conjunc-
tiv a e , vagina, and wounds contain th e in fe c tiv e agent.
Secretions of the
nose and throat o f carriers a ls o spread the in fe c tio n .
Mode of Transmission.
Diphtheria i s spread by personal contact, by
a r t ic le s so ile d with in fected throat and nasal d isch arges, and by Infected
milk su p p lie s.
Carriers play a part in th e transm ission o f the d ise a se , and
th e ir presence in a community accounts f o r the occurrence of diphtheria among
persons who have not been in contact with a diphtheria p a tien t.
The organism
a lso has been Isolated from the u rin e, the s t o o l, the pus of discharging ea rs,
burns, and wounds.
115
S u s c e p tib ility .
Approximately 60 per cent of children under ten years
of age are su scep tib le to diphtheria.
Individual r esista n ce v a ries greatly
from extreme s u s c e p tib ility to natural immunity.
A ll races are su scep tib le.
Females are a ffec te d more frequently than m ales.
Negroes seem to be r e la ­
t iv e ly immune.
As th e r e s u lt o f t e s t s carried out by Park and h is co-workers on 20,000
persons, the follow in g percentages o f su scep tib le in dividuals a t d ifferen t
ages may be given*1
Age
Percentage Susceptible
At b ir th ............................. ..
Under 4 months...................
Four to 6 months...............
S ix to 9 months................. ,
Nine months to 1 y e a r ...
One to 2 y e a r s .................. ,
Two to 3 years...................
Three to 5 y e a r s .............. .
Five to 10 years........... . .
Tan to 20 years................. .
Over 20 years..................... .
per cent or le s s
ft
ft
ft
vt
n
f«
tv
ff
If
ff
tt
ft
T?
tt
ft
ff
tt
w
ft
ff
•t
tt
ft
tt
»f
tt
ff
n
it
tt
ft
tt
tt
tt
ff
tt
ft
tt
ff
tt
Ninety per cent of children are immune a t b ir th , due to an inherited pro­
te c tio n from the mother.
Recovery from an attack o f the d isea se is Ibllowed
in many, but not in a l l , cases by a c tiv e immunity.
Pathology.
Diphtheria le sio n s are sim ila r regard less of lo ca tio n .
Degen­
eration o f the surface c e l l s i s follow ed by tha formation of a thick pseudo­
membrane o o n sistln g of fib r in , leu co cy tes, red blood corpu scles, b acteria, and
dead e p it h e lia l c e l l s .
The aotion of the to x in on th e heart causes fa tty de­
gen eration .
Incubation Period.
This period i s from one to seven, u su ally two to fo u r,
days.
1.
Charles F. Bolduan and N ils W. Bolduan, Public Health and Hygiene, p. 116.
116
Complications and Sequelae,
Csrvioel a d e n itis , o t i t i s media, albumin­
u r ia , n e p h r itis , m yocarditis, and peripheral n e u r itis oeour as com plications
o f diphtheria*
th e r ia .
Broncho-pneumonia i s p articularly common in laryngeal diph­
The oommon p aralyses are o f the so ft p a la te.
The heart involvement
may be severe enough to produce fa ilu r e .
Period o f Coam unlcabillty.
Infected in dividuals may transm it th e d i s ­
ease from tw enty-four hours before th e onset u n til the diphtheria b a c il li
have disappeared from the se cr etio n s of the nose and throat and from the
le s io n s , usu ally a period Of about two weeks.
O ccasionally v ir u le n t organ­
isms remain in th e se c r e tio n s two to s ix months.
A v iru len ce t e s t should be
made in any case where p o sitiv e cultu res are reported th ree weeks or longer
a f te r th e onset o f th e d ise a se .
Prognosis.
P r a c tic a lly every patient who rec e iv e s s u f f ic ie n t a n ti-to x in
ea rly in th e d isea se w ill recover.
Otherwise, the prognosis i s d ecep tive,
and i t i s dependent on the age of the p atien t, the la t e use o f a n ti-to x in ,
th e lo c a tio n and ex ten t o f th e membrane, and the presence of com plications.
M ortality* The case f a t a lit y rate is from 6 to 7 per c e n t.
Prophylaxis:
The Sohick T est.
This t e s t , which i s fo r th e purpose of
d e te ctin g s u s c e p t ib ilit y to diphtheria, i s made by in je c tin g intraderm ally
on the fle x o r surface of the forearm 1/50 of a minimum le t h a l dose of diph­
th eria to x in in 0*1 c c . or 0*8 c c . of normal sa lin e s o lu tio n .
A p ositve
reaction i s shown by redness and s lig h t induration w ith in fo r ty -e ig h t to
seventy-two hours.
A pseudo-reaotion in d io a tes hypersensitiveness of the t is s u e c e l l s to
th e p rotein in th e to x in d ilu tio n .
I t is more oommon in old er age groups.
THE DIPHTHERIA DEATH
(D e a th s
ANTITOXIN
p e r
LINE
1 0 0 ,0 0 0 )
T O X IN ANTITOXIN
T O X O ID
ISO
Pi i - 1
'#t
', t >• ><
/H.M
P ‘ / .'
t
3V.'
*’ < > U i
100
' if
t
' (
f
6«
*i
i'
?
v * yi ^
•V/}
rA V
»V
Ip ‘i t? I
frK
t? i:«
. 'i
'
k
k
^
f
i
'
1
50
l’? i-1,'
i '11?i
rIt" T
* f»
. ii’ (■,y- y i..-
'4 ‘ ^ i
’/ A<>! ‘‘<
k4
*'
tJ - (J >
M. ‘
i.
<L t
*
T
, / Vil
1917
1923
I929 1932 192
7 . This graph i s p lo tted from an adaptation of the death
ra tes fo r diphtheria in New York C ity .
117
A con trol o f heated to x in may be in jected intraderm ally a t th e same
time that th e Schick t e s t i s made*
Comparison prevents errors in deter*
mining s u s c e p tib ility to d ip h th eria.
I t is advisable to read the Schick
t e s t a week a f t e r i t i s given , fo r by t h is time pseudo-reactions can be
ruled out*
Any d isc o lo r a tio n a t the s it e of th e in je c tio n should be con­
sidered p o sitiv e*
At the time the t e s t is read a su scep tib le person should
show only a ty p ica l rea ctio n where the Schick t e s t was made - nothing a t the
s i t e o f co n tro l.
I f both t e s t s show a reaction a fte r fo r ty -e ig h t hours, the
individual nay be s e n s it iv e to the broth solu tion in which the to x in i s pre­
pared.
A ctive Immunization.
A r t if ic ia lly acquired a c tiv e lnmunity may be pro­
duced in su so ep tib le in d iv id u a ls by the use of toxoid or to x in -a n tito x in .
These preparations stim ulate the body to produoe i t s own a n tito x in .
Toxin-anti to x in was the o r ig in a l preparation used by Park in 1914.
He
found that horse serum se n sitiz e d individuals to future in je c tio n s o f a n ti­
to x in s , so goat serum was su b stitu ted .
Ona cubic centim eter o f to x in -a n ti-
to x in mixture contains 0X 1+dose of diphtheria to x in (th at dose of to x in which
when mixed with 1 u n it o f a n tito x in w il l s t i l l have enough to x ic ity to k i l l a
250-gram guinea pig in four days) plus .075 of a u nit of a n tito x in .
c essiv e in je c tio n s o f 1 c c . should be given a t weekly in te r v a ls .
Three suc­
The f i r s t
to x ln -a n tito x ln in je c tio n may be used in children in place of the Schick t e s t .
Local and c o n stitu tio n a l reactions are very s lig h t in ch ild ren , but in
the older age groups severe reactions may be encountered, due to an acquired
hyperseasitivene8s to p ro tein s.
Diphtheria toxoid i s prepared by the addition of formalin to the to x in ,
a fte r which the mixture i s Incubated for one month.
Formalin destroys the
118
the t o x ic it y without markedly lessen in g the powers of tha to x in .
This
toxoid i s the immunizing agent most w idely used a t present.
Toxoid may be administered as follow s:
In children under three years
of a g e( two in je c tio n s o f 1 c c . each are glron.
two doses i s two weeks.
i s 0.25 c c .
i s given.
g iv en .
The in terval between th e
In sch ool children and adu lts the f i r s t in je c tio n
I f no annoying rea ction s follow* a second in jectio n of 0 .5 c e .
I f th ere i s no marked reaction* a th ird in jec tio n of 1 c c . i s
These in je c tio n s are given a t in te r v a ls o f one to two weeks."*"
Adults should avoid fa tig u e when taking th ese in je c tio n s.
Alum p recip itated toxoid i s prepared by adding alum to the toxoid .
Havens found that t h is preparation, because o f i t s slow absorption* had
greater immunizing power than the toxoid so lu tio n .
tim es produces severe lo c a l rea ctio n s in older
This preparation some­
children and a d u lts.
A Schick t e s t should be done three to s ix months a fter immunization
and repeated at three-year in te r v a ls .
I f the t e s t i s positive* the in je c ­
tio n s should be repeated.
The most su ita b le age fo r immunization of in fan ts is s ix to nine months*
as during the f i r s t three years o f l i f e the s u s c e p tib ility to diphtheria and
the m ortality rate are g r e a te s t.
Immunity is given w ithin s ix months to about 75 per cent o f in d ivid u als
who re ceiv e in je c tio n s o f to x ln -a n tito x in .
P r a c tic a lly a l l children vho r e ­
ceiv e three in je c tio n s of toxoid a t monthly Intervals develop Immunity.
Passive Immunization.
This i s not necessary fo r exposed parsons over
f iv e years of age* where d a ily in sp ection by the physician or nurse i s
1.
Bureau o f la b o r a to r ie s, Department of Health* City o f New Tark* 1938.
119
carried, o u t.
Infants and ch ild ren under f ir e who are exposed to diphtheria
in th e fam ily should receiv e a prophylactic dose o f a n tito x in without Schick
t e s t in g , i f they are not know to he immune.
In I n s titu tio n a l outbreaks individuals should be is o la te d and Schick
t e s te d .
Nose and throat cultures should be taken.
C arriers.
About 20 per cent of diphtheria p a tien ts harbor organisms
in th e nose and throat a fte r recovery.
Frequently the organisms found in
the th roats o f convalescent p a tien ts and of ca rriers are v ir u le n t.
These
persons should be iso la te d u n til a virulence t e s t in d ic a te s that the b a c ill i
are n on viru len t.
Various methods are employed to rid c a r r ie r s of v iru len t
b a c i l l i , the removal o f t o n s ils and adenoids being considered most e f f e c t iv e .
A 2 per cent so lu tio n o f gentian v io le t sprayed in the nose and throat occa­
s io n a lly produces sa tis fa c to r y r e s u lts .
Treatment.
to x in .
The s p e c ific treatment for th is d isea se i s diphtheria a n ti­
I t should be administered as early as p o ss ib le , as the to x in combines
with the t is s u e s i f no a n tito x in is present to counteract i t s e f f e c t .
The
m ortality r a te is increased by each day*s d ela y .
The dosage o f a n tito x in v a ries according to the age and w eigit of the
p a tien t and to the se v e r ity o f the attack.
The average dose for the moderate­
l y i l l p a tien t i s 10,000 u n its intram uscularly.
The s it e u su a lly se le cted
for the in je c tio n of a n tito x in i s the outer aspect of the th ig h , as the serum
w i l l reaoh the muscle t is s u e quickly.
This i s the most comfortable s i t e for
the p a tie n t, and the danger o f abscess is a lig h t.
intravenously in severe oases.
A n titoxin i s administered
120
A s e n s it iv it y t e s t should always he done i f the h istory of the case in d ica te s previous in je c tio n s o f horse serum, or an a lle r g ic co n d itio n .
If a
decided reaction r e s u lt s , the a n tito x in should be given intram uscularly in
divided d oses.
The p atien t should be kept f la t in bed during the course of th e d ise a se .
Elim ination should be c a r e fu lly watched.
Enemata or la x a tiv es may be ordered.
Hot throat ir r ig a tio n s o r g argles are soothing to the p a tie n t.
F lu id s should
be offered frequently, and dextrose in large amounts should be g iv en .
treatment i s symptomatic.
Rest i s paramount.
Administration o f A n tito x in .
Serum R eactions.
Other
(For procedure, see Appendix A.)
R eaction to d iphtheria an titoxin i s infrequent because
o f the highly refin ed nature o f the serum now a v a ila b le .
A s t e r i l e syringe
and epinephrine Should be ready for u se i f a serum reaction Should occur.
(See page 4 0 .)
Methods of Control:
Recognition and Reporting.
and laboratory fin d in g s determine the d iagn osis.
The d i n i o a l p ictu re
The disease should be re­
ported Immediately in order th a t treatment may be in stitu te d and quarantine
esta b lish ed .
Iso la tio n .
The p a tien t should be iso la ted u n til two cu ltu res from tha
throat and nose, taken a t in te r v a ls o f twenty-four hours, have been found
free from diphtheria b a c i l l i .
A viru lence t e s t should be made i f the throat
cu ltu res are p o sitiv e th ree weeks a fte r the onset of the d ise a se .
From four
to seven days u sually ela p se before the r e s u lt of th is t e s t i s reported. Mean­
w h ile, nose and throat cu ltu re s are taken d a lly .
le n t, iso la tio n may be term inated.
I f the organism i s a v lru -
I f cultures s t i l l are found to be p o s itiv e
a fte r f iv e weeks, the h ea lth o f f ic e r may declare the in d ividu al a d ip hth eria
ca rrier.
NASAL
DIPHTHERIA
A d m itte d
M ale
Name.
Age....
6 y rs.
Case No.
November
M onth.
10
D a y o f M onth.
11
D a y o f Illn ess.
H o u r o f D a y.
RESP.
PULSE T
TEM P.
em p.
170
108 '
160
107 '
150
106 '
140
105 '
130
104 '
120
103 '
da;
102 '
100
101
100'
99 '
70
96 '
40
F ig . 8 . Temperature chart of a p a tien t with nasal diptheria.
(See page 121.)
121
Quarantine.
A ll intim ate contacts are quarantined u n til nose and throat
cultures are proved to be n eg a tiv e.
Cultures of contacts are taken by school
nurses in order to guard again st ca rriers ot unsuspected cases in th e age
group most s u s c e p tib le .
Immunization.
theria to x in .
In most communities the house i s plaoarded.
A ctive Immunization is obtained by preparations of diph­
P assive immunization is obtained through diphtheria a n tito x in .
Nursing Care in Nasal Diphtheria
Nasal d ip h th eria i s the d ip h th eritic involvement of the nasal mucosa.
Unless i t i s an exten sion from the pharynx, the co n stitu tio n a l symptoms are
m ild.
There i s u su a lly a b ila t e r a l discharge which may be sero-sanguinous,
and e p ista x ls i s common.
with cr u sts.
The upper li p is frequently excoriated and covered
The membrane i s seldom seen exoept on examination with a rhino-
speculum.
Nasal d ip h th eria i s r e s ista n t to lo ca l treatment,
the diseharge per­
s is tin g for weeks u n less adequately treated with a n tito x in .
Children who
have the d ise a s e , although not very i l l , can cause severe diphtheria in sus­
cep tib le persons.
NUrses in contact w ith diphtheria p atien ts must be immune to the d ise a se .
Medical a se p tic technic should be carried out.
Comfort o f the P a tie n t.
A d a lly bath should be given and good habits
of personal hygiene e sta b lish ed .
Since the patient usu ally f e e l s w e ll, pro­
v isio n should be made to keep him happy during the enforced is o la t io n .
Personal Hygiene:
care of the Nose.
Since the discharge oauses excor­
ia tio n s and accompanying discom fort, the nasal passages must be kept clean .
122
The nose should be cleaned with cotton swabs, which should immediately be
discarded into a paper bag fastened at the b ed sid e.
profuse, argyrol paoks may be ordered.
a period o f twenty minutes.
When the diseharge is
These are inserted tw ice d a ily for
I f su ctio n is necessary, a Sorenson pump i s
used, care being taken to prevent trauma and bleeding.
Two to th ree drops o f a mild a n tis e p tic so lu tio n may be in s t ille d into
each n o s t r il two to three times a day.
S olu tion s oantaining o i l should never
be used because o f the danger o f lip o id pneumonia.
The ex co ria tio n s, i f Crusted, may be softened with e ith e r warm mineral
or o liv e o i l , then scrubbed with green soap and h eavily covered with zinc
oxide ointment or v a se lin e .
Only hea’sy ointments through whloh th e discharge
cannot penetrate e a s ily should be used.
The p a tie n t *a n a ils must be kept
short to prevent ir r it a tio n from scratching and, i f necessary, the hands re­
strain ed .
D ie t.
The d ie t c o n sists o f nourishing fo o d s.
Fluids should be given
f r e e ly , sugar should be added to fr u it ju ic e s , and lo llip o p s may be given
a fte r meals to increase the carbohydrate in tak e.
Complications:
Cervical A d en itis.
Complications are rare in nasal diph­
th e r ia , because the toxin o f the KLebs-Loeffler b a c illu s i s not e a s ily absorbed
through the mucous membrane of the n ose.
C ervical a d en itis may occur, fo r
which an ic e - c o lla r may be applied to the th r o a t.
This condition u su ally sub­
s id e s without su rgical in terferen ce.
O tit is Media and S in u s it is .
When o t i t i s media and s in u s it is occur, they
axe cared for as prescribed by the p h ysician .
PHARYNGEAL
DIPHTHERIA
A d m itte d ..
Male
Name...
.A,........ 6 y r s
. Case No..
D ecem ber
M onth.
D a y o f M onth.
_a_
6
D a y o f Illn ess.
3
H our o f D ay.
Resp.
T E M P.
PULSI T e m p .
170
108 ° _
160
107 ° _
150
106 ° _
140
105 ° _
130
104 ° _
120
103 ° _
110
102 ° _
100
101 ° _
90
100 °
80
99 ° _
70
98 °
60
97
70
50
96 ° _
60
40
95 °
oir
Iffci
o ::.
i r i Hi?
e
9/
$
42°
htjiEj r Lc. A: it
GI
e
aimjis
mm
41°
i n l t ^ Y E tb
3
.40°
II
§
A
I
* 39°
II i
?
38°
37°
36°
50
40
30
t
we
ee
• •
20
F ig . 9 . Temperature chart o f a p atien t w ith pharyngeal diphtheria
and serum sic k n ess. (See page 40, 123.)
( P h a ry n g e a l D i p h t h e r i a - c o n tin u e d )
A d m itte d
______________ _____________ ___ ____________
Name________________________________________
Age_____ ___
Case No.
Decem ber
M onth.
D a y o f M onth.
D a y o f Illn ess.
10
10
11
11
12
n'7
xo
14
14
15
H o u r o f D a y.
R ESP.
P
170
108‘
160
107‘
150
106'
140
105'
130
104'
120
103'
110
102'
100
101
90
100'
80
50
TEM P.
ulse t e m p .
©:>
183
Nursing Care In Pharyngeal Diphtheria
Pharyngeal diphtheria i s the d ip h th e r itic involvement of the mucous
membrane of the pharynx, the membrane appearing on th e t o n s ils , uvula, or
palate*
The color of the membrane depends on the amount o f blood in i t ,
and u su a lly i s a d irty ,g ra y ish w h ite, though i t may be almost black*
The p atien t complains of a lig h t sore th ro a t, dysphagia, and a fe e lin g
o f weakness*
The cerv ic a l glands may be s li g h t l y enlarged*
The temperature
i s c h a r a c te r is tic a lly low and the pulse ra te u su a lly i s h igh .
I f a n tito x in i s not administered ea rly in the d is e a s e , the patient be­
comes extremely to x ic and a l l symptoms are exaggerated.
h igh , 103° - 105° F.
to swallow.
The temperature i s
Membranes cover the th r o a t, and the patient i s unable
Marked p rostration , extreme p a llo r , n asal discharge, and, at
tim es, delirium or coma may be p resea t.
tie n t* s breath permeates the room.
The stron g, s ic k ly odor of the pa­
The oarvioal glands are swollen and there
i s edema of the nsok, a condition which is referred to a s "bull neck."
The prognosis in very to x ic cases is poor, d esp ite the prompt adminis­
t r a tio n o f a n tito x in .
ComfOrt of the P a tien t.
The p a tien t must be kept f l a t in bed, absolute
r e s t being of primary importance because cardiac involvement i s not evident
e a r ly in the d ise a se .
The d a lly bath is om itted in severe ea ses.
L ittle
d i f f i c u l t y w i l l be experienced in solving problems of nursing care i f persons
w ith pharyngeal diphtheria are treated as e a r ly post-op erative p a tie n ts.
Re­
s tr a in t s are used only when necessary, as frighten ed children expend too much
e f f o r t in trying to fre e them selves.
V en tila tio n must be accomplished without d r a ft, and the temperature of
the room or ward should be kept at 70° F .
124
Personal Hygiene;
Care o f the Skin.
The akin must be c a r e fu lly ob­
served for p etech ia s, tin y blue or red subcutaneous hemorrhages under the
Skin.
Aiooliol rubs are given three times a day to prevent pressure so res.
Care of the Eyes.
The eyes should be Irrigated w ith boric acid so lu ­
tio n .
Care o f the Nose and Throat.
A Sorenson pump may be used a t low suction
i f the patient has a profuse nasal discharge.
The p atien t must l i e on h is s id e , his head supported with a sm all p illo w ,
when throat ir r ig a tio n s are given .
A so lu tio n containing equal parts of sodium
chloride and sodium bicarbonate i s used for the ir r ig a tio n , and the return flow
i s observed for membrane and blood.
I f ths ir r ig a tio n produces nausea, i t
should be discontinued and the physician
Care of the Mouth.
n o tifie d .
Mouth care must be assidu ou s.
Whenths patien t
is ad­
m itted to the h o sp ita l the teeth and tongue freq uen tly are covered with blood
and sordes, and the l i p s are cracked and bleeding.
Sordes may be softened with
mineral o i l , then swabbed with sodium bicarbonate and w ater.
The mouth should
be cleansed w ith 50 per cent hydrogen peroxide (follow ed by rinsin g with w ater),
or a so lu tio n o f equal p arts of lemon ju ic e , boric a c id , and glycerine before
food is taken.
The mouth should always be rinsed w ith a mouthwash and water
a fte r food is taken.
Cold cream, boric ointment, or mineral o i l Should be ap­
p lie d to the l i p s to keep them in good condition.
E lim ination.
to x ic m a teria ls.
Laxatives or anemata may be ordered to fr e e the body o f
Urine output should be noted c a r e fu lly , and reported i f in ­
s u f f ic ie n t in proportion to the Intake.
The p atien t should bekept
aid elim in ation through the sk in , and to
keep up r e s ista n c e .
warn to
125
D ie t.
The p atien t must be fed by the nurse u n til he i s con valescen t.
S oft foods, such as c e r e a ls , vegetab le purees, and fr u it ju ices with dextrose
may be given, a high c a lo r ic and high carbohydrate d iet being in d ica ted .
If
the p atien t is unable to swallow, intravenous infusions of gluoose u su a lly
are given by th e ph ysician .
Complications and Sequelae:
M yocarditis.
Destruction of the heart
muscles by the toxin may occur even in p a tien ts who have appeared only s li g h t ­
ly t o x ic .
The f i r s t in d ica tio n o f a heart involvement may be a s lig h t ly i r ­
regular pulse;
for t h is reason , the nurse should count the pulse for a whole
minute and carefu lly observe any change in th s rate or rhythm.
In the more
severe cases there may be nausea, vom iting, abdominal pain, weak p u lse, feeb le
heart sounds, tender l i v e r , enlargement of the h eart, f a l l in blood p ressure,
prostration, and cyanosis o f the lip s or fin g er t ip s .
Late circulatory fa ilu r e may occur during the third week of the d is e a s e ,
when the patient seems w e ll on the road to recovery.
A sudden change in pulse
rate may appear, and the p a tien t may lapse in to unconsciousness and die in a
short tim e.
I f the p a tie n t su rv ives, the recovery usually is complete.
The electro-cardiogram i s valuable in d etectin g myocardial changes.
P alatal P a r a ly sis.
f i r s t and second week.
This com plication occasionally occurs between the
I t i s in d icated by regurgitation
nose, a nasal v o lo e , and even by in a b ilit y to swallow.
ex ten siv e , the p atien t must be fe d by naval gavage.
at flu id s through the
I f the involvement i s
As ths paralysis su b sid es,
the nasal twang disappears.
Ocular P a ra ly sis.
This condition occasion ally occurs, and i s Indicated
by blurred v isio n and in a b ilit y o f the eyes to focu s.
the patient*s eyes c lo s e ly fo r th ese symptoms.
The nurse should observe
126
P a ra ly sis of tbe Respiratory Muscles*
muscles is uncommon, but may occur.
P a ra ly sis o f the respiratory
I t i s an acute con d ition and unless the
p a tien t is immediately relieved by a r t if ic ia l r e sp ir a tio n he w i l l die from
su ffo c a tio n .
P aralysis of the E xtrem ities.
In th is com p lication , which sometimes
o ccu rs, th e p atien t complains of numbness and o f in a b ilit y to use the a f­
fe c te d lim bs.
MUrslng Care in Laiyngeal Diphtheria
Laryngeal diphtheria is the dip htheritic involvement o f the mucous mem­
brane o f the larynx, commonly known as "croup."
In t h is condition the forma­
tio n o f the membrane in the a ir passages causes a ir hunger, symptoms of which
are r e s t le s s n e s s , dyspnea, and cyanosis.
As breathing Is d i f f i c u l t , the acces­
sory m uscles of resp ira tio n must be used, causing w ell-d e fin ed indentations
above, between, and below the sternum.
These in d en tation s, known as retraction s,
are termed "supra," " in fra," and "substernal."
With th e d if f ic u lt breathing
there i s a respiratory strid o r (a crowing sound).
Frequently aphonia occurs.
The temperature ranges from 102° - 103° F . ; the pulse i s very rapid.
Constitu­
tio n a l symptoms u su ally are s lig h t .
When membrane is revealed by laryngoscopic examination, i t is removed by
suotion ; the larynx may again become blocked in a short tim e.
When there are
symptoms o f acute su ffo ca tio n , as r e stle ssn e ss and cy a n o sis, the physician i s
h u rried ly summoned, and a laryngoscopy is performed.
(See Appendix A.)
A
nurse must always be present to watch a croup p a tien t fo r recurrence of resp ir­
atory d i f f i c u l t y .
187
General Care.
The nurse must learn to remain calm as she watches a
croup p a tien t, as he i s quick to sense any sign of alarm and to react accord­
in g ly .
Warm m oist a ir is soothing to the ir r ita te d larynx;
means of a croup ten t and k e t t le .
must e n tir e ly cover the c u b ic le .
i t i s supplied by
Tbs ten t may be of heavy hickory clo th and
In a home, a tent may be improvised by
fashioning sheets above the crib or bed, by the use of an umbrella, or by
covering a wooden frame.
A t e a -k e t tle , an e le c tr ic percolator, or a p itch er
with a cover made of paper may serve as a k e t t le .
When not ad visab le to use
a te n t, r e s u lts may be secured by closin g the windows and door t i & t l y , a l ­
lowing the steam to f i l l the room.
M edications.
One or two drams of whisky in an ounce of orange ju ic e or
well-sweetened water i s given as a sed ative.
This should n eith er be used in
formulae, nor should i t be d ilu ted in a large amount of f lu id , as the p atien t
takes flu id s with d if f ic u lt y .
To induce vom iting and ths expulsion of plugs o f mucus or membrane, one
or two drams o f syrup o f ipecac d ilu ted in warm water may be given to the pa­
t ie n t .
The r e s u lts o f the medication should be ca refu lly observed, and the
physician n o tifie d i f the p a tien t does not vomit.
The vomitus should be ex­
amined for mucus and membrane.
Personal Hygiene;
Care o f ths Mouth.
The mouth is cleansed with a 8 per
cent so lu tio n o f sodium bicarbonate in order to remove the mucus before giving
flu id s or flood.
When dyspnea i s marked the p atien t cannot rin se h is mouth or
gargle, therefore the mouth must be scrupulously cared fo r by the nurse.
E lim ination,
The urine output should be ca refu lly watched.
enemata nay be prescribed to aid elim in ation .
Laxatives or
128
D ie t* Fluids are given freq u en tly in small amounts, and co n sist mainly
o f those high in c a lo r ie va lu e.
Sugar i s added fr e e ly to a l l f lu id s .
During
periods of coughing the p atien t should be watched ca re fu lly because of the
danger o f aspirating f lu id s .
Intubation.
Intubation (the in sertio n of a hard rubber tube into th e
larynx) is performed i f resp ira tory d is tr e s s in creases or i s prolonged. (See
Appendix A .)
Following intubation the p atien t i s much r e lie v e d , but he must be watched
con stan tly fo r sig n s of respiratory obstruction caused by plugging of the tube
w ith mucus or membrane.
Autoextubation (coupling up th e tube) may occur and,
i f no sig n s of dyspnea or cyanosis are evid en t, the tube is not replaced.
The
intubation tube can o ften be removed in four or f iv e days, but frequently re­
in ser tio n i s necessary.
The nurse should hold the Child in her arms to keep
him from being frightened; th is frequ en tly prevents the need for further in ­
tu bation .
The pulse should be taken every f if t e e n minutes, as a change in
rate may in d icate the approach o f exhaustion.
I f symptoms of acute respiratory
d is tr e s s occur, th e physician should be hurriedly summoned.
Since the Insertion of an intubation tube dlsp laoes the e p ig lo tt is and
g rea tly increases the danger o f asp iratin g f lu id s , the patient i s fed by nasal
gavage.
The patien t may be taught to swallow without aspiration i f only very
sm all q u a n tities of f lu id are o ffered ; but learning a new habit requires much
energy, and recovery may be delayed.
Containers of flu id s should never be
l e f t w ithin reach of th e p a tie n t.
In a communloable d isease h o sp ita l the intubation s e t should always be
ready for use.
129
Tracheotomy.
I f the patient con tin u ally coughs up the Intubation tube,
or i f he i s unable to go without i t after a period of three weeks, a trache­
otomy i s performed. (See Appendix A.)
The p atien t must be watched ca r e fu lly ,
as the tube may become plugged with mucus.
When the inner tube i s removed,
i t i s replaced by a s t e r ile tube which is kept a vailab le fo r immediate u se,
care being taken to c lo se the key.
Before replacing the inner tube, i t may
be necessary to
remove mucus from the outer tube by su c tio n .
tube is removed
a c c id e n ta lly , i t must be replaced
by a s t e r i l e tube or the
wound held open with a d ila to r u n til the physician a r r iv e s .
i s changed when
necessary.
The inner tube may be
or w ith one-inch gauze bandage forced through the
Com plications;
Acute Su ffocation .
I f the outer
The dressing
cleaned with pipe cleaners
tube w ith a metalap p licator.
Acute su ffo ca tio n i s the most dreaded
com plication, and death ensues u nless r e l i e f i s given promptly.
Broneho-pneumonia.
Broncho-pneumonla is the most frequent com plication.
There i s a marked Increase in temperature and r e sp ir a tio n .
The p atien t i s
prostrated; he may be elevated on p illo w s, and h is p o sitio n Changed frequently
to f a c i l i t a t e breathing.
to reduce the temperature.
Tepid sponges, and an ice-ca p to the head may help
The abdomen i s watched fo r d iste n tio n and,
if
n ecessary, turpentine stupes may be ordered, or a r e c ta l tube in serted .
I f empyema occurs, the patient is treated as a su r g ica l ease, and asep tic
technic continues to be observed.
D is in fe c tio n :
Concurrent.
A ll nose and throat discharges and a r t ic le s
s o ile d with discharges should be properly disposed o f .
Paper handkerchiefs
and d ressin gs should be placed in a paper bag and burned.
In th e home, the lin en should be b o iled fo r f if t e e n m inutes, or soaked in
a
per cent e re so l so lu tio n for two hours.
A ll m ilk b o t tle s must be washed
with soap and water and b oiled fo r f if t e e n minutes.
130
Terminal.
The patient must have a cleansing bath and Shampoo, a fte r
which he i s dressed in clean c lo th in g .
The room must be washed thoxougily
with soap and water, and aired fo r twenty-four hours.
E ssen tia l Points to Remember;
1.
Diphtheria i s e s p e c ia lly dangerous for children under four years of age.
2.
B io lo g ic a l products (a n tito x in , to x in -a n tito x in , and toxoid) should be
kept in th e r e fr ig e r a to r .
They should newer be l e f t for a long time in
a warm room or near a ra d ia to r.
The expiration date should be ca r e fu lly
noted.
3.
Constant watchfulness i s n ecessary, as symptoms of com plications should
be reported to the physician immediately.
Intubated p a tien ts should never
be l e f t alone.
Home Care
Nursing In stru ctio n s.
I t is important to is o la te the p a tie n t, and the
p hysician’s orderBshould be follow ed c a r e fu lly .
To avoid cardiac com plications,
the patient should be kept in bed and his a c t iv it y r e s tr ic te d .
should be ca lled i f any unusual symptoms appear.
The physician
The return to normal a c t iv it y
should be gradual, and convalescence ca refu lly watched.
A ph ysical examination
o f p atien ts should be made w ithin s ix months a fte r recovery.
131
Community P rotection
A ll children from s ix to nine months o f age should be incoulated again st
diphtheria, and a periodic follow -up should be made to see what proportion of
the children of these ages have been immunized.
munization of a l l ch ild ren should be arranged.
and inspected.
Campaigns to secure the im­
Milk should be pasteurized
Diphtheria c a r r ie r s should be con trolled .
S elected References
Bolduan, Charles F ., and Bolduan, N ils W., Public Health and Hygiene. 2nd
Edition Revised. P h ilad elp h ia: W. B. Saunders Company, 1937. P. 372.
Carter, Charles F ., Microbiology and Pathology.
The C. V. Mosby Company, 1939.
P. 756.
2nd Edition.
S t. Louis:
D ivision of Public Health .Nursing and D ivision of CommunicableD iseases,
Manual of Communicable D iseases fo r Public Health Nurses. Albany: New
York State Department of Health, 1939. P. 84.
N effson, A. H ., and Wishik, S. M., Acute In fectiou s Croup.
P e d ia tr ic s, L. (October, 1934), p. 433.
Palmer, Lee, Diphtheria.
pp. 218-22.
Journal of
Kentucky Medical Journal, XXXVI (June, 1938),
Park, William H ., and W illiams, Anna W., Pathogenic Microorganisms. 11th
Edition Revised. P h iladelphia: Lea and Febiger, 1939. P. 1056.
Rosenau, Milton J ., Preventive Medicine and Hygiene. 6th E dition.
D. Appleton-Century Company, 1935. P. xxv 4- 1482.
New York:
Schamberg, Jay F ., and Kolmer, J .
A., Acute In fectiou s D iseases. 2nd E d ition
Revised. Philadelphia: Lea and Febiger, 1928. P. v i i + 888.
CHAPTER X E II
SEPTIC SORE THROAT
D e fin itio n .
S ep tic sore throat is an epidemic type o f aore throat
ch aracterized by sudden onset with m alaise, headache, fev er, and painful
sw ellin g o f th e e e r v io a l lymph glands.
Synonyms? Epidemic Sore Throat;
Streptococcus Sore Throat.
H isto ry .
Forty-two outbreaks of s e p tic sore th roat have been recorded
in th e United S ta te s .
Cases due to in fected m ilk freq u en tly have bean re­
ported in Great B rita in over a period o f yea rs.
The f i r s t recognized ep i­
demic in t h is country oecuxred in Boston, in 1911.
Since then, outbreaks
have occurred in a l l sec tio n s of the country.
P revalence.
The disease usually occurs in epidem ics, nhioh appear sud­
denly and run th e ir course in from two to e ig h t weeks.
graphic areas ifcere m ilk i s not pasteurized.
to a s in g le source o f milk supply.
I t i s fbund in geo­
Host epidemics have been traced
The incidence i s highest in th e wLnter
and spring months.
E tio lo g y .
Streptococcus epldemicus is thought to be the c h ie f organism
causing s e p tic sore th ro a t.
Sources of In fe ctio n .
harbor th e organism.
It was f i r s t described by D avis, in 1912.
The nose and throat d ischarges of in feeted persons
The udder o f a cow in feeted by a milker i s a common
source of in fe c tio n .
(132)
133
Mode of Transmission.
human co n ta ct.
Ths d isea se i s transm itted by d irect or in d irect
Consumption of raw m ilk contaminated by an in fected person
or carrier i s responsible fo r some c a se s.
Milk contaminated by an Infected
udder also may transm it the d ise a se .
S u s c e p tib ility .
S u s c e p tib ility i s gen eral, but young ch ild ren do not
contract the d isea se as r ea d ily as adults*
Pathology.
Inflammatory le sio n s of the throat and evidence of the
cloudy sw elling o f the tis s u e s are the only pathological conditions fbund.
Incubation Period.
The Incubation period is from one to three days.
Course of the D isea se;
C lin ic a l P ictu re.
The onset is u su ally sudden
and i s characterized by severe sore th ro a t, fever, and p rostration .
The
t o n s ils are inflamed and may be covered with a th in grayish membrane, which
resembles the membrane o f diphtheria or o f V incent's angina.
The c e r v ic a l
glands are enlarged and ten d er.
As the in fe c tio n develops the temperature r is e s to 102° - 104° S’. The
leucocyte count i s moderately h igh, u su a lly not exceeding 20,000.
The p a tien t
experiences extreme d if f ic u lt y in swallowing, and there may be delirium or
stupor.
I f the attack is m ild , sore throat and general discom fort may be the
only symptoms.
In two to s i x days the symptoms usually subside, but the cer­
v ic a l glands may remain sw ollen .
Period o f Convalescence.
Convalescence may be prolonged.
Complications and Sequelae.
The most frequent com plications are suppura­
tio n o f the c e r v ic a l g lan d s, a r t h r it is , n e p h r itis, o t i t i s media, and endocar­
d itis .
P e r ito n it is , pneumonia, and septicem ia also may occur.
Period o f Communloability.
In man, th e disease is transm issible as long
as the c lin ic a l symptoms are p resen t.
A human being may become a ca rrier a fte r
134
the c lin ic a l recovery.
The d isease nay he transm itted by c a t tle u n til
strep to co cci are no longer discharged.
P rognosis.
Most p a tien ts recover com pletely.
M ortality.
In severe epidemics the m ortality rate may be h igh, espec­
i a l l y in the com plications o f p e r it o n it is and septicem ia.
In the United
S ta te s , in 1934, 2,000 out o f 7,000 reported eases d ie d .1
Treatment.
The treatment i s symptomatic.
with e x c e lle n t r e s u lt s .
Methods o f Control:
Sulfanilam ide has been used
Anti streptococcus serum has been used.
Recognition and Reporting.
nized by c lin ic a l symptoms and laboratory d ia g n o sis.
The d isea se is recog­
The h ealth o ffic e r
should be n o tifie d Immediately, in order to a scerta in the sources of contam­
inated m ilk, or to lo ca te the c a r r ie r .
I s o la tio n .
The p atien t should be iso la te d u n t il complete recovery as
in d icated by the attending physician.
Quarantine.
There i s no quarantine period.
Nursing Care
I s o la t io n .
Medioal a sep tic technic should be s t r io t ly observed.
The
cau sative organisms are in the nose and throat se c r e tio n s. .
Comfort of the p a tie n t.
The patient must have absolute r e s t in bed.
A cleansing bath is given d a ily , and alcoh ol rubs are given frequ ently. Tepid
sponges may be ordered to reduce the temperature, which u su ally is high.
1.
G. s i Eucker, Control o f Septic Sore Throat.
H ealth. XXVII (A pril, 1937), p. 313.
American Journal of Public
135
Personal Hygiene:
m eticulous.
Care o f the Mouth and Throat.
Mouth eare should he
Ths sore throat may be reliev ed by the ap p lication of an le e -
c o lla r , and by hot ir r ig a tio n s of s a lin e and sodium bicarbonate so lu tio n .
P ie t .
The d ie t may present a problem,
liq u id s usu ally are giv en , a l ­
though so lid s may be b e tte r to le ra ted by some p a tie n ts.
should be as high a s p o ss ib le .
The flu id Intake
P a tien ts who are unable to swallow are given
Intravenous in fu sio n s o f 5 per cent glu cose.
Complications:
Septicem ia.
There may be a r is e in temperature, w ith
c h i l l s and an in term itten t fe v er .
P e r ito n itis .
Vomiting may be the f i r s t indication of th is con d ition .
Cervical A d e n itis.
N ephritis.
(For nursing ca re, see page 72.)
(For nursing eare, see page 109.)
Bronoho-pneumonia.
O titis Media.
(For nursing care, see page 72.)
(For nursing care, see page 71.)
Prostration i s o ften q u ite marked so th at the nurse should constantly
observe the p atien t fo r symptoms of complications as be may be too i l l to
oomplain o f discom fort.
The treatment of com plications w ill be prescribed
by th e physician.
Convalescence.
These p a tien ts t ir e e a s ily and are vexy nervous.
They
should have an abundance o f nourishing 10od and adequate r e s t . Return to
f u l l a o tiv ity should be resumed gradually.
D isin fectio n :
Concurrent.
A rtlo le s so iled with discharges from the
nose and throat of the p a tien t should be properly disposed o f .
Terminal.
hours.
The u nit should be thoroughly cleaned and aired for s ix
136
E s s e n tia l P o in ts to Remember:
1.
The p a tie n t w ith s e p tic sore th ro a t r e q u ire s s k i l f u l nursing care
throughout th e course of th e d is e a s e .
2.
C om plications may have serious r e s u l t s .
Home Care
N ursing I n s tr u c tio n s .
The p a tie n t should have ab so lu te r e s t in bed,
and should be watched f o r symptoms of com plications.
He should be is o la te d
and a l l contam inated a r t i c l e s should be d is in f e c te d .
Any unusual symptoms
should be re p o rte d a t once.
Community P ro te c tio n
M ilk should be p a ste u riz e d , and th e r e should be a search f o r c a r r ie r s
among th e m ilk ers of cows.
Good personal hygiene i s im portant, and th e use
of common e a tin g u te n s ils should be avoided.
S elected R eferences
B roadhurst, Je an , and Given, L eila I . , M icrobiology A pplied to N ursing. 4 th
E d itio n R evised. P h ila d e lp h ia : J . B. L ip p in c o tt Company, 1939. P. x ix *• 654.
Hucker, G. J . , C ontrol of S ep tic Sore T h ro a t.
H e a lth , 2XVII (A p ril, 1937), p . 313.
American Journal of Public
P ills b u r y , Mary E ., N ursing Care of Communicable D ise a se s. 5th E d itio n .
R evised. P h ila d e lp h ia : J . B. L ip p in co tt Company, 1938. P. ix t 604.
Rosenau, M ilton J . , P reventive Medicine and Hygiene. 6th E d itio n .
York: D. Appleton-Century-Company, 1935. P . v i i ■» 1482.
New
CHAPTER XIV
VINCENT’S ANGINA
D e fin itio n .
V incent ’ 0 angina i s a communicable d isea se characterized
by ulcero-oembranous inflammation of th e t is s u e s of the throat and mouth.
When prim arily attack in g the to n s ils and the pharynx, i t i s known as Vincent’s
angina; when occurring prim arily on th e gums and in th e mouth, i t is known as
g in g iv it is or trench mouth.
H isto ry .
Synonyms:
Trench Mouth; Vincentes In fe c tio n .
The fusiform b a c illu s was f i r s t observed by P la u t, in 1894.
Two years la t e r Vincent described the sp irillu m which bears h is name.
Prevalence.
V incent’ s angina occurs most frequently among poorly nour­
ished ch ild ren , and among Individuals with neglected or diseased te e th .
The
d isease was prevalent among troops during the World War, and was commonly r e ­
ferred to as "trench mouth.”
E tio lo g y .
The d isea se i s caused by a fusiform b a c illu s and a sp irillu m
growing togeth er in the pharynx and mouth.
A u th orities d if f e r as to whether
the b a c illu s and sp irillu m are separate organisms growing in sym biosis, or
whether one represents a stage o f development o f the o th e r .1
The diagn osis i s made by microscopio examination of smears of the mouth.
The d isea se must be d iffe r e n tia te d from other throat con ditions such a s diph­
th e r ia , s y p h ilis , s e p tic sore th roat, and agranulocytic angina.
1.
Charles F . Carter, Microbiology and Pathology, p . 411.
(137)
138
Sources o f In fe ctio n * The in fe c tiv e agents are found in the le s io n s o f
persons having the d ise a s e .
Mode of Transmission.
C arriers a lso may be a source o f in fe c tio n .
This d isea se i s transm itted by direct contact w ith
in fected persons or w ith a r t i c l e s , such as eating u te n s ils .
S u sc e p tib ility .
A ll races are s u sc e p tib le .
Adults are more freq u en tly
a ffe cte d than ch ild ren , and males are more su scep tib le than fem ales.
One
attack i s not known to produce immunity.
Pathology.
A pseudo-membrane, beneath which ulceration occurs, may be
found on the t o n s ils , the s o ft p a la te , and in the mouth.
A lesio n on the
la te r a l w all o f the pharynx may cause an erosion o f a blood v essel r e s u ltin g
in hemorrhage.
O ccasionally a blood count w i l l reveal the presence of agran­
u lo c y to s is.
Incubation Period.
The incubation period has not been determined.
Course o f the D isea se.
The onset of V incent’s angina is abrupt with
p ain fu l sore throat and d i f f ic u lt y in swallowing.
t o n s illa r , but may be g in g iv a l or pharyngeal.
The lesio n s u su ally are
The i n i t i a l lesio n appears as
a red area covered w ith a th in yellow or grayish membrane which, when r e ­
moved, reveals a bleeding su rfa ce.
U lceration i s ch a ra cteristic.
A ll gradations o f s e v e r ity may be seen in t h is d isea se, ranging from
a small patch on the t o n s i l to exten sive involvement o f the tis s u e s o f th e
pharynx and mouth, accompanied by severe toxem ia.
U sually, the c o n s titu tio n a l symptoms are m ild, s lig h t elevation o f
temperature with headache and m alaise being th e only evidence of in fe c tio n .
Enlargement o f the c e r v ic a l lymph nodes is common.
Complications and Sequelae.
A secondary in fe c tio n may complicate the
d ise a se , but com plications and sequelae are rare.
139
Period o f Communicablllty.
The disease I s communicable as long as the
In fe c tiv e agents are found in the mouth.
Prognosis»
The prognosis is favorable in uncomplicated ca ses.
Treatment.
S p e c ific treatment includes the use of sodium perborate in
lo c a l a p p lic a tio n s, a lso in solu tion as a g a rg le.
A gargle of equal parts of
hydrogen peroxide and water, used hourly, is e f f e c t iv e in in h ib itin g the growth
of the organisms.
Neo-arsephenamine (10 per cent in g ly cerin e) and a c r iv io le t
(1 per cen t) may be applied lo c a lly ;
neo-arsephenamine or acri fla v in e are ad­
m inistered intravenously in severe cases.
Removal of in fe c te d t o n s ils or teeth may elim inate a p ersisten t in fe c tio n .
Methods o f Control;
Recognition and Reporting.
by th e c l i n i c a l symptoms and laboratory d iagn osis.
The d isease i s recognized
When found in sch o o ls, in
barracks, or on sh ip s, i t should be reported.
I s o la tio n .
Iso la tio n of the patient in the home is
not necessary i f he
w i l l c a r e fu lly observe h ab its o f personal c le a n lin e ss .
Quarantine.
Quarantine is not necessary.
Nursing Care
I s o la tio n .
In the h o sp ita l the p atient i s iso la te d and msdloal asep tic
technic observed.
Comfort of the P a tie n t.
Care o f the Mouth.
sid e r a tio n .
meals*
Rest in bed i s in d icated in severe cases.
C leanliness of tb s mouth i s the most important con­
In mild c a se s, a n tisep tic mouthwashes are used before and a fte r
Sodium pierborate in the form of a paste may be applied to the affected
p a r ts, a fte r which the mouth should be rinsed;
i t a lso may be used as a gargle.
140
The teeth should he brushed, or they nay be cleaned with cotton swabs.
When
involvement of the mouth and throat is extensive or severe, s p e c if ic treatment
i s prescribed by the p h ysician .
Any unusual bleeding from the mouth should
be reported immediately.
D ie t.
A nourishing d ie t i s e s s e n t ia l.
I f a patien t experiences d i f f i ­
cu lty in swallowing, s o ft or liq u id foods nay be ordered.
D isin fe c tio n ;
Concurrent.
into ths t o i l e t or hopper.
Discharges from the mouth should be discarded
Paper handkerchiefs soiled with o ra l and n asal s e ­
cretions should be burned.
Terminal.
The unit should be washed with soap and water, then aired fo r
s ix hours.
E ssen tia l Points to Remember:
1.
Any inflammation of the mouth and throat should be reported to a physician.
2.
The ch ief role of the nurse in t h is d isease is as a teacher of personal
hygiene.
Home Care
Nursing In stru ctio n s.
The in fected individual should have h is own tow el,
t o i l e t a r t ic le s , and drinking g la s s .
His dishes should be s t e r ili z e d , and he
should be instructed to wash h is hands a fte r cleaning h is te e th , and to keep
h is hands away from h is mouth.
141
Community P rotection
Correction of diseased conditions of te e th and t o n s ils , education of
childrennin personal hygiene and n u tritio n a l needs, and encouragement o f
oral hygiene in the schools should help to reduce the incidence of Vincent’s
angina.
Selected References
Bloodgood, J . C ., Oral Lesions Due to Vincent’ s Angina. Journal of the
American Medical A ssociation, LXXXVIII (A pril 9, 1927), p. 1142.
Carter, Charles V ., Microbiology aid Pathology.
The C. V. Mosby Company, 1939. P. 756.
Meade, S terlin g V ., Diseases of the Mouth.
C. V. Mosby Company, 1940. P. 1060.
Second E d ition.
5th E dition .
S t. Louis:
S t. Louis:
Park, William H ., and Williams, Anna W., Pathogenic Microorganisms.
Edition R evised. Philadelphia: Lea and Febiger, 1939. P. 1056.
The
11th
CHAPTER XV
MUMPS
D e fin itio n .
Mumps i s an acute communicable d isease ch aracterized by
pain fu l sw ellin g of the sa liv a ry glan d s, e s p e c ia lly o f the p a ro tid s.
Mild c o n stitu tio n a l symptoms u su ally are present.
Mumps i s the common
name f o r Epidemic P a r o t it is .
H istory.
Mumps has been recognized as a s p e c ific d isea se sin c e the
six teen th century.
In 1916, Marth W ollstein, using f ilt e r e d mouth washings
o f p a tie n ts, produced the d isease in c a ts .
In 1934, Johnson and Goodpasture
transferred the d ise a se from human cases to monkeys.
Prevalence.
The d isea se u su ally occurs in children between the ages o f
four to twelve y e a r s.
When young adu lts from rural d is t r ic t s are in clo se
con tact, as in barracks or sch o o ls, mumps invariably occu rs.
During the
World War over 200,000 cases of mumps occurred among the United S ta te s troop s.
The appearance o f mumps u su a lly i s sporadic and epidemic, except in urban
cen ters, where i t i s endemic.
Though not d e fin ite ly sea so n a l, i t seldom
occurs in the summer months.
E tio log y .
Experimental evidence in dicates that the cause of th e disease
i s a f ilt e r a b le v iru s found in the s a liv a .
Source o f I n fe c tio n .
Seoretions of the mouth, and p o ssib ly of the nose,
contain the in fe c tiv e agent.
(1 4 2 )
143
Mode of Transmission.
Mumps Is transm itted by d ir e c t contact with the
in fected person, or by a r t ic le s fr e sh ly s o ile d with discharges from an in ­
fected person.
I t rarely i s conveyed by a th ird person.
S u s c e p tib ility .
S u sc e p tib ility i s supposed to be general.
One attack
o f the d isea se oonfers an immunity which u su ally i s permanent, but a second
attack may oocur.
Pathology.
Opportunities to study the anatomy o f the salivary glands
have been few, as death does not occur during an attack o f mumps u nless
another d isease already i s p resen t.
Incubation Period.
The incubation period i s from twelve to twenty days,
the average length of time being eighteen days.
Course o f the D isease:
C lin ic a l P ictu re.
The prodromal period, la stin g
from one to th ree days, i s characterized by headache, m alaise, muscular aches,
and pain when chewing or swallowing.
Mumps can invade any o f the salivary glan d s, one of the p arotid s, or
both o f them, being the most commdnly a ffe c te d .
o f the ear, and may extend down the neck.
tender.
The sw elling l i e s in front
The swollen area is moderately
Both s id e s o f the face may be involved a t the same tim e, or the in ­
volvement may be f i r s t on one s id e , then follow on the other in two or th ree
days.
U sually, both sid e s o f the face are a ffected before the d isea se has run
i t s course.
The skin i s ten se and shin y, but seldom red.
Children u sually have mild co n stitu tio n a l symptoms, but adu lts may be
o
o
very s ic k . Fever (101 - 103 F . j may accompany the o n set, then subside in
three or four days.
The p a tien t u su ally has severs headache fo r several days.
The tongue is furred, chewing and swallowing may be almost im possible, and the
patient may complain o f a queer ta ste in the mouth.
duct u sually i s swollen and red;
The opening of Stan son’s
Wharton’s duct also may be sw ollen.
144
When mumps occurs on one sid e on ly, the p a tien t holds h is head to the
swollen side*
The simultaneous sw elling of a l l th e groups of glands in the
neck resembles a f a tt y c o lla r extending crossw ise from ear to ear and under
the ch in , down almost to the c la v ic le s .
The p a tien t presents a ludicrous
appearance.
Period of Convalescence.
The sw ellin g of the glands u su ally subsides
in about nine days, and disappears by th e tw elfth day.
Convalescence is un­
e v e n tfu l.
Complications and Sequelae.
The com plications of mumps Include o r c h itis ,
o o p h o r itis, p a n c r e a titis, and o ccasion ally m enlngo-enoephalitis.
Permanent
impairment of hearing may be a seq u el.
Period o f Communlcablllty.
The period of in f a c t iv it y i s unknown, but it
i s thought to extend from a day befbrs the c lin ic a l sig n s appear u n til the
sw ellin g of the salivary glands has subsided.
Prognosis.
Under twelve years of a g e, mumps i s a mild d isea se and free
from com plications.
Above th is age, com plications are more common, but mumps
ra rely i s f a t a l .
Treatment.
c a tio n s.
Rest in bed i s extremely Important, in order to avoid compli­
The d ie t should be flu id when th ere i s d if f ic u lt y in opening the
mouth, or when chewing.
Local ap p lication s of heat and cold are soothing. The
com plications are treated symptomatically as they occur.
Mild la x a tiv es may
be given .
Methods of Control:
the c lin ic a l p ictu re.
Recognition and Reporting.
Mumps is recognized by
I t i s a reportable d ise a se in some communities.
i s l e s s dangerous before puberty than a t a la te r age.
Mpmps
145
I so la tio n .
I s o la tio n i s advised for the period of iu f e c t iv lt y , e sp e c i­
a lly in in s t it u t io n s .
Immunization.
A short period of passive immunity may r e s u lt from in je c ­
tio n s of convalescents* serum or whole blood.
This i s u se fu l in in s titu tio n s
to prevent the spread o f the d ise a se , and to lighten the a t ta c ts •
Nursing Care
I so la tio n .
The p a tie n t should be Isolated and medical a se p tic technic
observed.
Comfort of the P a tie n t.
A d a ily bath should be g iv en .
A hot water
b o ttle orciLeotrio pad may be applied to the affected area, or an le e - c o lla r
may be ordered.
Personal H ygiene:
Care o f the Mouth and Nose.
Frequently a th in , puru­
len t discharge exudes from the a ffe c te d salivary gland in to the mouth, thus
sp ecial mouth care i s in d ica ted .
Saline or sodium bicarbonate so lu tio n may
be used as a mouthwash and g a rg le.
The mucous membrane o f the nose should be
kept d e a n .
D iet.
In many ca ses the p atien t can take only liq u id nourishment.
nogs ' and milk d rin k s, to which glucose i s added, may be g iv en .
p a rticu la rly those o f an acid
Egg­
Fruit ju ic e s,
nature, may cause pain when taken into the
mouth, but many p a tie n ts do not have th is d if f ic u lt y .
I f the sw ellin g is not
marked, the p atien t can take a s o f t d ie t without discom fort.
F lu id s should
be offered freq u en tly .
Complications;
O rc h itis.
develop a u n ila te r a l o r c h it is .
Nearly one third of the adult males attacked
The condition frequently i s b ila t e r a l.
This
146
may occur at any time in th e i l l n e s s , but u su ally i t occurs a t the end of
the f i r s t week*
The p ain fu l sw ellin g of the t e s t ic le s i s associated with
fev e r, severe headache, and vom iting.
I t u su ally subsides with treatm ent,
but a small percentage o f p a tie n ts develop complete atrophy o f the t e s t i c l e .
When o r c h itis i s p resen t, th e patient should be kept f la t in bed, and
an ice-cap or cold compresses may be applied to the a ffected area.
TbB
scrotum should be supported with two s tr ip s o f adhesive which form a bridge
between the th igh s, ca lled a "Bellevue bridge."
Sedatives may be ordered
to a lle v ia te the pain*
O ophoritis.
mild*
Involvement o f th e ovaries may occur, but usually i t is
This i s evidenced by lower abdominal pain, headache, and nausea.
An ice-cap may be ordered applied to the area.
P a n crea titis.
A general inflammation of the pancreas may occur, the
symptoms being headache, vom iting, and ep ig a stric tenderness.
The t r e a t ­
ment depends upon the se v e r ity o f the symptoms*
M eningo-ancephalitis.
This co n d itio n , due to the s p e c ific organism o f
mumps, occurs o cca sio n a lly , the symptoms disappearing in a few days*
Convalescence.
Children under twelve years of age should be kept in
bed u n til twenty-four hours a f te r the fev er subsides.
Adults should remain
in bed u n til two days a f te r the sw ellin g of the glands has disappeared.
Rest is o ften d if f ic u lt to en fo rce, but the nurse, remembering the import­
ance of preventing com plications, should be able to convince the p atien t
o f the importance o f r e s tr ic te d a c t iv it y .
D isin fectio n : Concurrent*
Paper handkerchiefs so iled with discharges
from the mouth and nose should be burned*
b o ile d .
Contaminated a r t ic le s should be
147
Terminal,
The unit should, be cleaned with soap and water.
Mattresses
and p illow s should be exposed to sunlight and fresh a ir for s ix hours.
E sse n tia l P oin ts to Remember:
1.
Mumps in a d u lts and at the age of puberty may have serious consequences.
2.
Complications are b est avoided by keeping the patient in bed.
Home Care
Nursing In stru ctio n s.
Adolescents and ad u lts should be iso la ted and
kept quiet in bed, inflammation of the g e n ita ls being apt to occur as a
com plication of mumps.
I f allowed to progress, t h is condition may lead to
s t e r i l i t y , e s p e c ia lly in male patients,,
Selected References
Fishback, H. R ., Mumps Complicated by Acute M eningo-encephalitis.
Journal of Medicine, UCCF (March, 1939), pp. 273-75.
I llin o is
Richardson, Dennett L ., Infectiou s D iseases and A septic Nursing Technic.
P h iladelphia: W. B. Saunders Company, 1928, P. 182,
Rosenau, Milton J . , Preventive Medicine and Hygiene. 6th E dition.
D. Appleton-Century Company, 1935. P. xxv + 1482.
New York:
Schamberg, Jay F ., and Kolmer, John A ., Acute In fectio u s D iseases.
tio n R evised. Philadelphia: Lea and Febiger, 1928. P. 888.
2nd Edi­
CHAPTER
XVI
WHOOPING COUGH
D e fin itio n .
Whooping cough i s a s p e c ific communicable d ise a se charac­
terized by acute inflanm ation o f the respiratory system and by spasmodic
attacks of coughing, which end in a ifcoop.
Whooping cough i s th e common
name fo r P ertu ssin .
H istory.
Whooping cough was f i r s t described in the six teen th century
by Guillaume B a illo u ; la t e r , in 1674, i t was mentioned by W illis .*
Jules
Bordet and Octave Gengou iso la te d the s p e c ific b a c illu s in 1906, the casual
rela tio n of which was demonstrated, according to Koch's p o stu la te s, by
2
Mallory and o th er s0
Prevalence. The geographical d istr ib u tio n of whooping cough i s world­
wide.
Sporadic cases appear in every community, and from time to time e p i­
demics occur; 90 per cent of the reported cases are in c i t i e s .
The d is ­
ease i s prevalent during the ea rly spring months, with a secondary r is e in
July and August.
E tiology.
The g en era lly accepted causative agent i s Hemophilus per­
t u s s is , the b a c illu s o f Bordet and Gengou.
Some in v estig a to rs do not ac­
cept the p e rtu ssis b a c illu s as th e e t io lo g ic a l agent.
1.
F ielding Garrison, An Introduction to the H istory of M edicine, p . 863.
2.
F. B. M allory, A. A. Home, and F. F. Henderson, The R elation of the
Bordet-Gengou B a c illu s to the Lesion of P e r tu ssis. Journal o f
Medical Research, XVII (March, 1913), pp. 395-397.
(1 4 8 )
149
A culture p la te o f the Bordet-Gengou (glycerin e-p otato) medium ie held
in fro n t of the p a tie n t's mouth during several explosive coughs* The p late
o
is
incubated a t 37 C. A fter two days the co lo n ies which appear are smooth,
p early, and surrounded by a small zone
Source o f In fectio n .
of hemolysis*
Discharges from the laryngeal and bronchial mucous
membranes are the source o f in fe c tio n .
Mode of Transmission.
Whooping cough i s transm itted by d irect contact
w ith in fected persons, by a r t ic le s fr e sh ly s o ile d with discharges from the
laryngeal and bronchial mucous membranes, and by cough droplets*
Missed
cases spread the disease*
S u s c e p tib ility .
Whooping cough i s a d isea se o f infancy and childhood,
but no age i s immune;
in a d u lts i t may have serious resu lts*
i s higher in females than in m ales.
The incidence
One attack usually confers immunity,
but a second attack may sometimes occur*
Pathology.
Pathological fin d in gs are not d is tin c tiv e ; the method o f
producing the spasmodic cough and ty p ic a l whoop i s not w ell understood*
Some in v estig a to r s suggest that
to x in s are absorbed in thetrachea and act
upon th e cen tral nervous system
to produce the cough*^
The leucocyte count in the
paroxysmal stage i s from 15,000 to 40,000
or higher, the lymphocytes averaging 60 to
Incubation Period.
80 per ce n t.
The incubation period is in d e fin ite , but u su a lly i s
from seven to ten days a fte r exposure, seldom longer than sixteen days*
Course o f the D isease* The onset
is
(or catarrhal stage) o f
characterized by catarrhal symptoms of the nose and th roat,
whoopingcough
and by adry,
1* J . F* Schamberg and J . A. Kolmer, Acute In fectio u s D iseases, p. 800.
150
hacking cough.
The temperature may be s lig h t ly elev a ted , and the individual
may he l i s t l e s s and ir r it a b le .
Gradually the cough becomes more severe, es­
p e c ia lly a t n ig h t, and the d isease merges into the spasmodic sta g e, when i t
can be recognized c l i n i c a l l y .
The spasmodic (or paroxysmal) stage i s marked by coughing at intervals
of varying frequency.
During the paroxysm, the p atien t u tters a s e r ie s of
sh o rt, rapid, sputtering coughs, between which there i s no in sp iration ;
then fo llo w s a sudden deep in sp iration through the ten se vocal cords, pro­
ducing a p ecu lia r crowing sound, or whoop; the faoe becomes cyanotic; the
v ein s of the head and neck become swollen; th e tongue hangs from the mouth;
the e y e -b a lls protrude; strin g s of mucus bang from the n o s t r ils .
may c o n s is t o f from three to ten whoops.
The paroxysm
The p a tien t f in a lly secures r e l i e f
by expectorating small amounts of tenacious mucus, and by vom iting.
As soon
as the plug o f mucus i s ex p elled , the paroxysm ends.
Repeated paroxysms o f coughing, lo s s of breath, whooping, and vomiting
often leave the p atien t exhausted, perspiring and, apparently dazed.
The pa­
t ie n t su ffer s g rea tly during the paroxysm, as evidenced by the anxious con­
gested f a c ie s , the tendency to clutch a t surrounding objeots for support, and
the r e l i e f when the attack i s over.
The duration o f the paroxysmal stage usu ally is four to s ix weeks, a l ­
though i t may vary from one to eight weeks.
As the d isea se progresses, the
coughing attack s became m ilder, the in ter v a ls between them are longer, and
they f in a lly disappear.
Period of Convalescence.
improvement i s noted.
As the vom iting and whooping cease, general
Recovery i s only a matter of time in uncomplicated
151
cases.
For some months a f te r th e attack, any fresh r e sp ir a to ry in fec tio n
may be follow ed by return o f th e paroxysmal cough, but th ese recurrences
are not thought to be in fe c tio u s .
Complications and Sequelae.
Complications which are most lik e ly to
occur during the paroxysmal stage include broncho-pneumonia, o t i t i s media,
marasmus, h ern ia, hemorrhages, and neurological co n d itio n s, e s p e c ia lly con­
vu lsio n s.
Sequelse may include tuberculosis and b ro n ch iecta sis.
Period of Communicability.
Whooping cough i s most r e a d ily spread from
the onset o f th e f i r s t catarrhal symptoms u n til the whoop appears, which i s
from seven to fourteen days.
After the whoop appears the communicable stage
continues fo r approximately th ree weeks.
Prognosis.
Whooping cough i s a very serious d isease in ch ild ren under
f iv e , p a r tic u la r ly so in children under two.
n osis i s good.
In uncomplicated cases the prog­
Secondary in fe c tio n s are responsible fo r the serious r e s u lts
o f t h is d ise a se .
M o rta lity .
The m ortality i s high.
During the f i r s t s ix months of
1939, in the w hite race, the m ortality rate for the United S ta te s was 1.9 per
100.000 ca ses exposed to the d isease; in the colored race i t was 2.2 per
100.000 c a s e s.
Both races showed a hi^ier m ortality ra te than was shown fo r
measles and s c a r le t fever.^
In New York City, in 1939, there was only one
death l e s s from whooping cough than from diphtheria, m easles, and sca rlet
fever combined.
1 . S t a t i s t i c a l B u lle t in , 2X.
July, 1939, p . 5 .
New York: Metropolitan L ife Insurance Company,
152
Prophylaxis:
Sauer Vaccine.
The Sauer vaccine is probably the most
widely used in immunization a g a in st Whooping cough.
Since th is vaccine is
prepared with human blood, th ere i s no danger of s e n sitiz in g an in dividual
to animal p rotein.
The b e st age f o r immunization i s six to twelve months;
immunity i s esta b lish e d , i t i s sa id , in four months.
The value of vaccines
has not been d e f in it e ly e sta b lish e d .
Kreuger's Undenatured B a c te r ia l Antigen.
This is recommended fo r pro­
phylaxis even a fte r exposure.
Treatment.
Fresh a i r , sunshine, and adequate nourishing food are impor­
tant in the treatment of whooping cough.
Phenobarbital given f if t e e n minutes before meals may reduce the se v e r ity
of the paroxysms and prevent vom iting; a few drops of benzol benzoate on
sugar a lso may prove h e lp fu l.
ease include:
Other drugs used in the treatment of t h is d is ­
a n tip y rin , p a reg oric, quinine, and sodium bromide.
Ether in o i l i s given as a reten tio n enema.
scribed as a general to n ic during convalescence.
Cod liv e r o i l i s pre­
U ltr a -v io le t ray t r e a t­
ments may be ordered.
Methods o f C ontrol:
Recognition and Reporting.
Whooping cough i s recog­
nized by the c l i n i c a l symptoms, and by th e d iffe r e n tia l leucocyte cou nt.
The
diagnosis may be confirmed by b a c te r io lo g ic a l examination o f bronchial secre­
tio n s .
I t is a reportable d isea se
I so la tio n .
in some communities.
The p atien t should be separated from su scep tib le ch ild ren ,
and should be excluded from p u b lic assem blies for the period of assumed in fe c t i v i t y , which i s thought to end by the fourth week.
Quarantine.
Some h ealth a u th o r itie s recommend the exclu sion o f nonimmune
children from school and public assem blies fo r ten days a fte r th e ir la s t exposure
153
to a recognized case, except those children who are observed d a ily by a
physician or by a nurse upon a r r iv a l a t sch ool.
Immunization .
The value o f vaccines fo r a c tiv e immunization has not
been d e fin ite ly e sta b lish ed , but they are recommended by some p h ysician s.
Convalescents* serum fo r p assive immunization u su ally affords protection
when given w ithin the incubation period.
Serum of the highest t i t e r is ob1
tained from convalescent p a tie n ts during the f if t h weak of i l l n e s s .
Nursing Care
I s o la tio n .
A patient with whooping cough may be cared for in a room in
a general h o sp ita l i f medical a se p tic tech n ic i s observed.
In urban cen ters,
p a tien ts who cannot be oared fo r a t home are sent to a communicable d isea se
h o sp ita l.
In the homa, the p a tien t should be kept from contact with su scep tib le
in d iv id u a ls.
Environment.
The room should be w ell v en tila ted and free from d r a fts,
with the temperature kept a t 68° - 70° F ., and the humidity a t 50 per cen t.
The condition of p a tien ts with whooping cough i s aggravated by h o t, c lo se
rooms;
cold a ir has the same e f f e c t .
Comfort of the P a tie n t.
severe.
p illo w s.
Rest in bed i s indicated i f the paroxysms are
The patient i s more comfortable in Fowler’s p o sitio n , supported by
When a paroxysm b eg in s, the nurse should be at the p a tie n t’s bedside
to a lla y h is fe a r s, and to change h is p o sitio n i f necessary;
port him by placing her hand on h is abdomen.
1.
she should sup­
The danger of asphyxiation should
W. E. Bray, Synopsis of C lin ic a l Laboratory Methods, p. 408.
154
always be kept in mind, esp e cia lly i f the p atien t is an in fa n t, who may aspirate
vom itus.
A d a ily bath should be given, care being taken to avoid drafts and
sudden changes of temperature in the room.
The p a tie n t, whether in bed or ambulatory, should be warmly dressed.
A
t ig h t abdominal binder affords comfort during attack s of coughing, and helps to
prevent hernia.
Personal Hygiene:
Care of the Mouth.
The mouth should be kept clean.
The
p a tien t should rin se h is mouth with water and a 2 per cent sodium bicarbonate
so lu tio n a fte r vom iting.
The mucus which c o l l e c t s in the mouth a fter coughing
should be removed with gauze;
E lim ination.
occasionally suction i s necessary.
As paroxysms are more severe i f con stip ation is present,
la x a tiv e s and enemata may be ordered to correct the cond ition .
D ie t.
The food should be nourishing and e a s ily d ig e stib le and should con­
s i s t la r g e ly of vegetab les and f r u it s .
As frequently there is a d eficien cy of
Vitamin C, the d ie t should include an abundance of citru s f r u it s .
soned, or very hot or very cold foods should be avoided.
Highly sea­
D istention of the
stomach causes pressure on the diaphragm and frequently e x c ite s coughing;
amount
the
o f flu id s taken with the m eals, th erefo re , should be sm all, and so lid s
always should be given f i r s t .
The flu id intake should be maintained between
m eals.
Small amounts of food should be given frequently rather than three large
m eals.
The p atien t should be re-fed , a fte r vom iting, with food equal in caloric
value to th a t l o s t , a s food which is given immediately a fte r an attack of cough­
ing and vomiting i s more lik e ly to be reta in ed .
Special care in the feeding of in fa n ts i s important.
h a liv e r o i l should supplement the d ie t .
Cod liv e r o i l or
The food or formula should be given
P E R T U S S I S
(Wi'ioopin£ Cough)
A d m itte d
vjame..
------A g e .......... 1
F e i f l a l S _______________________
8 „ .f fiQ jS .,............ Ca«e
No.._.....
May
M onth.
D a y o f M onth.
D a y o f Illn ess.
2a
21
10
22
11
25
14
15
26
15
H ou r o f D a y.
RESP.
TEM P.
PU LSI T E M P .
170
108 '
160
107 '
150
106 '
140
105 '
130
104 '
120
103 '
110
102'
100
101
2
£21 =2Li
100 '
c * a r 5 . P a r p a c . • tio'
F ig . 1 0 . Temperature chart o f a’ p atien t with whooping cough and
broncho-pneumonia. (See page 155.)
155
slow ly and the p a tien t moved as l i t t l e as p o ssib le.
be kept in read in ess.
twenty minutes.
Extra feedings should
I f vomiting occurs, the Infant should be r e-fed in
An accurate weight chart should be kept fo r a l l in fa n ts.
Psychological Elements.
The patient should be kept q u ie t, a s e x c it e ­
ment, laughing, or crying may bring on a paroxysm,
con troversial issu e s
with children should be avoided, sin ce paroxysms may r e s u lt .
No attempt should be made to feed a ch ild p atien t while he is crying
or frightened u n til he has been comforted and reassured.
I f the sig h t of
food provokes a paroxysm, h is a tte n tio n should be d irected to other th in gs
while he i s being fe d .
Since ohlldren o ften cough to a ttr a c t atten tio n , they should be encour­
aged to ex ercise s e lf - c o n tr o l.
Special measures should be employed to keep
the child from coughing, such a s the o ffe r of a reward for lessen in g the time
between paroxysms.
For example, a record of the number of paroxyans may be
kept and a goal s e t fo r fewer each day.
The child should be taught to cover
his nose and mouth when coughing.
Complications and Sequelae:
Broncho-pneumonia.
B ro n ch itis, Which is
present in a l l severe cases of whooping cough, may develop into broncho­
pneumonia, the most serio u s o f a ll com plications.
I t s onset i s indicated by
a r ise in temperature and increased resp ira tio n s.
An x>ray of the ch est shows
ch a ra cteristic s ig n s .
Broncho-pneumonia may occur at any age, but i t is most
dangerous in in fa n ts.
The p a tien t always i s extremely i l l , and he requires the most s k i lf u l
nursing care.
(See page 7 2 .)
stim ulants are prescribed.
He u su ally i s placed in an oxygen te n t, and
156
Convulsions.
In in fa n ts, the asphyxia associated with the whooping may
be s u ffic ie n tly severe to cause convulsions.
Tetany, cerebral hemorrhage,
or to x ic en cep h alitis may be the cause of th is com plication.
baths u sually are ordered.
Hot mustard
The nurse must be on th e a le r t for symptoms of
th is com plication.
Hemorrhages.
The s tr a in imposed by the paroxysms i s shown by the fr e ­
quency of lo ca lized hemorrhages in the eye, nose, and under the skin.
These
conditions should be reported to the p hysician.
Hernia.
Inguinal h ern ia, um bilical hernia, or prolapse of the rectum
o ccasion ally resu lt from severe paroxysms.
hernia.
An abdominal binder may prevent
I f prolapse of the rectum occurs, the nurse should gen tly push i t
back and apply a pad held in p lace by a binder.
O titis Media.
This condition o ccasion ally occurs.
(For nursing care,
see page 71.)
Marasmus.
Uncontrolled vom iting, which so frequently follow s the cough,
in te r fe re s serio u sly with n u tr itio n , and jnay lead to d efin ite marasmus in
children.
The treatment for th is condition is prescribed by the p hysician .
Pulmonaiy Tuberculosis.
whooping cou^i.
This d isease sometimes follow s an attack of
The p a tien t should have at le a s t two physical examinations
w ithin the period of a year a f te r the attack , as a preventive measure.
B ronchiectasis.
This condition may be a la te sequel of whooping cough,
appearing long a fte r the a tta c k .
Convalescence.
As the p a tien t frequently lo s e s much weight, s k ilf u l
nursing care is required to resto re him to h is normal condition.
food and frequent r e s t periods are indicated;
gradual.
Nourishing
return to a c tiv ity should be
157
D is in fe c tio n :
Concurrent.
As tbs in fe c tiv e agent i s in the secretions
o f the nose and th ro a t, equipment s o ile d with th ese secretion s diould he
washed w ith soap and water, and used handkerchiefs should be burned.
Terminal.
The unit should be thoroughly washed with soap and water,
and aired for s ix hours.
s’
E sse n tia l P oin ts to Remember:
1.
Suspect whooping cough i f the follow ing symptoms are present:
couf&, i f whooping cough i s prevalent;
se v e r ity ;
(a) a
(b) a cough th at increases in
(c) a cough that i s more severe at n igh t;
(d) a cou^i that
i s follow ed by vom iting.
2.
Encourage the ch ild to exercise s e lf - c o n t r o l.
3.
Teach the ch ild health habits whenever the opportunity a r is e s .
Home Care
Nursing In stru ctio n s.
Infants and young children should be c lo se ly
watched to prevent choking and aspiration s of mucus.
The Child patient
should be kept q u iet and extra rest periods should be provided.
He should
be r e-fe d twenty minutes a fte r vomiting, avoiding very hot or very cold
food s.
He should be kept in the open a ir as much as p ossib le unless the
physician orders otherw ise.
158
Community Protection
During an epidemic the public should be taught to keep in fan ts and
children away from other children as much as p o ssib le , and to consult a
physician when they f i r s t begin coughing.
Contact with in d ividu als who
have catarrhal symptoms and coughs should be avoided.
S elected .References
Bray, W. E. Synopsis o f C lin ic a l Laboratory Methods,
Louis: The C. V. Mosby Company, 1938. P. 408.
2nd E dition .
Choate, A. B ., .Nursing Care of P atien ts with Whooping Cough.
Journal o f Nursing, XXXV (November, 1935), pp. 1033-36.
S t.
American
Emerson, Haven, E ssen tia l Problems in P e r tu ssis. American Journal of
Public Health, XXIX (A p ril, 1939), pp. 337-40.
Gardener, Douglas, Vitamin C in the Control o f Whooping Cough*
Medical Journal, October 8, 1938, pp, 742-44.
B ritish
Garrison, F ielding H ., An Introduction to the H istory of M edicine. 3rd
Edition Revised. Philadelphia: W. B. Saunders Company, 1921. P. 942.
Sauer, L. W., Whooping Cough. Journal of th e American Medical A ssociation,
CXII (January 28, 1939), pp. 305-08.
Schamberg, J. F.,and Kolmer, J. A ., Acute In fectio u s D isea ses. 2nd Edition
Revised. Philadelphia: Lea and Febiger, 1928. P. v i i ■+• 888.
Schermerhorh, n. J . , A. Report on the Progress of the Grand Rapids P ertu ssis
Immunization Study. Journal of P e d ia tr ic s, XIII (August, 1938), p. 279.
CHAPTER XVII
MENINGOCOCCUS MENINGITIS
D e fin itio n .
Meningococcus m eningitis Is an acute communicable d isease
characterized by involvement o f the naso-pharynx, followed by invasion of
the blood and, la t e r , of the lin in g membranes (meninges) of the brain and
spinal cord.
Fever;
Synonyms: Epidemic Cerebto-spinal M eningitis;
Cerebro-spinal
Epidemic M en in gitis.
H istory.
The f i r s t epidemic o f meningitis was reported in Geneva,
Switzerland, in 1805;
in 1807 there was an outbreak of i t in M assachusetts.
Frequent epidemics have sin ce occurred, the one in New York in 1904-1905 re­
su ltin g in 3,455 deaths out o f 6,755 cases.
During the World War m eningitis
was a severe d ise a s e , e s p e c ia lly among the young r e c r u its, but sin ce 1929,
when 9,660 cases were reported in the United S ta tes, the trend o f i t s in c i­
dence has been downward.
The organism of meningococcus m en in gitis was iden­
t if i e d in 1887, by Weichselbaum, and in 1915 it was c la s s if ie d into four groups.
Prevalence.
The d istr ib u tio n of th is disease i s world-wide.
I t u su ally
occurs in the w inter and spring months, and i s found most o fte n in children
under ten years of age and in young a d u lts.
Epidemics seem to appear in o yoles,
as is in d icated by the occurrence o f epidemic m eningitis in New York C ity .1
Cases a lso occur sp o r a d ica lly .
Local epidemics appear to be rela te d to over­
crowded co n d itio n s, as on sh ip s, in mines, or in barracks.
1.
Charles F. Bolduan and N ils W. Bolduan, Public Health and Hygiene, p. 170.
(159)
160
E tio lo g y .
The causal agent i s the meningococcus (Neisseria ln tr a c e llu -
l a r i s , or .Dlploooccus ln tr a c e llu la r ls m en in g itid is);
i t usually occurs in
p a irs, and is e a s ily destroyed by h ea t, drying, and d isin fe c ta n ts.
Seventy-five per cent o f the cases o f m eningitis are due to the meningo­
coccus.
Agents causing the remaining 85 per cent are:
the pneumoooccus,
the streptococcus, the staphylococcus, and the tubercle and influenza b a c i l l i .
Source of In fectio n .
The cau sative organism of m eningitis is present in
the nose and throat discharges o f the in feoted persons.
Mode of Transmission.
The d isea se is spread by d irect or in d ir e c t con­
ta c t with secretion s of the nose and throat of p a tien ts or healthy c a r r ie r s .
Carriers seem to be responsible fo r the spread of the d isease, e s p e c ia lly
during epidemics.
S u s c e p tib ility .
The d ise a se occurs in a l l ages, but children under f iv e
are e s p e c ia lly suscep tib le;
among ad u lts su s c e p tib ility i s lim ited , except
in those from rural omraunities who come together in crowded liv in g quarters,
as barracks, lodging houBes or s h ip s.
No one race seems more su scep tib le
than another.
Pathology.
tr a c t.
The meningococcus en ters the body through the respiratory
I t invades the blood, grows, and probably produces toxins;
then i t
attack s the meninges covering the brain and spinal cord, and causes an acute
inflammation which i s evidenced by a th ick purulent spinal flu id under in ­
creased pressure.
Autopsies reveal a th ick fibrinous exudate which i s more
marked a t the base of the brain and which may encooaoh upon the cra n ia l nerves,
e s p e c ia lly the o p tic and auditory n erv es.
eye i t s e l f ;
The inflammation may extend to the
other organs o f the body a ls o may show signs of in fe c tio n .
blood shows a polymorphonuclear
le u o o c y to sis.
The
161
Incubation Period* The period of incubation i s from two to ten days,
u su ally about seven days.
Course of the D isease.
The c lin ic a l p ictu re shows the onset of the
d isea se to b e, u su a lly , abrupt, with headache and vom iting, followed by fever
and p ro stra tio n .
Convulsions may occur, e s p e c ia lly in in fa n ts.
Soon a fte r the onset the neck becomes s t i f f , and the patient may be
o
stuporous or lapse into coma. The temperature may be as high as 105 F . ; the
pulse rate u su ally i s in proportion to the temperature, or more rapid i f the
patient is very to x ic ;
the resp iration s are irreg u la r.
The p atien t i s very
s e n s itiv e to sensory stim u li, as lig h t , n o ise , and touch.
Involvement of the
o p tic nerve may lead to b lin d ness, but blindness i s most often due to panoph­
th a lm itis .
Strabismus may resu lt i f the motor nerves of the muscles con trol­
lin g the ey eb a ll are a ffe c te d .
Facial p a ra ly sis may occur, and impairment of
hearing may r e s u lt from inflammation of the auditory apparatus.
Cutaneous le sio n s frequently are present and herpes of the lip s i s
common.
Hemorrhagic spots (sm all red p etechiae) may appear under th e skin on th e ex­
tr e m itie s, neck, and fa c e , for which reason the d isease formerly was c a lle d
"spotted fev er."
Tremors of the extrem ities are common and s p a s tic ity o f the
muscles i s a c h a r a c te r istic sig n .
As the extensor muscles o f the back are stronger than the fle x o r s , the
ch ild p a tien t may assume the c h a r a c te r istic p o sitio n o f opisthotonos, in which
the spine i s arched backward to an extreme degree.
When the th ig i i s flexed
on the abdomen, i t i s impossible to extend the le g from the knee;
i s knom as Kernig’s sig n .
When an attempt i s made to f le x the head on the
c h e st, the le g s are r e fle x ly drawn up, with the knees bent;
sig n .
th is sign
th is is Brudzinski's
162
Lumbar puncture reveals a purulent spinal flu id under increased pres­
sure.
The c e l l s are c h ie fly polymorphonuclear leu co cy tes, and there may be
several thousand per cubic centimeter;
the sugar is reduced in quantity;
and the d ip lo co c ci may be seen on smears in sid e and outside the pus c e l l s ,
or they must be grown on culture media to make a d e fin ite d iagn osis.
The
course u su ally runs from seven to fourteen days, depending upon the type*
Types of the D isease.
found, a s fo llo w s:
gococcus m en in g itis.
Three types of meningococcus m eningitis may be
(1) The ordinary type, which i s the usual form of menin­
This foxm may be very mild or quite severq, and some
p etec h ia l le s io n s may be scattered over the body.
(2) The septicem ic type,
in which septicem ia precedes and accompanies the m eningitis;
rash shows a tendency to recur in crops.
course or be rapidly f a t a l .
the hemorrhagic
These cases may run a prolonged
Often the meninges escape In fection and the
spin al flu id f a i l s to show changes.
(3) The fulm inating type, which may pro­
duce severe skin m anifestations and be so rap id ly f a t a l that the spinal flu id
shows no evidence o f meningeal ir r it a tio n .
Period of Convalescence.
Convalescence u su ally i s prolonged.
tio n may be extreme and muscle weakness marked.
Complications and Sequelae.
Emacia­
Relapses are not uncommon.
Common com plications are:
pneumonia,
o t i t i s media, a r t h r it is , c y s t i t i s , en d ocard itis, hydrocephalus, and ocular
co n d itio n s, as c o n ju n c tiv itis and strabism us.
Sequelae Include deafness, b lind ness, and chronic m yocarditis or endo­
c a r d it is .
Period of Communicability.
This period i s about two weeks, or u n til the
p atien t i s fre e from the in fe c tiv e agent.
163
Prognosis.
The outcome is dependent upon the type of in fe c tio n , the
resistan ce o f the in d iv id u a l, and upon early treatment.
M ortality.
of lif e .
The m o rta lity rate i s high, esp ecia lly in the f i r s t year
Within the past twenty years the use of antiserum has reduced the
m ortality to 20 or 30 per cen t.
Treatment.
S p e c ific treatment co n sists in th e adm inistration o f a n ti-
meningococcus serum, e ith e r intravenously or in tra th eea lly , or b oth.
Since
1937, sulfanilam ide has been used su c c e ssfu lly in the treatment of t h is d is ­
ease.
A combination o f antiserum and sulfanilam ide may o ffe r the b e st r e s u lt s .
Methods o f C ontrol:
Recognition and Reporting.
The d isea se is recognized
by the c lin ic a l symptoms and by microscopic and b a cterio lo g ic a l examination of
the spinal f lu i d .
I so la tio n .
This i s a reportable d isease.
The p a tien t should be iso la ted fo r fourteen days from the on­
s e t o f the d isea se or u n t il three su ccessive cultures from the naso-pharynx,
at in tervals o f not l e s s than fiv e days, have been found free from m eningococci.
Quarantine.
Quarantine i s not enforced.
Immunization.
P olyvalent vaccines are availab le, but are in th e experi­
mental sta g e.
Nursing Care
Is o la tio n .
The p a tien t should be iso la ted by medical a sep tic tech n ic .
Comfort o f the P a tie n t.
A very quiet location should be s e le c te d fo r the
p a tie n t’s bed, and a s lig h t ly darkened room lessen s the ir r ita tio n due to
bright lig h t .
The nurse should remember that a patient with m en in gitis i s
annoyed by loud n o ise s and by sudden movement or jarring of h is bed.
164
In case o f oopisthotonos, sp e c ia l care i s indicated when l i f t i n g the
head and removing the p illo w s.
Small p illo w s w i ll be found h elp fu l in pro­
vid in g for th e p a tie n t’ s comfort,
touching the s e n sitiv e part.
A cradle may keep the bedclothes from
An ice-ca p to th e head may help to r e lie v e
the headache.
Personal Hygiene:
Care of the Skin.
Most p atien ts are d e lirio u s or
comatose, and s k ilf u l care i s required to keep the skin in good con d ition .
A d a ily bath and frequent alcoh ol rubs should be given.
Bony prominences
should be rubbed with cocoa b u tter, and the p o sitio n should be changed as
freq u en tly as i s fe a s ib le .
Cotton or rubber rings fo r the ears, h e e ls , and
elbows may be used, and an a ir ring may be placed under the buttocks.
If
the i l l n e s s i s prolonged and emaciation extreme, an a ir mattress may be
ordered.
As ir r ita tio n may resu lt from the ap p lication of iodine a t the
s i t e o f the lumbar puncture, p a rticu la r a tten tio n should be paid to removing
a l l the iodine w ith alcoh ol.
Care o f the Mouth and Nose.
The mouth should be cleaned before and
a f te r feed in gs w ith an a n tise p tic mouthwash.
Boric ointment should be ap­
p lie d to herpes on the lip s and around the mouth.
The nose should be cleaned
a t le a s t tw ice a day with cotton swabs and m ineral o i l .
Care o f the Eyes.
The p a tie n t’s eyes must be protected from bright lig h t*
Cold compresses may be ordered, and the eyes should be irrigated several tim es
during th e day with boric so lu tio n .
The nurse should watch c lo se ly for any
abnormal condition of the ey es.
n ation.
There may be reten tio n o f urine and fe c e s , or incontinence.
C atheterization frequently i s necessary.
Elim ination must be ca refu lly watched,
and an accurate account kept o f intake and output.
165
D ie t.
During the acute stage the d ie t should c o n sist o f alkaline flu id s
o f high c a lo r ic valu e, given frequently in sm all amounts.
Fruit ju ices with
d ex tro se, cream soups, and egg-nogs u su ally are acceptab le.
ord of c a lo r ic intake should be kept.
An. accurate rec­
Water should be given frequently.
I t may be necessary to feed small ch ild ren by n asal gavage.
Older c h il­
dren and a d u lts may take flu id s by spoon, medicine dropper, or small rubber
sy rin g e.
When a l l other methods f a i l , a c h ild o f one or two years of age may
take flu id s v ery w e ll i f given in a b o t tle .
In such cases hab its of feeding
may be s a c r ific e d temporarily.
M edication:
r e s tle s s n e s s .
S ed atives.
Sedatives u su ally are ordered for insomnia and
I f sulfanilam ide i s given , the nurse should observe the patient
fo r cumulative or to x ic symptoms.
Lumbar Puncture.
Lumbar puncture i s always done.
fo r preparing for th is procedure and a s s is t in g w ith i t .
The nurse is responsible
(See Appendix A.)
When a c is te r n a l puncture i s ordered, th e neck and back of head should be
shaved.
A fter the procedure, the fo o t of the bed Should be elevated .
When
th e lumbar and c is te r n a l routes are blocked o f f , e s p e c ia lly in infan ts with
an open fo n ta n e lle , the physician may reso rt to a ven tricu lar puncture.
Serum S ick n ess.
r ea c tio n .
The nurse should watch fo r symptoms of a delayed serum
(For nursing care, see pages 4 1 -4 3 .)
Compile a t l ons.
Complications are trea ted as the physician orders.
The
nurse Should watch fo r such symptoms as strabism us, d ip lo p ia , c o n ju n c tiv itis,
blurred v is io n , haziness of the an terior chamber (ju s t below the cornea),
impaired hearing, and weakness of f a c ia l m uscles.
A sudden r is e of tempera­
ture or lo c a liz e d pain may in d ica te secondary in fe c tio n .
166
Convalescence.
As convalescence may extend over a long period of tim e,
the nurse should h elp the p atien t to adjust to the enforced in a c t iv it y .
Reading aloud i s a welcome form o f entertainment;
i t a lso prevents the pa­
tie n t from using h is e y e s, which u su ally are weakened by t h is d is e a s e .
should be taken to prevent e x e rtio n .
Care
A highly nourishing d ie t i s necessaxy
to repair t is s u e l o s s .
D isin fe c tio n :
Concurrent.
A ll nose, throat, and ear discharges must
be d isin fe cte d or burned.
Terminal.
The p a tie n t should be given a cleansing bath and shampoo,
and placed in a clean u n it.
for twenty-four hours.
The unit must be washed thoroughly and aired
M attresses and pillow s should be a ir e d .
E ssen tial P oin ts to Remember:
1.
The p a tien t should have complete r e s t .
2.
The skin req u ires sp e c ia l ca re.
3.
The d isea se is transm itted most frequently by unknown o a r r ie r s .
4.
The p a tien t should be watched for symptoms of sequelae.
Horns Care
NUraing In s tr u c tio n s .
During illn e s s the patient should be kept q u iet,
and in a room alone; during convalescence he should avoid unnecessary exer­
tio n .
The p atien t should be watched for unusual symptoms, which should be
reported Immediately i f they occur.
16?
Community P rotection
In an epidemic the public should be instructed to prevent overcrowding
o f persons in barracks, on sh ip s, and on transportation conveyances, and to
avoid c h illin g and body fa tig u e .
S elected References
Bolduan, Charles F . , and Bolduan, N ils W., Public Health and Hygiene. 2nd
Edition Revised. Philadelphia: W. B.
Saunders Company, 1937.P. 372
Carter, Charles F ., Microbiology and Pathology.
The C. V. Mosby Company, 1939. P. 756.
2nd Edition.
S t. Louis:
De Kleime, William, Cerebro-Spinal M eningitis in Flood Refugee Center.
South Medical Journal, XXXI (January, 1938), pp. 75-8.
E d ito r ia l, Strains of Meningococci. Journal of the American Medical Assoc ia tio n , CIX (December 11, 1937), p . 1990.
Garrison, Fielding H ., An Introduction
E dition Revised. Philadelphia: W.
to the History of Medicine. 3rd
B.
Saunders Company, 1921.P. 942.
N eal, J. B ., Meningococcus M eningitis in Children. Journal of the American
Medical A ssociation, CV (August 24, 1935), pp. 568-71.
__________ The Treatment of Acute In fectio n s of the Central Nervous System
with Sulfanilam ide. Journal of the American Medical A ssociation , CXI
(October 8, 1938), p. 1353.
Rees, W. T ., Cerebro-spinal M en in gitis. Philadelphia Department of Health,
Monthly B u lletin , October 30, 1930, pp. 6-18.
CHAPTER XVTII
POLIOMYELITIS
D e fin itio n .
P o lio m y e litis is an acute communicable d isease charac­
te rize d by sig n s of a general systemic in fe c tio n and, u su a lly , by in volve­
ment o f the cen tral nervous system, which may be followed by p a ra ly sis.
Synonyms;
In fa n tile P aralysis;
Acute Anterior P o lio m y elitis;
Heine -
Medin D isease.
H istory.
P o lio m y elitis i s thought to be a d isease of great a n tiq u ity ,
one evidence being an Egyptian s te la of the eighteenth dynasty, now in the
Carlsburg Glyptohek a t Copenhagen, which d ep icts a high priedt of the temple
o f A starte with a withered le g .
Michael Underwood, an English physician, f i r s t described p o lio m y elitis
in 1784;
von Heine f i r s t described deform ities resu ltin g from t h is d isea se
in 1840;
and Medin f i r s t described the various c lin le a l types observed in
epidemics in Sweden In 1890.
In 1855, Duehenne pointed out that the paraly­
s is is due to d e fin ite le sio n s in the anterior horns of the spinal cord.
Wiclaiian f i r s t suggested ca rriers as a source of in fe c tio n .
Rhesus monkeys are the only availab le animals to which the d isea se can
be transm itted.
At le a s t two monkeys are used for every d iagn osis, making
the co st of research very high.
R ecently, some in v estig a to rs have succeeded
in transm itting the d isease to cotton r a t s .
Landsteiner and Popper trans­
m itted the d isease from man to monkeys in 1909, and in the same year Flezner
(168)
169
transm itted the d isea se from monkey to monkey, thus providing a method for
continuous stu d y.
In the United S ta te s , in 1938, the National Foundation fo r In fa n tile
F ara ly sis was organized to spread knowledge o f the importance of early diagn oeis and prolonged a fte r -c a r e .
P revalence.
The d isea se occurs throughout the world, but more frequently
in the tenqperate zone.
f a l l months.
In epidemic form i t occurs in the summer and early
No major epidemlos have occurred in tr o p ic a l co u n tries.
In
the United S ta te s the la rg e st epidemic yet recorded occurred in New York City
in 1916, when 9,000 cases were reported.
again v is it e d th at c i t y .
In 1931, 1933, and 1935, epidemics
In 1934, an epidemic appeared in Los Angeles.
Even
in epidemic form the incidence of the d isease i s low, rarely exceeding three
cases per one thousand o f population.1
Sporadic cases occur in a l l communities, a t tim es increasing to epidemic
proportions.
Fewer ca ses are reported in c i t i e s than in ru ra l communities.
In c i t i e s ,
i t i s thought th a t the large number of unrecognized cases which no doubt e x is t
help in a general immunization of the population.
E tio lo g y .
The causal organism is a f ilt e r a b le viru s which i s found in
the t o n s i l s , lymph nodes, nose, throat, and fe c e s;
blood .and cerebro-spinal flu id o f infected persons.
a ls o , i t is found in the
I t r e s is t s drying, freez­
in g , and ordinary d isin fe c ta n ts , but is destroyed by heating to 50° C. for
th ir ty m inutes, or in a short time when exposed to su n lig h t.
Hydrogen peroxide
and potassium permanganate, both of which are oxydizing agen ts, w i l l destroy
the v ir u s.
1.
J. M. Landon and L. W. Smith, P o lio m y e litis, p. 65.
170
Sources o f I n fe c tio n .
Discharges from the nose, th ro a t, and in te s tin a l
tra ct of acute and convalescent c a s e s, missed cases, and ca rriers are the
sources o f the in fe c tio n .
Mode o f Transmission.
Raw food and unpasteurized milk may be fa c to r s .
The entrance of the virus in to the body i s , prob­
ab ly, most often through the nose and th ro a t.
S u s c e p tib ility .
Children usu ally are more su scep tible than a d u lts, most
o f the cases occurring under ten years of age.
In recent epidem ics, th e d is ­
ease seems to be s h if t in g to the older age group. Males are more frequently
a ffected than fem ales, and a l l races appear to be su scep tib le, although some
a u th o rities b e lie v e th a t Negroes are le s s suscep tible than the w hite or yellow
races.
Pathology.
From experiments with monkeys, in v estig a to rs have accepted
the theory that the v ir u s en ters th e nose or naso-pharynx and is carried by
the olfactory nerves to the o lfa c to r y bulb, thence to the hypothalamus and
thalamus; from there by the spino-thalam ic tra ct to th e p o sterio r horns, and
then to the a n terio r horns o f the sp in a l cord.
Another route which the viru s
m
may follow i s from the hypothalamus to the medulla and pons.
I t has been shown experim entally th at the gastro- in t e s t in a l tra ct may be
a pathway fo r spread o f the v ir u s .
The tis s u e s of the e n tir e body may be in ­
volved, not alone the cen tr a l nervous system.
There are marked changes in
the g a str o -in te stin a l t r a c t , in the lymphoid tissu e s o f the sp leen , and in
the t o n s ils .
The e n tir e sp in a l cord, the meninges, and parts of the brain
are a ffected ; but the gray matter of the cord, e sp e c ia lly in the a n terior
horns, i s more e x te n siv e ly in volved .
The v iru s m u ltip lie s, attack in g the
motor nerve c e l l s , and producing a perivascular I n filtr a tio n of sm all mono­
nuclear c e l l s , edema, and hemorrhages with the destruction o f nerve c e l l s .
171
As the acute stage of the d ise a se subsides, motor c e l l s that have bean com­
pressed by edema may recover th e ir fu n ction , but c e lls that have been de­
stroyed are not regenerated.
The motor nerve trunks from these c e l l s atrophy,
and the muscles which they supply shrink from d isu se.
As the inflammation
sub sid es, the nerve tis s u e Is replaced by neuroglia c e lls and scar t is s u e .
The spinal flu id Is under Increased pressure, and examination rev ea ls
an increase in oelj.8, u su a lly from f i f t y to two hundred, the m ajority being
lymphocytes.
The albumin and g lob u lin may be s lig h t ly increased; the sugar
i s u n affected .
The blood shows no c h a r a c te r istic pathological changes.
Incubation Period.
This period i s probably from seven to fourteen days,
but may extend to twenty-one days.
There may be no symptoms during th is
period.
/
Course of the D isease.
The c lin ic a l course of p o lio m y elitis may be d i­
vided into three stages which produce three forms of the d isea se: the abor­
t iv e , the p rep aralytic, and the p a r a ly tic .
The f i r s t sta g e, that o f general in vasion , la s t s one or two days.
A
s lig h t g a str o -in te stin a l disturbance with fever u su ally i s follow ed by head­
ache and m alaise.
The p h ysical examination reveals nothing more than the
physician fin d s when a p atien t has a cold or g a str o -in te stin a l disturbance.
As a d iagn osis is very d i f f i c u l t to make at th is sta g e, cases frequently are
m issed.
The d isease may progress no fu r th e r , but, i f i t continues into the
second sta g e, signs of involvement of the cen tral nervous system, c h ie fly
meningeal ir r it a tio n , appear. The headache may be severe, the temperature
o
o
i s elevated (101 - 103 F«), and the p atien t complains of pain in the back
of the neck and in the lim bs.
On examination the physician fin d s s t if f n e s s
172
o f the neck, changes in the deep r e f le x e s , muscle tenderness, a s t i f f tack ,
known as "poker spine," and often a Kernig or a Brudzinskl sign .
A lumbar
puncture w i l l reveal changes in the spinal f lu id .
The d isease may end a t th is stage or continue in to the third sta g e, in
which severe involvement o f the nervous system r e s u lts in p a ra ly sis.
Fre­
quently the progress of the in fe c tio n i s rapid and p aralysis may be the f i r s t
sign of the d isea se.
The paralyses are most
commonly
type (fla c c id p a ra ly sis), o f a sp in a l or bulbar typ e, or a
of
alower motorneurone
combination of
th ese typ es.
The average duration o f the acute stage
The muscle tenderness may p e r s is t for a long
Types o f the D isease:
Spinal T5fpe.
i s , approximately, one week.
tim s.
P aralysis may attack certain groups
o f muscles supplied by a sin g le nerve rath er than those of an en tire extrem­
ity .
In the lower ex trem ities, m uscles of the anterior surface of the le g s
and thighs are most commonly a ffected ;
in the upper extrem ities, the d elto id
muscles are most often a ffec ted .
The muscles of the back, thorax, and abdomen may be affected .
Respira­
tory d if f ic u lt y occurs when the in te r c o s ta l muscles or the diaphragm are in ­
volved .
When the in terco sta l muscles are involved, the respiration s are
abdominal in character and increased in r a t e .
I f the diaphragm is paralyzed,
the In terco sta l and accessory muscles must perform the functions of resp ira ­
t io n .
When the diaphragm and ln te r c o sta ls are both involved, asphyxiation
may r e s u lt u n less a r t i f i c i a l resp ira tio n i s resorted t o .
Brahdy and Lenarsky, ^ whose study was made at Willard Parker H ospital,
recommend th at only those p a tie n ts with p aralysis o f the respiratory muscles
1.
M. B. Brahdy and M. Lenarsky, Respiratory F ailure in Acute Epidemic P o lio ­
m y e litis , Journal o f P e d ia tr ic s , VII (A pril, 1936), p . 400.
173
due to le s io n s o f the sp in a l cord he placed in the resp ira to r.
Bulbar Type.
p aralyses r e s u lt .
In the involvement of th e cranial nerve n u c le i, bulbar
F acial p alsy, nasal speech, d if f ic u lt y in swallowing,
and accumulation o f mucus in the throat are the commonest o f symptoms.
The
combination o f the bulbar and spinal types i s not uncommon.
Period o f Convalescence.
a period o f , u su a lly ,
As soon as the p a r a ly sis ceases to spread -
two days a fte r it i s f i r s t n oticed -
thetemperature
returns to normal and the meningeal symptoms subside.
Complications and seq u elae.
A ta lecta sis and pneumonia occasion ally
occur in p a tie n ts with respiratory p a ra ly sis.
Atrophy of the paralyzed
p arts and deform ity are the usual sequelae.
Period o f Communicabillty.
E lis period i s not d e f in it e ly known, but
probably extends from the onset of symptoms through th e f ir s t ten days of
the d ise a s e .
P rogn osis.
A ll ca ses of p o lio m y elitis do not r e s u lt in p a r a ly sis.
Pa­
r a ly s is may improve markedly, even com pletely, during the f i r s t few months,
but th e re a fte r the progress i s slew.
The bulbar types are serious i f they involve the muscles o f d eg lu titio n
or the v i t a l nerve cen ters.
When p atients w ith the bulbar type recover, nor­
mal fu n ction o f speech, fa c e , and swallowing i s restored .
P atien ts with res­
p iratory p a r a ly sis recover slow ly, and are su scep tib le to a ta le c ta s is and
pneumonia.
When bulbar and respiratory p a ra ly sis occur togeth er, the prognosis
i s poor.
M o rta lity .
per ce n t.
Ifce death rate in epidemics of p o lio m y e litis i s from 10 to 20
174
Treatment.
Pooled, normal human serum and convalescents' serum, admin­
istered e ith e r intram uscularly or intravenously in the preparalytic sta g e ,
has been used with varying claims o f su ccess.
A lumbar puncture is performed
for d iagn osis, and i t may be repeated i f there i s evidence of increased in tra ­
cranial pressure.
The resp irator (the iron lung) i s o f great value where
there i s exten sive resp ira to ry p a r a ly sis, e s p e c ia lly when th is is due to
in ter c o sta l or dlaphragmatio involvement.
Support of the p aralytic muscles
is given early; when the tenderness has subsided, more exten sive orthopedic
treatment is resorted t o .
Methods of Control;
Recognition and Reporting.
P o lio m y elitis i s recog­
nized by the c l i n i c a l symptoms and by the m icroscopical and chemical examina­
tio n of sp in al f lu i d .
I so la tio n .
I t i s a reportable d isea se.
P a tien ts should he iso la ted fo r a t le a s t fourteen days a fte r
the onset of the d is e a s e .
Quarantine,
days.
ch ild ren who.have been exposed are quarantined for fourteen
Adults whose work brings them in contact with children or with food to
be eaten uncooked are quarantined for the same period.
Immunization. Two methods o f a ctiv e immunization have been attempted:
1
2
Kolmar used an attenuated v ir u s, and Brodie used a k ille d v ir u s. Neither
o f these preparations appears to be e f f e c t iv e .
Spraying the n asal pharynx
with e ith e r 0 .5 per cent p ic r ic acid and 0 .5 per cent sodium aluminum sulphate
in normal sa lin e so lu tio n , or with 1 per cant zinc sulphate and 1 per cent
pontocaine has a lso proved u n sa tisfa cto ry .
1.
J. A. Kolroer, A S u ccessfu l Method of Vaccination Against Anterior P o lio ­
m y e lit is , Journal o f the American Medical A ssociation , CIV (February 9,
1935), p . 356.
2.
M. Brodie and William H. Faxk, An Active Immunization Against Anterior
P o lio m y e litis . New York S tate Journal a t Medicine, XXXV (August 15,
1935), p . 815.
I
175
Convalescents* serum has been used in order to obtain a p assive immunity,
but the r e su lts have not been proved.
Nursing Care
M M M H M tliM M M H I
I so la tio n .
The p a tien t may be cared for in the ward or in a room of a
general h o sp ita l i f p rovision s are made fo r medical a sep tic tech n ic .
Comfort of the P a tie n t.
In the acute stage o f the d isease absolu te rest
i s indicated to avoid muscle fa tig u e;
as p o ssib le .
the patient should be moved as l i t t l e
The a ffe cte d parts should be kept in the p o sitio n prescribed by
the physician, and should be wrapped in cotton or wool to keep them warn.
P illow s and sand-bags are used for immobilization and to prevent stretch in g
of the weakened m uscles.
Boards may be used beneath the m attress to afford
a firm surface for the tender sp in e, and a f la t pillow may be placed under
the head.
When the p atien t has d if f ic u lt y in bending the head forward, a sponge
rubber square with a hole cut in the center i s more comfortable than a p illo w .
The foot is supported a t a right angle to the leg to avoid fo o t drop, and a
cradle i s used to prevent the bed cloth es from touching the fo o t.
The extrem i­
t i e s may be kept at r e s t in s p lin ts a fte r the muscle pain has lessen ed . P la ster
ca sts may be applied to properly immobilize the ex trem ities.
I t is the respon-
i b i l i t y of the nurse to observe whether the oast i s causing undue r e s tr ic tio n
or ir r ita tio n of the t is s u e s .
The edges of the cast must be w e ll protected
to prevent ir r it a tio n from rough surfaces.
The patient with p o lio m y e litis is r e s tle s s and apprehensive, and h is pains
are often sev ere.
He requires the most s k ilf u l nursing care, both to provide
reassurance and comfort, and to prevent future deformity.
P 0 L I 0 M YE I T T
(Bu lbar Type)
I S
A d m i tt e d ..
Name..
F e m a le
..Age..
M onth.
„t___
Case No.__
A u g u st
D a y o f M onth.
19
20
21
25
D a y o f Illn ess.
10
H our of D ay.
R esp.
PU LSi T
T EM P.
em p.
170
108 '
160
107
150
106 '
140
105 '
130
104 '
120
103 '
110
10 2 '
100
101
100'
F r a : i£ ; f e : ’i 6
■c.a
50
F ig . 11. Temperature chart o f ' a p a tien t with p oliom yelitis
(bulbar typd). (See. page 176.)
176
Personal Hygiene:
prevent pressure so r e s.
Care of the Skin.
Care o f the skin is important to
D iligen t care, such as rubbing with alcohol and
cocoa b u tter, and the use o f a ir rings is n ecessa iy .
The nurse must not mas­
sage the a ffec te d parts without an order from the p h y sicia n .
Care of the Nose and Throat.
Special care of the nose and throat i s in ­
d ica ted .
E lim ination.
present a problem.
Constipation due to poor tone o f the abdominal w all may
Laxatives a t n igh t, followed by soap-suds enemata in the
morning, u su ally w i l l be found n ecessaiy.
A ca refu l record o f the urinary
output should be k ep t, as reten tion with overflow i s occasion ally present.
Care of the Bulbar Type.
A nurse should be in constant attendance, and
should watch f o r sign s in d icatin g that p aralysis i s spreading.
has d if f ic u lt y in swallowing, flu id s by mouth are not g iv en .
As the patient
The foot of the
bed is elevated f if t e e n to twenty degrees, and the p a tie n t's head turned to
one sid e; or he may bei turned on his abdomen.
in the pharynx i s removed by su ction .
Mucus which rapidly accumulates
The skin around the mouth should be pro­
tected with zinc oxide ointment, as drooling causes excoriation .
Intravenous
in fu sio n s o f glu cose may be given by the physician to reduce cerebral edema.
Atropin grains 1/150 may be ordered to check secr e tio n s.
As the p a tien t may aspirate flu id given by nasal gavage, duodonel feedings
are in d icated , and are given by means of a Levine tube.
Rectal feedings or
intravenous in fu sio n s may be given.
Care o f the P atien t tn the Respirator.
reported;
Danger sig n a ls should be promptly
-these sig n a ls are cyanosis and breathing which in d icates that only
the accessory muscles of respiration are being used.
177
As emergencies may a r ise at any tim e, the nuree should have available
in the resp ira to r room a tank equipped for nasal adm inistration of oxygen
and a stim ulant tra y .
the head end;
The resp irator i s opened by unlooking the clamps at
the carriage is then pulled o u t.
covered with one large sheet and a draw-sheet.
The m attress should be
A covered p illcw should be
placed under the m attress at the head, to ra ise the shoulders.
The sponge
rubber diaphragm, through which the p a tie n t's head must p a ss, must be fastened
secu rely.
Two or more nurses are required to place a p a tien t in the resp ira to r.
The p a tien t i s placed on the m attress on his back, with his head to one sid e
and h is chin down on h is ch est.
One nurse stands at the front of the resp ir­
ator and, placing the palms o f her hands in sid e the opening in the rubber
diaphragm, p u lls outward, to enlarge the opening so th at she may s lip the
p a tie n t's head through e a s ily and r e st i t on a sm all firm p illo w on the pro­
jectin g s h e lf .
Two other nurses may be required to support the p a tie n t's
body when moving him to get h is head through the opening o f the diaphragm.
The shoulders Should be flu sh with the end o f the m attress, and should be
protected with su ita b le pads.
Care should be taken to p rotect the neck from
ir r ita tio n by fla n n e le tte bandage or so ft sheet-wadding.
I f there is involve­
ment o f the lower e x tre m ities, covered sand-bags are arranged to hold the fe e t
and limbs in the p o sitio n prescribed by the physician .
The arms are placed in
a comfortable p o sitio n and the p a tien t is covered with a sheet and a lig h t
blanket.
The carriage i s pushed in , the clamps clo se d , and the sw itch to the motor
is turned on .
The n egative pressure within the r esp ir a to r, which causes the
chest w all to be a lte r n a te ly relaxed and compressed, i s ind icated by the water
178
manometer, and should be watched c lo s e ly by the nurse.
Depth and ra te of
respiration w ill be prescribed by the physician to meet th e needs of the
o
p a tien t. The temperature w ith in the resp ira to r should vary from 70 75° F . , the humidity 30 to 40 per can t.
The temperature w ithin th e resp ira ­
tor may be reduced, i f n ecessa ry, by turning out the lig h t .
During the hot
summer months c lo th s may be wrung out in ice-water and placed over the r e s ­
p irator, and an e l e c t r i c fan may be placed near i t to prevent overheating.
The nurse must encourage the patient to relax completely and not tr y
to breathe against th e r e sp ir a to r .
As soon as the p a tie n t's breathing be­
comes synchronized w ith the working of the machine, there i s marked improve­
ment .
Port-holes a t the sid e o f the resp irator may be opened at in terv a ls to
attend to the needs o f the p a tie n t, such as adjusting sand-bags, changing
the p osition of e x tr e m itie s, and givin g a bedpan.
A ll work should be done
quickly so that the n egative pressure w ill not be interfered with more than
i s n ecessaiy.
Before opening th e resp ir a to r a l l equipment should be at hand, e sp e c i­
a lly the oxygen tank, sin ce the patient may need oxygen w hile he is being
cared fo r .
Tno nurses draw out the carriage and, working gen tly and quickly,
they bathe the p a tie n t, remake the bed, adjust the sand-bags and the p illo w s,
and give the prescribed treatm ent.
turning him S lig h tly on h is sid e:
The p a tien t's p o sitio n may be changed by
one nurse turns the head and the other
turns the body, care being taken that the head and body are turned in the
same direction a t th e same tim e.
To avoid the onset o f pneumonia, emphasis
must be placed on m aintaining a regular schedule o f turning the p a tie n t.
179
The skin should be kept clean and dry.
The nurse must pay p articu lar
a tte n tio n to the skin of the neck to prevent abrasions, the padding around
the neck should be changed at le a s t every four hours, and the area washed,
d ried , and powdered.
The sheet should be kept fr e e ftorn wfinkleq, and pres­
sure on bony prominences should be reliev ed by cotton or rubber r in g s.
Feeding the patient i s sometimes d i f f i c u l t .
to swallow when exhaling.
The nurse must teach him
At f i r s t the p atien t can to le r a te only sn a il
q u a n tities of f lu id s , but as he becomes accustomed to the rhythm of the
resp irator he can swallow s o ft foods.
He a ls o experiences d iff ic u lty in
ta lk in g , and only by c lo se observation can the nurse understand h is w ishes.
Constant reassurance i s necessary u n til he becamBS accustomed to h is new
surroundings.
As the muscles o f resp iration recover, the p a tien t is removed from the
resp irator for gradually increasing periods of tim e.
P atien ts with resp ira­
tory involvement may be i l l for a long tim e, and they need constant h&lp in
maintaining a healthy a ttitu d e .
Various methods of entertainment may be pro­
vided:
mirrors may be adjusted so th at a c t i v i t i e s outside his room may be
seen;
books and pictures may be placed on a book-rest fastened to the res­
pirator;
w a lls .
toys may be suspended overhead;
or p ictu res may be hung on the
The radio supplies entertainment fo r varied in te r e s ts .
Complications.
As the acute stage in p o lio m y e litis oovers a short period,
com plications are rare.
In cases of resp iratory p aralysis the nurse, by s k i l ­
f u l oare, attempts to prevent h ypostatic pneumonia.
Convalescence.
After the pain and muscle tenderness subside, the patient
with p o lio m y elitis requires d iversion to make h is enforced in a c tiv ity le s s
irksome.
180
D is in fe c tio n :
fe c te d o r burned.
C oncurrent.
Nose and th ro a t d isch a rg es should be d is in ­
D ischarges from th e alim entary t r a c t should be discarded
in t o i l e t s , o r d is in f e c te d before being discarded i f plumbing f a c i l i t i e s are
n o t a v a ila b le .
Term inal.
The u n it should be washed w ith warm w ater and soap, and a ire d
f o r tw enty-four h o u rs.
The m attress and p illow s a re a ir e d .
E s s e n tia l P o in ts to Remember:
1.
Keep the a ffe c te d p a r ts a t r e s t and do not massage them.
2.
Encourage independence.
3.
Help th e p a tie n t to make h is handicap an in c e n tiv e to accomplishment.
Home Care
N ursing I n s tr u c tio n s .
The p a tie n t should be kept q u ie t, and a l l orders
o f the p h y sician should be c a re fu lly follow ed.
Other members of the fam ily
should be observed fo r symptoms which may in d ic a te the onset of the d ise a se .
A ll d isch arg es should be d is in fe c te d .
S elected References
Bolduan, C harles F . , The 1935 Outbreak of P o lio m y e litis . New York C ity :
New York C ity Department of H ealth, Q uarterly B u lle tin . I l l (November 1*
1935), p . 81.
Brahdy, M. B ., and Lenarsky, M., D if f ic u lty in Swallowing in Acute Epidemic
P o lio m y e litis . Jo u rn al o f the American M edical A sso c ia tio n , C III (Ju ly ,
1934), p . 229.
R esp irato ry F a ilu re in Acute Epidemic P o lio m y e litis .
o f P e d i a t r i c s , VII (A p ril, 1936), p. 420.
Journal
181
Brodie, M., and Park, William H ., An A ctive Immunization Against Anterior
P o lio m y e litis, New York S ta te Journal of Medicine, XXXV (August 15,
1935), p. 815.
Ferxy, Mary, Nursing Care in P o lio m y e litis .
1938), pp. 177-81.
Canadian Nurse, XXXIV (A pril,
G illiam , A. G., Epidem iological study of an Epidemic, Diagnosed aB P o lio ­
m y e litis , Occurring Among the Personnel o f the Los Angeles County
General H ospital during the Summer of 1934. Washington, D.C.: United
S tates Public Health S er v ice , B u lle tin No. 840 (A p ril, 1938), pp. 1-90.
Landon, John F ., Smith, L. W., and Lynch, Theresa I . , P o lio m y elitis.
York: Macmillan Company, 1934. P. x i t 275.
New
CHAPTER XIX
EPIDEMIC ENCEPHALITIS *
D e fin itio n .
Epidemic en c e p h a litis i s an acute In fectiou s d isea se
a ffe c tin g the cen tra l nervous system, and characterized by a v a r ie ty of
symptoms and sign s in d iffe r e n t c a se s, depending upon th e s it e o f the
le s io n s .
The term "sleeping sickness" applied to th is d isease i s mis­
lead in g, a s i t tends to confound epidemic en cep h a litis with "African
sleeping sick n ess."
Synonyms:
E nceph alitis Lethargies;
von Economo’s
E n cep h a litis.
H istory* L it t le seems to be known about the h istory of epidemic en­
c e p h a litis .
In 1915 the f i r s t cases of the d ise a se , a s recognized today,
occurred in Rumania and France, and an epidemic followed in 1916-1917. The
d isease spread to England in 1918, and f i r s t appeared in the United S ta te s
in the f a l l of that y ear, the f i r s t case being reported by Dr. Josephine 6 .
Neal of the New York C ity Health Department.
Three typ es of e n c e p h a litis have been d iffe r e n tia te d during the past
seven years from e n c e p h a litis le th a r g ie s:
en cep h a litis;
the S t. Louis type;
Japanese B
and ea stern and western equine encephalom yelitis.
* This chapter r e fe r s in general to epidemic (von Economo*s ) e n c e p h a litis ,
but fo r purposes o f c la r it y reference is made to other forms of the
d ise a se .
( 188 )
183
Pre-valance.
E ncephalitis i s more prevalent in th e temperate zone.
No
important epidemics o f von Economo*s en c e p h a litis have been reported in the
United S ta tes sin ce 1926.
Epidemic en cep h alitis occurs in the w inter months.
Japanese types occur in the summer months.
The S t. Louis and
Outbreaks o f en cep h a litis due
to the equine virus o f encephalom yelitis a lso occur, apparently, in the
summer.
E tio lo g y .
The causative agent of epidemic en cep h a litis i s undetermined.
Some a u th o r itie s b eliev e that i t may be due p o ssib ly to a neurotropic form
o f herpes v ir u s.
A s p e c ific v iru s has been proved to be the cause of the
S t. Louis type, and a d e fin ite viru s a lso has been iso la te d for the Japanese
B typ e.
The v iru s causing eastern equine encephalom yelitis d iffe r s from the virus
causing the western type of th is d ise a se .
I t recen tly has been proved that
th is d isease i s transm itted to man.
Cases o f en cep h a litis follow in g m easles, v a ccin a tio n , and other acute
in fe c tio n s have been described in considerable numbers during the past twenty
years.
Nothing d e fin ite i s known of the etio lo g y o f these forms of encepha­
l i t i s , as th e ir c lin ic a l p ictu res vary over a wide range.
Sources of In fe ctio n .
Nasal and o ra l dls charges of in fected individuals
or ca rriers probably are the sources of in fe c tio n , except in the case of en­
c e p h a litis due to the equine v ir u se s .
Mode o f Transmission.
The d isea se probably i s transm itted by d irect con­
ta c t w ith an in fected in dividual or c a r r ie r , or in d ir e c tly by a r t ic le s fresh ly
so ile d with the discharges from th e nose and throat of in fected persons.
Abor­
t iv e and unrecognized oases may be responsible fo r transm itting the d ise a s e .
184
I t has been shown experim entally th at equine encephalom yelitis may be tran s­
mitted by in s e c ts , e s p e c ia lly m osquitoes.
S u s c e p tib ility .
A ll ages are suscep tible to the d isea se, the maximum
o f cases occurring among a d o lescen ts.
than fem ales.
Males are s lig h t ly more su scep tib le
In the epidemics of the S t. Louis type and the Japanese B
type the p a tie n ts were o f middle age, or old er.
Pathology.
Changes may be found throughout the brain, but the mid-
brain, the b asal g a n g lia , the pons, and medulla show the g rea test in volve­
ment.
The sp in a l cord may show changes.
The sp in a l f lu id u su ally shows a variably increased c e l l count, c h ie f ly
o f the mononuclear v a r ie ty ; the glob ulin usually is increased, and th e sugar
content may be increased .
Incubation P eriod .
The blood shows a leu co cy to sis.
This period is thought to be from four to twenty-one
days.
Course of the D ise a se :
C lin ica l P ictu re.
In gen eral, prodromal symptoms
range from a few hours to several days, and include headache, m alaise, fe v e r ,
drowsiness, g a s tr o -in te s tin a l disturbances!and sometimes con vulsions, e s p e c i­
a lly in ch ild ren .
The onset o f the disease may be acute with th e ea rly ap­
pearance o f the c h a r a c te r istic m anifestations of lethargy, weakness, and eye
signs, or sig n s o f involvement of the central nervous system may not be ob­
served fo r sev e ra l weeks.
The ocu lar s ig n s include nystagmus, d ip lop ia, unequal p u p ils, p t o s is ,
and p a ra ly sis o f the eye m uscles, which may produce strabismus; s t i f f neck
and K em ig's sig n may be present; motor disturbances are frequent and varied;
and f ib r llla t in g tremors are common.
Sensory disturbances are rare.
acute sta g e o f t h is d isea se la 3 ts from four to eight weeks or lo n g er.
The
The
185
p a tien ts convalesce very slow ly, and in about 10 per cent o f the cases some
progressive d isea se o f the cen tral nervous system occurs.
The chronic stage
may follow the onset immediately or develop a fte r a period of years.
Some­
tim es the d isea se i s very mild and passes undiagnosed.
Complications and Sequelae.
Complications seldom occur during the acute
s ta g e , but the d isea se i s dreaded because of the danger of the chronic stage.
This sta g e may include mental or psychie impairment (e sp e c ia lly in ch ild ren ),
headache, or insomnia;
curve a lso may occur.
changes in p erson ality and conversion of the sleep
Organic changes may be ev id en t, such as p to sis and
sq u in t, f a c i a l asymmetry, d iffic u lty in speech and d e g lu titio n , paralysis of
an extrem ity, tremors, and t i c s .
Parkinson’s syndrome (p aralysis agitans)
i s a common symptom of the chronic stage, and i t may appear a fte r a long
in te r v a l.
I t is characterized by a mask-like f a c i a l expression (as in repose),
s p a s t ic it y of the voluntary m uscles, and marked trem ors.
Period o f Communlcability.
This period has not been determined, but the
d isea se probably is transm issible during the acute f e b r ile sta g e .
Prognosis.
The prognosis v aries in d iffe r e n t epidem ics.
Many p atien ts
recovering from the acute illn e s s enter the chronic s ta g e , and about 10 per
cent develop conduct d isord ers, or psychoses severe enough to make commitment
n ecessa ry .
Many p a tien ts are incapacitated.
Treatment.
measure.
Lumbar puncture is done as a d iagn ostic and therapeutic
The treatment is symptomatic.
Sedatives u su ally are prescribed.
C onvalescents' serum has been used.
Methods o f Control: Recognition and Reporting.
by th e c l i n i c a l p ictu re.
I t i s a reportable d ise a se .
The d isea se is recognized
186
I so la tio n .
of the d ise a se .
The p atien t should be iso la ted fo r one week a fte r the onset
Suspected cases should be isolated u n til the diagnosis is
made.
Quarantine.
Quarantine i s not considered necessary.
Immunization.
No s a tis fa c to r y methods o f active or passive immunization
have been developed.
NUrsing Care
I so la tio n .
The p a tien t may be cared fo r on an open ward or in a room
o f a general h o sp ita l.
Medic&l a se p tic technic should be observede
Comfort o f the P a tie n t.
A qu iet environment is paramount.
g ic p atien t requires m eticulous p h y sica l care.
The leth a r­
He should be turned fr e ­
quently to prevent h yp ostatic pneumonia.
In the myoclonic type of the d ise a s e , in which there usually i s insomnia,
the p atien t thrashes about the bed, and a l l the sign s of overstim ulation are
p resent.
R estraints seem to aggravate th is condition, and th e ingenuity of
the nurse i s taxed to soothe the p atien t •
the crib should be padded.
these p a tie n ts.
For a ch ild p a tie n t, th e s id e s of
S k ilfu l nursing can do much to a lla y the fe a r s of
A lig h t touch, a g e n tle v o ice, and a calm manner may prevent
excitement and wom y .
Personal Hygiene:
tio n .
Care o f the Skin.
The skin requires constant a tten ­
Excessive p ersp iration and incontinence make prevention of pressure
sores an important con sid eration .
Frequent bathing i s indicated.
When the
p atien t i s comatose, he i s turned every two hours, and his back is washed
and rubbed with a lco h o l.
The bony prominences should be rubbed with cocoa
18?
b u tter, and rubber or cotton rings should be used to r e lie v e pressure.
When frequent lumbar punctures are done, sp ecia l care must be given to the
skin at th e s it e of the puncture.
Care of the Eyes.
may be very s e n s it iv e .
The eyes should be protected from li g h t , a s they
Boric irrig a tio n s are soothing.
Care of the Mouth.
feed in g .
I t may be necessary to U3e a mouth-gag, as the p atien t is not in
a condition to cooperate.
used;
The mouth should be cleansed before and a f t e r each
Cotton applicators and a mild a n tis e p tic may be
mineral o i l i s h elp fu l in softening the sordes;
vaselin e r e lie v e s
the dryness of the l i p s .
E lim ination.
The p a tien t u sually is con stip ated , and d a ily elim in ation
i s secured by la x a tiv e s or enemata.
The urinary output must be ca r e fu lly
matched, as reten tio n with overflow is not uncommon.
n ecessa iy .
C atheterization may be
An acourate account of sto o ls and urine must be noted on the pa­
t i e n t ’s c l i n i c a l record.
D ie t.
In the acute sta g e, the d iet co n sists of higgi c a lo r ic f lu id s ,
such as f r u it ju ic e s with dextrose, egg-nogs, or other milk drinks.
should be given f r e e ly .
Water
A child should receive at to a st 1,500 to 1,800
c a lo r ie s in twenty-four hours; an ad u lt, 2,800 c a lo r ie s .
I f the p a tien t is
unable to swallow, nasal gavage may be ordered, or the flu id supply may be
increased by glucose in fu sion s or hypodermoclysis.
L ater, vegetables are
added to the d ie t , and during convalescence a highly nourishing d iet is
ordered.
Com plications.
The nurse must watch f o r , and record, the s lig h t e s t
change in the condition of the p atien t.
Such symptoms as double v is io n ,
188
p t o s is , and o s c illa t in g movements of the eye may occur.
I n a b ility to use
m uscles, r ig id ity of the neck, or twitching should be reported.
C lin ic a l Recording.
Comprehensive observations of th e patient*s con­
d itio n are h elp fu l to the physician to whom he may be referred a fte r leavin g
the h o sp ita l.
A ll symptoms should be recorded as soon as noted.
Convalescence.
A fter the acute stage of th e d isease has passed, the
p a tie n t’s strength i s depleted, and h is mind i s confused.
to fancied s lig h t s .
He i s s e n sitiv e
The nurse should endeavor to d iscover and develop h is
in te r e s ts and do her part to help him again become a productive member of
s o c ie ty .
P atien ts with severe mental disorders require care in mental
h o s p ita ls .
'
E s se n tia l Points to —
Remembers
,— .
1.
The p atien t requires gentle handling and sympathetic understanding.
2 .
Unusual
sy m p to m s
should be reported to the physician immediately.
Home Care
Nursing In str u c tio n s.
The patient should be kept in quiet surroundings,
and disturbing n o ises and bright lig h ts should be avoided.
should be reported to the physician immediately.
Unusual symptoms
189
S elected R eferences
Bredeck, J . F ., e t a l , Follow-up S tu d ies o f th e 1933 S t, Louis Epidemic of
E n c e p h a litis . Jo u rn a l of th e American Medical A sso c ia tio n , CX (Ju ly ,
1938), p . 15.
Brown, A. W., In flu en ce of L a th arg ic E n c e p h a litis on I n te llig e n c e of C h il­
d ren . American Journal of D iseases of C h ild ren . LV (F ebruary, 1938),
pp. 304-21.
Epidemic E n c e p h a litis Report o f Survey o f the Mathewson Commission, F i r s t
R eport. New York: Columbia U n iv e rsity P re s s , 1929.
__________ , Third R eport.
Columbia U n iv e rsity P re s s , 1939,
H a ll, Stephen, The Mental Aspect of Epidemic E n c e p h a litis .
Jo u rn al (March, 1929), pp. 444-46,
B r itis h Medical
Muckenfuss, Ralph S ., U nited S ta te s Public Health S e rv ic e . Washington, D.C.:
P u b lic Health R ep o rts, XLVIII (November 3, 1933), p. 1341.
Report of the S t, Louis Outbreak of E n c e p h a litis , P u b lic Health B u lle tin .
No. 214 (January, 1935).
S c o lte n , Adrian, R esidual E n c e p h a litis - S o cial A spects of E n c ep h alitis
L e th a rg ic a . Trained Nurse and H o sp ital Review, LXXXIV (March, 1930),
pp. 349-50,
S teen , P a t r i c i a , Epidemic E n c e p h a litis .
(November, 1931), p , 1235.
American Jo u rn al of N ursing, XXXI
von Economo, C o n stan tin , E n c e p h a litis L e th a rg ic a . I t s Sequelae and I t s
Treatm ent. E dited by K. 0 ., Newman. New York: Oxford U n iv ersity P re s s ,
1931. P. 216.
CHAPTER XX
LEEROSY
D e fin itio n .
in three forms:
Leprosy i s a chronic communicable disease which occurs
(1) the nodular, characterized by the formation of nodules
in the skin and mucous membranes;
(2) the neural, or m aculo-anesthetic,
form, characterized by the formation of patches on the surface of the body,
and by nerve le sio n s ;
(3) the mixed form, which i s a combination of the
f ir s t two forms.
H istory.
ea ses.
Leprosy i s one of the most ancient of the oommunicable d is ­
Egypt, apparently, was i t s b irth p la ce, frequent references to it
being found in the Papyrus Ebers, w ritten twelve hundred years before the
Christian era.
From Egypt i t spread to various parts of the world, in clud ­
ing Rome, and the Romans in th e ir conquests carried the d isease far and wide.
During the Middle Ages i t became so wide-spread in Europe that segregation
of lep ers was r ig id ly enforced by th e establishm ent of sp ecia l houses c a lle d
la z a r e tto s, a term adopted as a r esu lt o f the b e lie f that Lazarus was a lep er.
In the th irte en th century, there were 19,000 lazarettos throughout Europe.
/This is o la tio n o f le p e r s, practiced for cen tu ries, has resu lted in the elim ­
in ation o f lep rosy as a great public menace.
Up t o recant years the general a ttitu d e toward leprosy was la r g e ly in ­
fluenced by th e alarming B ib lic a l referen ces to i t , which engendered a g rea t
fea r o f the d isea se among the p u b lic.
(190)
Now, in countries where leprosy i s
191
present, th e d ise a se i s regarded with no more concern than many oth er com­
municable d is e a s e s .
In 1894 the United S ta tes Public Health Service estab lish ed a lep ro­
sarium at C a r v ille , Louisiana, and in 1939 the government appropriated
#14,000,000 fo r new b u ild in g s.
The most famous leper colony in the world,
esta b lish ed in 1865 by the Hawaiian Government, i s situ ated on the islan d
o f Molokai.
P revalence.
Leprosy i s endemic at present in certain l o c a l i t i e s in
the Eastern and ’Western hemispheres.
There are about 4,000,000 reg istered
lep ers in the world, c h ie f ly in R ussia, Iceland, A sia, the P h ilip p in e Isla n d s,
Hawaii, in the Gulf s ta te s and a few in other areas of the United S ta te s .
E tio lo g y .
The causal organism o f the disease is the leprosy b a c illu s
(Mycobacterium le p r a e ) , which was discovered by Hansen in 1873, and confirmed
by N eisser in 1879.
I t resembles the tubercle b a c illu s.
Sources o f I n fe c tio n .
The le s io n s and body discharges are the sources
of in fe c tio n .
Mode o f Transm ission.
not known;
The exact mode of transfer o f leprosy b a c i l l i is
they probably enter the body through the mouth and nose.
d isea se i s not h ig h ly communicable;
The
I t i s contracted only by prolonged and
intim ate co n ta ct.
S u s c e p t ib ility .
S u sc e p tib ility to leprosy i s uncertain.
to be no r a c ia l immunity, and the d isease is not hereditary.
There appears
I t u su ally
occurs in young a d u lts, but children exhibit a high degree of s u s c e p t ib ilit y
i f l e f t in co n ta ct with leprous parents.
Pathology.
A d efen sive m u ltip lica tio n o f tissu e c e l ls occurs a t the
s it e of in fe c tio n .
The nodular type i s characterized by a tumor-like
192
overgrowth of the skin;
the an esthetic type, by the presence of lo c a liz e d
areas o f skin a n esth esia .
The b a c i l l i are found in the nerves and in a l l
mucous membranes.
The diagnosis o f leprosy i s made by sta in in g !$crrapii|gs f rom the nasal
septum.
The b a c i l l i are found in large numbers, and under the microscope
they resemble a packet o f cig a rs.
Incubation Period.
one to seven years;
The incubation period i s prolonged, probably from
some a u th o r ities sta te that th is period may vary from
a flew months to twenty years.
Course of the D isea se.
The prodromal symptoms o f leprosy may be head­
ache, r h i n i t i s , n e u r itis , g a str o -in te stin a l disturbances, and disturbances
of the ce n tr a l nervous system.
Some p atien ts have no symptoms u n t il the
d isea se is m an ifest.
Types of the D isea se: Nodular Leprosy.
In nodular lep ro sy , nodules
appear in crops on th e sk in , usu ally on the hands, f e e t , and fa c e .
Gradually,
the skin th ick en s, the eyebrows disappear, and some of th e nodules u lce r a te ,
w hile others are absorbed.
Cycles of the d isease occur at in terv a ls u n til
the whole body may become involved.
This type o f leprosy produces a p eculiar
thickening o f the akin o f the forehead and cheeks, givin g the fa ce of the
in d ividu al a lio n - lik e appearance.
I f the case is severe, exten sive necrosis
o f the t is s u e s may oocur, with the lo s s of fin gers and to e s .
G a stro -in testin a l
disturbances are common in th is type of the d isea se, and frequently tubercu­
l o s i s occurs.
P a tien ts with nodular leprosy may liv e ten or twenty years.
A nesthetic Leprosy.
A patient may have no prodromal symptoms o f th is
type of leprosy except severe n e u r itis .
p le te a n esth esia occur.
Loss of sensation and, f in a lly , com­
Trophic u lcers appear on the f e e t and hands, fin gers
193
and toes drop o f f , and b lis t e r s appear on th e trunk.
A fter sev era l years
o f th is stage the fin a l stage appears, accompanied by f a c ia l paralysis and
gangrene of the f e e t .
The patient may liv e fo r fif t e e n years.
The in s id i­
ous onset of a n esth etic leprosy is illu s t r a te d in the case of Father Damien
of Moldkai, who rea lized that he had contracted the d isease only when b o il­
ing water ran over h is foot and he f e l t no pain.
Mixed Leprosy.
This i s a combination o f the nodular and an esth etic
forms o f leprosy which frequently occurs.
Complications and Sequelae.
These include:
Many com plications occur in th is d ise a se .
hemorrhage, pneumonia, tu b e r c u lo sis, gangrene, aphonia, and
m u tilation of the fea tu res and the lim bs.
Period o f Communicabllity.
Leprosy i s communicable from the time the
open le sio n s begin to discharge b a c i l l i u n t il the le sio n s are healed.
Prognosis.
The prognosis o f nodular leprosy is poor, but the anesthetic
type may be arrested i f treated ea rly .
Treatment.
Many cases have been arrested in th e ir development by in je c ­
tio n s of acid e ste r s obtained from chaulmoogra o i l .
The in je c tio n s, which
are given intram uscularly, are very p ain fu l and cannot be tolerated by a l l
p a tie n ts.
Methods of co n tro l:
Recognition and Reporting.
The d isease i s recog­
nized by the c lin ic a l symptoms, and i s confirmed by laboratory d iagn osis.
Cases must be reported immediately.
Iso la tio n .
u n til
I f le sio n s are open, the p atien t i s iso la te d in a leprosarium
a l l the le sio n s are healed.
Paroled lep ers should be examined a t in ter­
v a ls of s ix months.
Quarantine.
Quarantine i s not necessary in th is d ise a se .
194
Immunization.
No methods o f a c tiv e or passive Immunization have been
discovered.
Nursing Care
Iso la tio n .
P a tien ts are sent to a leprosarium, but while waiting to be
transferred they may be cared fo r in a h o sp ita l or in a home i f medical
a sep tic technic is observed.
Personal Hygiene.
hygiene.
The p atien t should be taught good habits of personal
F a c ilit ie s fo r d a ily baths and clean clo th in g should be provided.
Mental gyglene.
Lepers u su ally are ambulatory, and they should remain
outdoors as much as p o ssib le .
provided fo r them.
Occupational therapy and recreation should be
They should be encouraged to continue treatm ents, because
i f there are no discharging le s io n s they may return to th e ir homes.
D ie t.
The d ie t fo r leprosy p a tie n ts should be highly nourishing.
Complications.
D isin fectio n :
The treatment o f com plications i s symptomatic.
Concurrent.
A ll body discharges must be d isin fe c te d ,
as w e ll as a r tic le s s o ile d with d isch arges.
f if t e e n minutes.
Linen should be boiled for
Food waste and handkerchiefs containing nose and throat
secretio n s should be burned.
Terminal,
The unit should be thoroughly cleaned with soap md water
upon th e death or discharge o f a p a tie n t.
E sse n tia l Points to Remember:
1.
Leprosy i s communicable only under s p e c ia l con d ition s.
195
2.
In the U nited S ta te s le p e rs with d isch arg in g le s io n s a re sent to a
leprosarium a t C a r v ille , L o u isian a.
3.
Lepers whose le s io n s have h ealed a re p aro led , and th ey must re p o rt to
the health a u th o r itie s in t h e i r home communities a t s ta te d in te r v a ls .
S ele c te d R eferences
C a rte r, C harles F . , M icrobiology and P athology.
The C, V. Mosby Company, 1939. P. 756.
2nd E d itio n .
Jack s, Leo V incent, Mother Marianne o f Molokai.
Company, 1935. P . xvi + 204.
New York:
S t. L ouis:
Macmillan
Park, William H., and W illiam s, Anna W., Pathogenic M icroorganisms. 11th
E d itio n R evised. P h ila d e lp h ia : Lea and F eb ig er, 1939. P . 1056.
Rosenau, M ilton J . , P rev en tiv e Medicine and Hygiene. 6th E d itio n .
D. Appleton-Century Company, 1935. P. xxv 4 14-82.
W right, Lena, N ursing a t M olokai.
(January, 1939), pp. 15-17.
New York:
P a c if ic Coast Journal of N ursing. XXV
CHAPTER XXI
SCABIES
D e fin itio n .
Scabies i s a communicable skin d isea se characterized by
eruptive le s io n s produced by an animal p arasite (Acarus s c a b ie i) .
H isto ry .
Scabies has been known fo r centuries as "the itc h ."
described the itc h mite in the tw elfth century.
on the p a r a sitic o rig in o f scabies in 1786.
Avenzoar
Wickman wrote a monograph
Ihe causative agent of the " itch
mite" was discovered by Renucci in 1834.
Prevalence.
The d isease i s widespread.
I t occurs sp orad ically and in
epidem ics, and i t i s a sso cia ted with n eglect of personal hygiene, and w ith
crowded con d ition s such as are found in tenements and barracks;
i t was com­
mon among the troops in the World War.
E tio lo g y .
The cause o f scab ies i s the itch mite (Acarus s c a b ie i).
The
female p a r a site , which i s e a s ily v is ib le under a magnifying g la s s , burrows
beneath the epidermis to deposit her eggs.
The burrow i s marked by a s lig h t
e lev a tio n a t one end, and by a grayish speck at the other end.
The male
m ite, which i s sm aller, remains on the surface of the sk in .
Source of I n fe c tio n .
Persons who harbor the itc h m ite, e s p e c ia lly on
the hands, cause the in fe s ta tio n o f oth ers.
Mode of Transmission.
The disease is transm itted by d ir e c t contact with
in fe ste d persons, or through to w els, bedding, or clo th in g .
(196)
197
S u s c e p tib ility .
There seems to be no immunity to scab ies; in d ivid u als
may become in fested and r e in fe ste d .
Pathology.
The primary le s io n is produced when the in se o t burrows be­
neath th e skin; i t sometimes extends one h a lf inch, in e ith e r a tortuous or
a str a ig h t l i n e .
d o ts.
In appearance i t resembles a th read -lik e row of dark gray
Itch in g papules, v e s ic le s , and pustules develop secon d arily.
Some­
tim es the staphylococcus gains entrance to the le s io n s and causes the forma­
tio n o f a b scesses.
Incubation Period.
The incubation period i s from tw enty-four to f o r ty -
eig h t hours a fte r the o r ig in a l in fe sta tio n , the length of time required fo r
the itc h m ite to burrow under the skin and deposit eggs.
Course o f th e D isease:
C lin ica l P icture.
The skin irtrita tio n in scabies
i s f e l t soon a f te r the invasion of the m ite, and a red lin e a r mark surrounds
the burrows.
The in te r d ig it a l spaces are the most common lo c a tio n o f these
burrows, but oth er parts of the body frequently are in volved .
qt the s i t e where the p a ra site r e sts a fter burrowing.
removed by opening a primary le sio n with a needle.
V e s ic le s occur
The itc h m ite can be
The only symptom o f scabies
i s in ten se itc h in g , and scratching of the le sio n s may cause d erm a titis.
The
d isea se probably never disappears spontaneously.
Complications and Sequelae.
In long neglected c a s e s, a true eczema or
impetiginous cru stin g r e s u lt s .
Period o f Communicabillty.
The disease i s tran sm issib le u n t il the itch
m ite and eggs are destroyed.
P rognosis.
The prognosis is gpod.
The disease term inates quickly with
treatm ent.
Treatment.
Sulphur ointment is the most e ffic a c io u s treatment fo r sca b ies.
198
Methods of Control:
Recognition and Reporting.
The condition should
be reported immediately i f found in sc h o o ls, or among groups liv in g in
c lo se con tact.
I s o la tio n .
Children should be excluded from school u n t il d is in fe s te d .
A ll in fested in d iv id u a ls should be excluded from recreation cen ters.
Quarantine.
Quarantine is not necessary.
Nursing Care
P a tien ts w ith other diseases who are admitted to the h o sp ita l may some­
tim es have sc a b ie s.
In such cases, medical a sep tic technic i s observed.
R estrain ts u su ally w ill have to be placed on the arms of in fan ts and
ch ild ren to prevent scratching.
The in fested person is given a hot clean sin g bath at bedtime and, a fte r
thorough drying, sulphur ointment is rubbed in to the sk in .
The ointment i s
removed in th e morning with warm water and soap, and the treatment i s repeated
fo r two or three days.
Some physicians p rescrib e th at an a p p lica tio n of o in t­
ment be l e f t on fo r three days, the p a tie n t’s clo th in g not to be removed dur­
ing that tim e.
The bath i s then given, fresh ointment i s ap p lied , and clean
clo th in g is put on the p a tie n t.
Complete change o f bedding, including blan­
k e ts , i s indicated a t each application of the ointm ent.
Ointment one fourth
to one h a lf strength should be used for in fa n ts and young ch ild ren .
D isin fe c tio n ;
Concurrent.
A ll clothing and bedding in contact with the
in d ividu al should be d isin fe cte d .
Terminal.
Bedding and clothing should be b oiled to destroy the m ites;
wool clo th in g should be cleaned with gasolin e;
the unit should be thoroughly
cleaned with soap and water, and aired fo r s ix hours.
199
E s s e n tia l P o in ts to Remember:
1.
Scabies is a sso c ia te d w ith lack of p erso n a l hygiene.
2.
The n u rse, by teach in g th e im portance of c le a n lin e s s to p aren ts and
c h ild re n , can help le sse n the prevalence of sc ab ies.
Home Care
Nursing I n s tr u c tio n s .
A ll bedding and underwear should be b o ile d .
C lothing which cannot be washed should be exposed to su n lig h t fo r s ix hours
b efo re being sent away fo r dry cle a n in g .
A r tic le s sent to th e c c le a n e r*s
should be wrapped, t i e d s e c u re ly , and tagged fo r s p e c ia l handling, with a
n o ta tio n in d ic a tin g th a t they have been worn by a person in fe s te d with
s c a b ie s.
R e in fe sta tio n should be watched f o r ; c le a n lin e s s of the body
and the surroundings is the only p rev en tiv e measure.
S e lec ted R eferences
Beckman, H arry, Treatment in General P r a c tic e . 3rd E d itio n Revised.
d e lp h ia: W. B. Saunders Company, 1939. P . 788.
P h ila ­
S to k es, John H0, Dermatology and Syphilology fo r Nurses Including S ocial
Hygiene. 2nd E d itio n R e se t. P h ila d e lp h ia : W. B. Saunders Company, 1935.
P* 368,
S ellew , Gladys, The Child in N ursing.
1938. P . 600.
P h ila d e lp h ia :
W. B* Saunders Company,
CHAPTER XXII
TETANUS
D e fin itio n .
Tetanus i s an acute in fectio u s disease characterized by
ton ic spasms of some o f the voluntary m uscles, and by co n stitu tio n a l symp­
toms.
Synonym:
H istory.
Lockjaw.
Tetanus was described by Hippocrates, but the disease was
not considered communicable u n til N ico la ier produced i t in animals by s o il
inoculations in 1884.
In 1889, K itasato grew the organisms in pure cu ltu re ,
and by inoculating animals proved that the b a c i l l i remain lo c a liz e d in the
wound and produce solu b le to x in s .
The follow ing year Kitasato and von
Behring produced tetanus a n tito x in , the value o f whioh, e sp e c ia lly during
wars, has been in estim ab le.
During the World War, in France, where the s o il i s saturated w ith the
spores of teta n u s, trench warfare favored the development o f th is f r ig h tfu l
d isea se, and i t occurred in a large proportion of the wounded s o ld ie r s .
As
soon as the a n tito x in was used as a routine prophylactic measure among the
wounded, tetanus p r a c tic a lly disappeared.
Prevalence.
Tetanus i s comparatively rare in the United S ta te s .
Cases
which do occur u su ally are reported in the A tlantic sta te s as the s o i l o f
the western s ta te s i s p r a c tic a lly free from tetanus spores.
u sually occurs in young m ales.
(200)
The d isease
201
E tio lo g y .
The causative organism of tetanus is the tetanus b a c illu s
(Clostridium t e t a n i) , which produces a powerful exotoxin under anaerobic
conditions;
t h is toxin is twenty times as poisonous as dried cobra venom.*
The tetanospasmin i s the part of the toxin which causes muscle spasms,
whereas the teta n o ly sin i s that part which a c ts to d isso lv e red blood
co rp u scles.
Toxins are most rea d ily produced in deep wounds contaminated
with other organisms, or in n ecro tic tib su e .
Under anaerobic co n d ition s, the tetanus b a c illi develop spores.
The
organisms in spore form have been known to grow a fte r eleven years in the
s o i l , or on wooden s p lin te r s .
The b a c illi and th eir spores fin d id ea l con­
d itio n s for growth in the in te s tin e s of animals; they are present to a v a r i­
able extent in th e in te s tin e s of man.
Tetanus spores are very r e s is ta n t to heat and d isin fe c ta n ts .
B ichloride
o f mercury 1:1000 with 0.5 per cent of hydrochloric acid destroys them in
th ir ty m inutes.
for one hour;
In spore form the organisms w ill r e s is t dry heat at 80° C.
exposure to steam under pressure at 120° C. fo r twenty minutes
i s necessary to destroy them.
Sources of I n fe c tio n .
2
The b a c il li are found in animal manure, human
fe c e s , and s t r e e t d u st.
Mode of Transmission.
Tetanus is transmitted through wound in fe c tio n s ,
e s p e c ia lly o f the hands and f e e t .
Punctured and lacerated wounds, where
there i s dead t is s u e , are more su scep tib le to the In fection than are cle a n cut or open wounds.
The organisms are introduced beneath the skin and into
1.
William H. Park and Anna W. W illiams, Pathogenic Microorganisms, p . 632.
2.
I b j^ f, p . 630.
202
the tis s u e s a t the time o f accident by s o i l or d ir t which has been contamin­
ated by animal manure.
The most common methods of tran sfer are n a il puncture,
s p lin te r s , la c er a tio n s, and blank cartridge wounds.
O ccasionally the organ­
isms are transm itted by hypodermic in je c tio n o f vaccin es, or through unclean
d ressin g s.
Tetanus b a c i l l i may gain access to the body of an infant through
the um bilical cord.
S u s c e p tib ility .
to many anim als.
S u sc e p tib ility is gen eral.
Tetanus i s common to man and
Horses, guinea p ig s, g o a ts, and mice are more suscep tible
than dogs, ra b b its, and c a ts .
Pathology.
Pathological changes are due to the a ctio n of the toxin of
the b a c illu s which tr a v e ls to the central nervous system by way of the nerves
and blood stream.
spinal cord.
The toxin a f fe c t s the motor c e l l s in the medulla and the
Autopsies reveal few sig n ific a n t le sio n s: the organs show moder­
ate con gestion , and few tetanus b a c illi are found, even at the s it e of in fe c tio n .
Incubation Period.
The incubation period u sually i s from four to twenty-
one days, although longer periods have been reported.
The period depends upon
the character and lo ca tio n of the wound.
Tetanus occurs in two c lin ic a l forms, acute and ch ron ic.
The acute form
i s characterized by a short incubation period o f four to fourteen days;
chronic by a longer period o f four to six weeks.
the
Acute tetanus As more lik e ly
to follow wounds about the head and fa c e .
Course of the D isease:
C lin ical P ictu re.
The f i r s t symptoms of tetanus
may be r e s tle s s n e s s and i r r it a b ilit y ; or the onset may be sudden, with s t i f f ­
ness of the neck and d if f ic u lt y in using the lower Jaw.
c u lt , sometimes im possible.
Swallowing is d i f f i ­
The head i s retra cted , the Jaws are r ig id , the
203
l ip s protrude, and the face has a sardonic smile (r isu s sardonicua) which
is due to th e unequal strength of the f a c ia l m uscles.
The muscles of the
body are involved in convulsive spasms, during which the patient is unable
to move or speak, and he frequently i s in a p o sitio n of opisthotonos.
Con­
vu lsion s may vary from a few to almost constant seizu res in twenty-four
hours.
The pain i s ex cru cia tin g , and the p atien t may appear as i f held in
a v is e .
He perspires p rofu sely, although th e temperature may not be e le ­
vated.
Tetanic spasms may fo llo w a s lig h t stim u lus, such as a noise or a
touch.
In the acute form of th e d isea se, death may be due to fix a tio n of the
respiratory muscles, or to exhaustion.
In f a t a l cases the duration at the
d isea se may be no longer than fo rty -eig h t hours.
In the chronic form, a l l
symptoms are m ilder, and trism us (lockjaw) may appear la te in the d isease.
Period of Convalescence.
The p atien t convalesces slow ly.
Period of Communicablllty.
The d isease i s not transferred from person
to person except in rare in sta n ces, a s when purulent m aterial from a d is ­
charging wound may transmit the d ise a se .
Prognosis.
Tetanus is always a serious d ise a s e , but the longer the
incubation period, the greater the p o s s ib ilit y of recovery.
M ortality.
In the acute form of the d is e a s e , the m ortality may be as
high as 50 to 90 per cent;
in the chronic form, 2 to 5 per cant.
Death
occurs in approximately 80 per cent of the p a tien ts who are not treated with
a n tito x in .
Treatment: S p e c ific Prophylaxis.
means of preventing tetan u s.
diphtheria a n tito x in .
Tetanus an tito x in is the s p e c ific
I t i s prepared in a manner sim ilar to th at of
A u n it of tetanus a n tito x in i s designated as that
204
amount s u ffic ie n t to n e u tr a lize 1,000 minimum le th a l doses of tetanus toxin;
the minimum le th a l dose of tetan u s toxin i s that amount needed to k i l l a 350gram guinea pig in four days.
In the treatment o f wounds in fec ted w ith s o i l , a subcutaneous in jec tio n
o f 1,500 u n its o f tetanus a n tito x in given on the day the patient receiv es
the wound is e f fe c t iv e in preventing tetan u s.
In cases with a long incuba­
tio n period, a second dose may be given , as the i n i t i a l in jection disappears
w ithin ten to tw elve days.
Repeated doses may be given at seven- or e ig h t-
day in terv a ls u n til the wound h e a ls.
A s e n s it iv it y t e s t should be adminis­
tered before a n tito x in i s g iv e n .
General Prophylaxis.
The wound is thoroughly cleaned by removing a l l
foreign matter and ex cisin g a l l fragments of necrotic tis s u e .
Wet dressings
o f an oxidizing agent are o f questioned valu e.
Active Treatment.
Once the d isease develops, large doses of tetanus
an titoxin are administered in traven ou sly, intram uscularly, and in tra th e c a lly .
(See Appendix A.)
These in je c tio n s , before which i t is sometimes necessary
to anesthetize the p atien t to a lla y convulsions, may be repeated for several
days.
Sedatives, such as ch lo ra l hydrate and bromides, are administered in
q u an tities s u ffic ie n t to produce the p h y sio lo g ica l e f fe c t of the drugs.
Methods of Control:
R ecognition and Reporting.
The disease i s recog­
nized by the c lin ic a l symptoms which may be confirmed by laboratory d ia g n o sis.
Tetanus is a reportable d is e a s e .
Iso la tio n .
I so la tio n i s not necessary u nless there are discharging
wounds.
Immunization.
Tetanus toxoid i s being used with encouraging r e s u lts
to produce a ctiv e immunity (two in je c tio n s of 1 c c. each being given at
205
three-week In te r v a ls);
tetanus a n tito x in , administered on the day th e wound
is received , confers passive Immunity.
A second or th ird in jec tio n may "be
given, i f necessary.
Nursing Care
As the d isea se
i s not communicable from person to person, the p a tien t
may be cared for in a general h o sp ita l.
I s o la tio n .
I so la tio n i s necessary only i f the wound i s discharging.
Comfort of the
is
P a tie n t.
The patient should be placed in a room th at
q u iet, and every e f fo r t should be made to sh ield him from disturbing
fa c to r s, such a s n o ise s and jarring of the bed, which may cause convulsions.
Any annoyance (even a s lig h t d raft) which produces tw itchings or convulsions
lessen s the chance of recovery.
During convulsions, the p atien t su ffers in ­
te n se ly , and frequent repeated dose3 of sed atives are given for r e l i e f .
Personal Hygiene:
Care of the Skin.
The p atien t should be bathed and
an alcohol rub given i f t h is procedure does not ir r it a t e him.
may be used to r e lie v e pressure.
Rubber rings
As the patient recovers from the acute
stage, sp e c ia l a tte n tio n should be given to the prevention of pressure so res.
Care o f the Eyes.
The eyes should be protected, a s the patient i s sen­
s it iv e to lig h t because of the involvement of the eye m uscles.
A s lig h t ly
darkened room minimizes the ir r it a tio n .
Care of the Mouth and Nose.
Oral and nasal hygiene should be maintained
i f the process does not cause convulsions.
E lim ination.
stip a te d .
D aily enemata u sually are ordered as the p atien t i s con­
Liquid petrolatum may be given as a la x a tiv e .
cu lty in void in g, c a th eteriza tio n may be necessary.
be ca re fu lly recorded.
I f there i s d i f f i ­
The urinary output should
206
D ie t.
Fluids are urged to combat dehydration.
When flu id s can be
taken by mouth, the g la ss drinking-tube should be protected by rubber tubing.
I f the p a tien t has d if f ic u lt y in swallowing, n asal gavage may be ordered, or
intravenous in fu sio n s may be given by the p h ysician .
f r u it ju ic e s to increase the carbohydrate in tak e.
Lactose i s added to
During convalescence as
much as 4,000 c a lo r ie s may be given d a ily .
Complications.
Complications are rare, but pneumonia may occur, and
the nurse should watch fo r symptoms in d icatin g i t s o n se t.
Such symptoms as
cyan osis, convulsive tw itch in gs, or a sudden r is e in temperature should be
reported immediately.
■Serum Reaction.
(For nursing care, see page 4 0 .)
Convalescence.
A fter the acute stage of i l l n e s s has passed, the p a tie n t’s
strength i s depleted;
he needs nourishing food and continuous care.
A ctiv ity
should be gradually resumed.
D isin fe c tio n :
Concurrent.
A ll d ressings should be wrapped in paper and
placed in the refu se can for in cin era tio n .
Instruments used in d ressin gs
should be autoclaved at 120° C. for at le a s t twenty m inutes.
Terminal.
The unit is washed with soap and water and the m attress and
p illo w s are aired fo r s ix hours.
E sse n tia l Points to Remember:
1.
Keep the p atien t q u ie t*
2.
Avoid a l l disturbing a c t iv it ie s in th e p a tie n t’ s room.
3.
Advise in d ividu als with wounds which may contain d ir t to see a physician
immediately.
207
Home Care
Nursing In stru ction s.
a l l sources of n o ise.
papers and burned.
Keep the p atien t in a room alone and elim inate
A ll contaminated dressin gs should be wrapped in news­
A nourishing d iet should be given .
Community P rotection
Education of the public in preventive measures, such as promotion of
safe and sane Fourth of July celeb ration s and in stru ctio n in the importance
of early administration of tetanus a n tito x in w ill r esu lt in eradication of
th is d isea se.
Selected References
Bergey, D. H ., and Brown, C. P ., Immunization Against Tetanus with Alum
P recip ita ted Tetanus Toxoid. American Journal of Public Health, XXIX
(A p ril, 1939), p. 334.
Bergey, D. H., and E tnis, Samuel, A ctive Immunization Against Tetanus In­
fe c tio n with Refined Tetanus Toxoid. Journal of Immunology, XXXI (Nov­
ember, 1936), p. 363.
Carter, Charles F ., Microbiology and Pathology.
The C, V, Mosby Company, 1939. P, 756,
2nd E d ition.
S t, Louis:
Gold, Herman, Active Immunization of A lle r g ic Individuals Against Tetanus
by Means of Tetanus Toxoid, Alum P r ecip ita ted Refined. Journal of
A llergy, IX (September, 1938), p. 545.
Park, William H., and Williams, Anna w ., Pathogenic Microorganisms. 11th
Edition Revised. Philadelphia: Lea and Febiger, 1939, P. 1056.
Zinsser, Hans, and Bayne-Jones, Stanhope, A Textbook of B acteriology.
Edition Revised. New York; D. Appleton-Century Company, 1939,
P. x x v iii 4 990.
8th
CHAPTER XXIII
RABIES
D e fin itio n .
Rabies i s an a cu te, s p e c if ic , uniformly fa ta l in fe c tio n
which i s communicated to su scep tib le mammals, usually through the b ite of
an in fected animal.
H istory.
Synonyms;
Rydrophobia; Lyssa.
Rabies i s an ancient d isease a ffe c tin g both animals and man.
Because o f the infrequent occurrence o f the disease in human beings, and be­
cause i t s period o f development a fte r the b ite o f a rabid animal i s so long,
i t s source was not known, nor was i t recognized as a separate disease u n til
the f i r s t century, when C elsus, a m edical w riter, f i r s t described human ra b ies.
In 1880, Pasteur discovered th at in ocu lation with fix ed viru s of gradually
increasing virulence prevented the disease in animals or persons who had
been b itte n , and in 1885 he gave th e f i r s t treatment to a human.’1' No sp eci­
f i c laboratory diagnosis o f r a b ies was p o ssib le u n til 1903, when Negri d is ­
covered in clu sion bodies in th e brain c e lls of animals which had th e d isea se.
In 1902, England succeeded in erad icatin g r a b ie s, but i t reappeared there in
1918, when dogs were brought in to th at country during the World War.
Prevalence.
Rabies occurs in almost a l l parts of the world.
I t i s most
common in Russia, France, Belgium, and I ta ly , but i t has not been known in
Scandinavia for a period o f f i f t y years.
1.
In England, Switzerland, and Holland,
Kenneth L. Burdon, A Textbook of M icrobiology, p. 553.
(208)
209
where quarantine laws are r ig id ly enforced and regu lation s require that dogs
be muzzled, the d isea se i s rare; in A ustralia i t i s unknown.
In the United
S ta te s, from 1900 to 1930 over 5,000 deaths from ra b ies occurred among humans.
E tio lo g y .
The causative agent of rabies i s a f ilt e r a b le v iru s which i s
found in the cen tral nervous system and in the s a liv a o f in fected anim als.
Source of In fe c tio n .
The source of in fe c tio n is the s a liv a of the in ­
fe cte d animals, e s p e c ia lly o f the dog and o f the c a t.
The s a liv a of a person
i l l w ith the d isea se i s lik ew ise in fe c tio u s.
Mode of Transmission.
Rabies is transm itted through a wound made by
the b ite of an in fected animal.
Transfer also may occur through a scratch
or an abrasion which has a c cid en ta lly become contaminated with the s a liv a of
a rabid animal.
Rabid animals are capable of transm itting the viru s to other
animals or human beings several days before they them selves develop symptoms.
S u s c e p tib ility .
A ll mammals are su scep tib le, but rabies is prim arily a
d isea se of lower animals, p a rticu la rly of wolves, dogs, and c a ts.
There i s ,
apparently, no natural immunity to the d isea se.
Pathology.
The in fe c tio n is conveyed to the cen tra l nervous system
c h ie fly by the path of nerve trunks.
The presence of Negri bodies in the
cytoplasm of nerve c e l l s is the ch ief pathological con d ition .
These bodies
are found in p r a c tic a lly a l l ca ses, and they are the b a sis of laboratory
d ia g n o sis.
Accumulations o f leucocytes about the blood v e s s e ls and nerve
c e l l s a lso may be found.
Incubation Period.
The incubation period v a r ie s, but in the m ajority
o f ca ses i t i s from twenty to s ix ty days, although i t may be prolonged to
s ix months.
IMS period depends upon the virulence of the viru s in the
s a liv a , the s i t e o f the in o cu lation , and the degree of exposure.
For example,
210
b ite s in the fa ce , where there is a rich nerve supply, have a short incuba­
tio n period; whereas, i f the part is b itte n through clo th in g , fewer organisms
enter the wound, and the incubation period is correspondingly longer.
The
period of incubation i s shorter in children than in a d u lts.
Course of the D isease.
three sta g es:
The symptoms of rab ies in man may be divided into
(1) the premonitory or melancholic stage;
con vu lsive, stage;
(2) the e x c ite d , or
(3) the p a ralytic sta g e.
When the 3tage of excitement is most pronounced, the d isea se is c a lle d
"furious," or co n vu lsive, rabies;
when t h is stage does not occur and paral­
y s is begins e a r ly , the d isease i s ca lled "dumb," or p a r a ly tic , r a b ie s.
Rabies in the Dog
Types of the D isea se:
Furious Rabies.
This type of the d isease is
characterized by changes in behavior, such as b itin g , r e s tle s s n e s s , paroxysms
o f fu ry, a p ecu lia r bark, and p a ra ly sis.
Death u su ally occurs w ithin three
to s ix days from the onset of the symptoms.
P a r a ly tic R abies.
This type is characterized by p a r a ly sis, a hoarse
bark, and death w ithin four or fiv e days.
Period of Oommunicabllity.
In the dog, the period o f communicability
extends from f if t e e n days before the c li n ic a l symptoms appear u n til death.
I t i s important that the dog suspected of ra b ies be captured a liv e and
kept under observation by a veterinarian fo r two weeks.
I f the dog is k ille d
or d ie s during the period of observation, its head, packed in ic e , is forwarded
to a s ta te or municipal laboratory.for examination.
I f the dog i s w e ll and
s t i l l l iv e s a fte r the required observation period, there i s no danger of in ­
fe c tio n from h is b it e .
R A B I E S
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211
Rabies in Man
Stages o f the D isea se: Premonitory Stage.
In t h is stage, the p atien t
i s m entally depressed and very ir r it a b le , and the fle sh around the b it e be­
comes inflamed
and i s e ith e r p ainful or numb.
Excitement S tage.
This stage l a s t s from one to th ree days, during which
time the s lig h t e s t n o ise , or suggestion of food or drink, produces v io le n t
spasms, e s p e c ia lly of th e mouth, th roat, and larynx.
The convulsive attacks
become gen eralized , and drooling and sp ittin g are common.
usu ally ranges from 100° - 103° E .;
The temperature
the pulse is irregular.
Death nay occur
at th is sta g e, or the d isea se may progress to the paralytio stage;
P a ra ly tic Stage.
paralyzed.
The convulsions cease and the p atien t becomes com pletely
Within six to eighteen hours coma and death fo llo w .
Period of Communicability.
In man, the disease probably i s communicable
during the acute sta g e , but the period of communicability has not been d efin ­
i t e ly d etem in ed .
Prognosis and M ortality.
per cen t.
Untreated human rabies has a m ortality of 100
About 16 per cent of those b itten develop the d isease when not
treated with v a ccin e.
Prompt immunization reduces the m ortality to le s s than
0 .1 per c e n t.
Prophylactic Treatment:
Antirabic Vaccine.
is the s p e c ific preventive measure for ra b ies.
Pasteur's an tirab ic vaccine
In principle th is i s an a ctiv e
immunization with the attenuated v iru s, given in increasing doses during the
incubation period.
The vaccine i s prepared from the brain and spinal cord o f rabbits inocu­
lated with v iru s (s tr e e t virus) obtained from rabid dogs.
Repeated inoculation
212
of rab b its r e s u lts in "fixed" virus of constant v iru len ce.
The spinal cord
is removed a s e p tic a lly from the rabbit and dried in the presence o f potassium
hydrate.
The shorter the time a cord is allowed to dry, the more potent is
the v iru s i t con tain s.
The v ir u se s are in jected in gradually increasing strength into a person
who has been b itte n by a rabid animal.
The complete course of treatment
requires from fourteen to twenty-one in je c tio n s.
Semple M odification of Antirabic Vaccine.
The Sample m odification of
the Pasteur method i s used in the preparation of an tirab ic vaccine by the
1
Bureau of Laboratories in New York City.
Rabbits are inoculated in tr a c r a n ia lly with fix e d rabies v ir u s.
When a rabbit i s com pletely paralyzed,
the brain is removed a s e p tic a lly . The rabies viru s i s k ille d by exposure
o
to 1 per cent phenol a t 37 C. fo r twenty-four hours. D iluted emulsions are
prepared f o r use in 2 cc. v i a l s .
Tests are made in su scep tib le animals to
prove the absence of viru len t v ir u s.
The course of treatm ent, using the Semple m od ification of the antirabic
va ccin e, c o n s is ts of a d a ily in jectio n of 2 c c . for fourteen days.
The in ­
jectio n s are made subcutaneously into the abdominal t is s u e s .
Treatment i s given immediately upon diagnosis o f rabies in the b itin g
anim al, or where in d ica tio n s point to rab ies.
than a d u lts .
Children receive sm aller doses
The treatment must be continued regardless of minor r ea ctio n s,
sin ce i t must be completed before the incubation period e la p se s .
C auterization.
A ll wounds should be thoroughly cauterized with fuming
n i t r i c acid immediately.
Upon diagnosis of rabies in the b itin g animal, or
where in d ica tio n s point to the p o ss ib ility of the development of r a b ie s, a
1.
William H. Park and Anna W. Williams, Pathogenic Microorganisms, 11th
Edition Revised, p. 749.
E13
course of treatment with antirabic vaccine should be in stitu te d at once as
a prophylactic measure.
Local and general complications may follow the antirabic treatment.
The lo c a l m anifestation may be a s lig h t discomfort a t the s it e of inocula­
tio n .
A general complication may be p aralysis which, however, rarely occurs.
McCoy, in reviewing cases of rabies in the United S ta tes in 1930, co llected
records of only three cases in 20,000 Pasteur treatm ents in which paralysis
developed.
The p aralysis seems to occur from the sixth to the tw entieth day
follow ing in je c tio n s .
The cause is not d e f in it e ly known.
A ctive Treatment.
f a t a l.
Once the symptoms develop, th e d isease is always
A ll a c tiv e treatment, th erefore, is p a llia t iv e .
Morphine, sodium
am ytal, and ch loral hydrate may be given to q uiet the p a tie n t.
or ether may am eliorate the v io len t convulsions;
Chloroform
cocaine so lu tio n may be
used to an esth etize the membranes of the th roat.
Methods of Control:
Recognition and Reporting.
The disease i s recog*
nized by the c lin ic a l symptoms and the h isto ry of th e wound, confirmed by
the discovery of Negri bodies in the brain of the b itin g animal, or by animal
in o cu la tio n .
Cases o f rabies or suspected rab ies among animals must be re­
ported immediately to the health o f f ic e r .
When a person is b itten by a dog,
the health o f fic e r should be n o tifie d immediately.
I s o la tio n .
Iso la tio n of the individual receiv in g treatment i s not nec­
essary i f he is under medical sup ervision .
Quarantine.
No quarantine is necessary fo r human b ein gs.
Animals should be placed under observation fo r two weeks.
I f the animal
has ra b ies, p ara ly sis w ill develop and death w i l l ensue, u sually w ithin ten
214
days.
I f the animal is a liv e a t the end of two weeks, he may be released
with sa fe ty .
Immunization.
A ctive immunity may be obtained in man i f the vaccine
i s given immediately a f te r the b it e , or a fte r the animal has been proved
to be rabid.
Fortunately, the long incubation period allows time for the
stim ulation of an tib od ies by the vaccin e.
Dogs may be a c tiv e ly immunized as a preventive measure.
Nursing Care
I so la tio n .
The p a tien t should be placed in a room alone and medical
a sep tic technic observed.
As drooling i s common and the sa liv a o f the pa­
tie n t contains the v ir u s, the nurse should wear rubber gloves whenever she
touches him.
When the p a tien t s p it s , th e nurse should wear a mask over her
mouth and nose.
Comfort of the P a tie n t.
The patient should be kept q u iet, and a l l d is ­
turbing fa c to r s, such as n oise and lig h t , should be elim inated.
never be l e f t alon e, as he i s apprehensive and needs reassurance.
He should
No attempt
should be made to bathe the p a tie n t, a s the sig h t or sound of water frightens
him.
Faucets should not be turned on, and water should not be brought into
the room.
The patient su ffers in te n se ly , and sed atives seem to have l i t t l e e f f e c t ,
although morphine i s b e n e fic ia l in allayin g spasms.
keep the patient from in juring him self or oth ers.
can be swallowed.
R estraints are used to
Semisolid food usu ally
The se n sitiv e n e ss of the throat may be diminished by lo c a l
ap p lication s o f oocaine.
Fluids may be given r e c t a lly .
215
Dig I n f e c tio n :
C oncurrent.
he d is in f e c te d or burned.
b o ile d fo r ten m inutes.
Term inal.
A ll d ischarges of the nose end mouth must
A r tic le s s o ile d w ith th ese d isch a rg es should be
Food w astes should be wrapped and burned.
The u n it should be washed w ith soap and w a te r, and a ir e d
fo r a t l e a s t s ix h o u rs.
E s s e n tia l P o in ts to Remember:
1.
Rabies can be prevented by a n tira b ic v accine.
2. The nurse can h elp in the c o n tr o l,o f rab ies by
in s tr u c tin g th o se w ith
whom she has c o n ta c t to r e p o r t dog or cat b ite s to a p h y sic ia n a t once.
Community P rotection
Persons b i t t e n by dogs should have the wounds c a u te riz e d a t once.
(A n tirab ic tre a tm e n t, which may be secured fre e of charge from th e h e a lth
departm ent, is given i f p re sc rib e d by the p h y sic ia n .)
When a dog b i t e s a
person, th e anim al should be tu rn e d over to the h e a lth departm ent f o r exam­
in a tio n .
The owners of dogs should be fa m ilia r w ith th e care of them and w ith
the re g u la tio n s concerning t h e i r lic e n sin g and r e s t r a i n t .
p ro p e rly muzzled o r leashed when taken in to public p la c e s .
Dogs should be
216
S elected References
Burdon, Kenneth L ., A Textbook of M icrobiology* New York: The Macmillan
Company, 1939. P . xv + 638.
D enison, George A ., and Leach, Charles N ., Incidence o f R abies in Dogs and
R ats as Determined by Survey. American Jo u rn al o f P u b lic H e a lth , XXX
(March, 1940), pp. 267-69.
D iv isio n of P u b lic H ealth N ursing and D iv isio n o f Communicable D iseases,
Manual of Communicable D iseases fo r P ublic H ealth N urses. Albany: New
York S ta te Department o f H ealth, 1939. P. 84.
P ark , W illiam H ., and W illiam s, Anna W., Pathogenic M icroorganism s.
E d itio n R evised. P h ila d e lp h ia : Lea and E eb ig er, 1939* P . , 1056.
Rosenau, M ilton J . , P rev en tiv e Medicine and H ygiene. 6 th E d itio n .
D. Appleton-Century Company, 1935. P . xxv + 1482.
11th
New York:
S u lk in , S. Edward, and W ille tt, Joseph C ., A Comparative Study o f th e Mouse
and Guinea Pig In o c u la tio n Methods in the D iagnosis o f R abies. American
Jo u rn al o f P u b lic H ealth, X5QX (August, 1939), pp. 921-26.
T y le r, C h arles, Rabies and Vaccine V irus.
P ark er H o s p ita l, 1931-1935.
L ectu res to Nurses a t th e W illard
CHAPTER XXIV
PSITTACOSIS
D e fin itio n .
P s itta c o s is i s an acute communicable d isease which i s
conveyed secondarily to man through contact with parrots, parakeets, love
b ir d s, and can aries, and i s characterized by symptoms resembling Influenza.
Synonym:
Parrot Fever.
H istory.
in 1879.
P s itt a c o s is was f i r s t described as pneumo-typhus, by R itte r ,
Since the year o f R itte r 's d iscovery, there have been several out­
breaks of the disease in various parts of the world:
in 1892, the incidence
of cases in Paris was e x te n siv e , and in 1930 many oountries were a ffe c te d .
During the 1930 outbreak b a c te r io lo g is ts in New York and London demonstrated
th a t a filt e r a b le v iru s, iso la te d from the excreta and sa liv a of parrots,
parakeets, and can aries, was the cause of the d ise a se .
These fin d in gs d is ­
prove the theory o f Nocard, who had described a " b acillu s p s itta c o s is ," in
1892.
In 1939, New York S tate added an amendment to the Sanitary Code fo r ­
bidding the importation of birds of the parrot fam ily.
This regulation has
been enforced in New York City sin ce 1938.^
Prevalence.
P s itta c o s is occurs among parsons who have been in contact
with diseased tro p ic a l b ir d s.
I t appears in th e form of sudden outbreaks in
homes where th ese birds are kept as p e ts.
1.
The Public Health Council of the S ta te of New York, The Sanitary Code.
Albany: New York S ta te Department of Health, 1938, p . 29.
(217)
218
E tio lo g y .
A f i l t e r a b l e v iru s i s th e causative agent of th e d is e a s e .
Sources o f I n f e c tio n . S aliv a and e x creta of p a r ro ts , p a ra k e e ts, love
b ird s , and c a n a rie s are th e so u rces of th e d ise a se .
I n fe c tio n may fo llo w
p a rro t b i t e s o r c o n ta c t w ith th e mouth o f in fected b ir d s , but most c a se s
are obscure in o r ig in .
Mode of T ran sm issio n .
The d ise a se i s tra n sm itte d by co n tact w ith th e
s a liv a or e x c re ta o f s ic k t r o p ic a l b ir d s .
The disease i s not r e a d ily t r a n s ­
m itte d from man to man.
S u s c e p ti b i l i t y .
A ll ages are s u sc e p tib le to p s it t a c o s i s , but th e d i s ­
ease ten d s t o be m ild in c h ild re n and young a d u lts .
Females a re more f r e ­
quently a ffe c te d th a n m ales, and th e re i s no r a c i a l immunity*
P ath o lo g y .
During th e i l l n e s s R ic k e tts ia bodies (sm all pleomorphic
organism s, named fo r t h e i r d isc o v e re r, R ic k e tts) may be found in th e blood.
Post-mortem exam inations re v e a l th e presence o f sm all, rounded bodies in th e
r e tic u lo - e n d o th e lia l c e l l s , l i v e r , sp lee n , and kidneys, and o f R ic k e tts ia
bodies in th e bone marrow.
In cu b atio n P e rio d .
In man, th e in cu b atio n period i s from s ix to s ix te e n
days, but i t may be lo n g e r.
Headache and nervousness may be p resen t a t t h i s
tim e.
Course o f th e D is e a s e ;
C lin ic a l P ic tu r e .
The onset o f p s itta c o s is
u su a lly i s sudden, w ith c h i l l i n e s s , fe v e r, and headache.
p r o s tr a te d , and th e tem perature may r is e to 104° F.
p ro g re ssiv e ly worse i s p re s e n t.
The p a tie n t i s
A cough which becomes
The sputum i s ten acio u s.
Abdominal d is t e n ­
tio n i s a freq u en t symptom and album inuria and re te n tio n o f u rin e o fte n o ccu r.
219
"Rose spots'* may be found on the abdomen.
headacbe, and sometimes delirium .
x -ra y .
Very to x ic p a tien ts have severe
Focal pneumonia u su a lly i s revealed by
The ty p ic a l case of p s itta c o s is resembles lobar pneumonia.
Period o f Convalescence.
The symptoms disappear grad u ally, and the
p a tie n t may f e e l b e tter in four weeks, although convalescence u su a lly is
long and ted io u s.
Complications and Sequelae.
P h leb itis is the commonest com plication.
Pneumonia may occur.
Period o f Communioabillty.
The disease i s communicable in man during
th e acute stage o f the i l l n e s s .
P rognosis.
There are few deaths in persons under th ir ty years of a g e.
M ortality.
The m ortality rate in large outbreaks i s from 20 to 30 per
Treatment.
The treatment o f p sitta c o sis i s symptomatic.
ce n t.
Methods o f Control:
Recognition and Reporting.
n ized by th e c l i n i c a l symptoms.
The d ise a se is recog­
I t i s a reportable d ise a s e .
The source of in fe c tio n should be in vestigated as i t
may be traced to
an
in fe c te d l o t o f b ird s.
I s o la tio n .
The p a tien t should be isolated during the acute stage of the
d isea se and while the cough i s p resent.
Quarantine.
Buildings in which birds have been kept should bequarantined
u n t il thoroughly cleaned and d isin fecte d .
Immunization.
Convalescents' serum has been used in some c a s e s, but i t s
value has not y et been proved.
220
Nursing Care
Medical asep tic technic should be carried out.
The use o f gauze masks
i s recommended by some a u th o rities for persons caring for p s itta c o s is pa­
t ie n t s .
The nursing care i s the same as for lobar pneumonia, the care of
which i s fam iliar to the nurse before she i s assigned to the communicable
d isease serv ice.
Rest is e s s e n tia l.
D isin fe c tio n :
Concurrent.
Sputum, fe c e s , and urine should be d isin ­
fected with 2 per cent cresol and then discarded.
Infected birds should be
k ille d , th eir bodies immersed in a 2 per cent creso l so lu tio n , and burned
before the feathers dry.
Terminal.
The u n it should be thoroughly cleaned, washed, and aired
for twenty-four hours.
E sse n tia l Points to Remember:
1.
Birds o f the parrot fam ily, e sp e c ia lly i f of tro p ica l o r ig in , may be
dangerous as household p e ts.
2.
Importation of birds of the parrot fam ily i s r e s tr ic te d .
3.
The nursing care of p s itta c o s is is the same as in lo b a r pneumonia.
Selected References
Armstrong, Charles, P s itt a c o s is .
(February, 1933), pp. 97-101.
American Journal of Nursing, XXXIII
Lansing, G. M., P s itta c o s is . P a c ific Coast Journal of Nursing, XXFIII
(August, 1932), pp. 459-61.
Park, William H ., and Williams, Anna W. Pathogenic Microorganisms. 11th
Edition Revised. Philadelphia: Lea and Febiger, 1939. P. 1056.
Rosenau, Milton J ., Preventive Medicine and Hygiene. 6th E dition.
York: D. Appleton-Century Company, 1935. P. xxv 4 1482.
New
CHAPTER XXV
YELLOW FEVER
D e fin itio n .
Yellow fever is an acute fe b r ile disease characterized
by jaundice o f the sk in , mucous membranes, and scle ra e, by albuminuria,
and frequently by hemorrhages, e s p e c ia lly from the stomach.
H istory.
An epidemic o f yellow fever in 1454 is recorded in the chron­
i c l e s of the ancient Mayas, and p ictu re-w ritin gs of the Aztecs in d icate that
the d isea se was prevalent among th at race in Mexico.
The early Spanish,
Portuguese* and Dutch explorers of Central and South America encountered the
disease in these co u n tr ie s, and they a l l referred to i t as "the yellow
fever."
Some a u th o r itie s b eliev e th at yellow fev er o r ig in a lly was brought
to the New World from West Africa on slave ship s.
I t was f i r s t described
in 1635 by du T erte, a Spanish p hysician.
Yellow fever was introduced into North America in 1668, when s a ilin g
v e s se ls returning from the tr o p ic s brought the disease to the ports of New
York and P h ilad elp h ia, and between 1668 and 1821 twenty epidemics of the d is ­
ease occurred in th e la t t e r c it y .
Up to the tw entieth century the d isea se
was present almost continuously in th e southern section of the United S ta te s ,
and frequent and v io le n t epidemics occurred in the Gulf p o rts.
The la s t
epidemic of yellow fev er in the United S tates occurred in New Orleans in 1905.
In 1889, F in lay, a Cuban p hysician, published in the American Journal
o f Medical Sciences the r e s u lts of h is experiments with yellow fev er. He was
(221)
222
the f i r s t in v e stig a to r to suggest that th e disease was transm itted by mos­
q u ito e s, but h is report a ttra cted l i t t l e a tten tio n .
Knowledge o f yellow fever remained scant u n til two periods of research
were in it ia t e d , the f i r s t in Cuba, in 1900, by the United S ta tes Army Com­
m ission , and the second in A frica, in 1927, by the R ockefeller Foundation.
At the c lo se of the Spanish-American War, Major VJalter Reed and h is co-workers,
who were sent by the United S ta tes Government to Cuba, demonstrated as a re­
su lt of th e ir stu d ies that the disease is transm itted by a mosquito, formerly
c a lle d the stegom yia, but recen tly known as Aedes aegyp ti.
In 1901 vigorous
antimosquito measures were in stitu te d in Havana by Major ( la te r General) Gorgas,
and resu lted in the disappearance of yellow fever.
Three years la te r Gorgas
applied sim ila r ly e f fe c t iv e measures in the panama Canal Zone, thus making
p o ssib le the b u ild in g of the Panama Canal, a project undertaken by the French,
in 1880-1888, but abandoned by them because of yellow fev er.
In 1927 the West
A frican Yellow Fever Commission of the R ockefeller Foundation succeeded in
transm itting yellow fev er to rhesus monkeys.
U n til th a t year a su scep tib le
animal in which th e d isease could be studied experim entally had not been found,
thus most o f what we know regarding the causative agent has been obtained since
then.
While t h is Commission was engaged in studying yellow fev er several scie n ­
t i s t s , among them Noguchi, contracted the disease and lo s t th e ir l i v e s .
Prevalence.
Yellow fever is wide-spread in the in ter io r of South America
and in 'West A frica .
In Rio de Janeiro, in 1929, there was an outbreak of the
d ise a se , but sin ce that time r ig id antimosquito measures have been enforced in
many of the Central and South American seaports and no serious epidemics have
occurred.
During periods of war or earthquake, however, when the enforcement
o f con trol measures breaks down, the seaports may become r e -in fe c te d w ith the
223
aegypti m osquitoes, and yellow fever epidemics may again occur.
The modem
development o f a ir transportation a lso c o n s titu te s a grave danger to a l l
in fe o tib le co u n tries, sin ce thousands of persons now tra v el by airplane
every year between the United S ta tes and South America; thus, a person who
has been b itte n by an aegypti in South America may be the source of an
outbreak of yellow fever in the United S ta te s .
E tio lo g y .
The causative agent of yellow fever i s a s p e c ific f ilt e r a b le
o
v iru s which i s destroyed in ten minutes when heated to 55 C. Outside o f a
liv in g host i t rapidly d ie s.
Source of In fec tio n .
in fe c tio n .
The blood of in fec ted persons i s the source of
The virus i s present in the p a tie n t’ s blood only during the f i r s t
three or four days follow ing the b ite of an in fec ted aegypti mosquito.
Mode o f Transmission.
Yellow fev er is transm itted by the b ite of in ­
fe c te d ifedea aegypti mosquitoes;
a few a llie d sp e cie s a lso are b elieved to
transmit the d isea se.
The method by which the mosquito transm its yellow fever is as follow s:
The viru s i s present in the circu la tin g blood of an in fected person during
the f i r s t three or four days o f i l l n e s s , although the p atien t may f e e l per­
f e c t l y w e ll during t h is period.
An aegypti mosquito b it e s the person in th is
stage of the d isease and may in gest sev e r a l thousands of in fe c tiv e doses of
v iru s with i t s normal blood meal; thus i t becomes a viru s carrier for the
rest of it s l i f e .
A fter the in fe c tiv e meal, about tw elve days elapse before
th e v ir u s, which causes no harm to the mosquito i t s e l f , reaches i t s salivary
glands; from then on the in se ct w i ll in je c t some of the viru s with each b it e .
Only the female aegypti i s capable of transm itting the d isea se, the proboscis
o f the male being too s o ft to penetrate the skin o f a human being. . The
224
duration of the mosquito’s l i f e i s not known, but an aegypti in f acted with
yellow fev er virus has been kept a liv e in the laboratory for over 200 days.
Yellow fev er, which i s best known as a d isea se of c i t i e s , e x is t s a lso
in tr o p ic a l fo r e sts where there are no aegypti mosquitoes; there i t i s c a lled
"jungle yellow fev er."
Jungle yellcw fever prim arily i s a d isease of lower
animals; i t is transm itted to man only a c c id e n ta lly .
serve as i t s hosts in the jungle is not yet known.
Exactly what animals
Jungle yellcw fever is
e s s e n t ia lly the same as that occurring in aegypti in fec ted c i t i e s , and a
person in fected in th e jungle may serve as th e source of in fe c tio n in c i t y
communities where there is heavy aegypti breeding.
S u s c e p t ib ility .
A ll ages and both sexes are su scep tib le to yellcw fev er.
The Negro race appears to be r e la tiv e ly immune.
One attack of the disease
produces life lo n g immunity.
Pathology.
Autopsy reveals pigmentation of the skin, due to diffused
hemoglobin; a l l the tis s u e s are jaundiced.
Hemorrhagic areas are found in
the lu n gs, the alimentary canal, and the brain; the kidneys show damaged
glom eruli; the liv e r usu ally is pale and m ottled.
M aterial resembling c o ffe e -
grounds (black vomitus) i s found in the stomach.
Incubation Period.
This period extends from th ree to s ix days a fte r a
su scep tib le person has been b itte n by an in fec ted aegypti mosquito.
During
th is period the in fected person f e e ls p e r fe c tly normal.
Course of the D isease: C lin ical P ictu re.
The onset of yellow fever
usu ally is very sudden with severe headache and fe v e r .
The patient is pros­
trated ; frequent vomiting occurs; insomnia i s pronounced.
The temperature
usu ally is 102° - 103° F . ; the pulse rate i s slow; the conjunctivas are in­
jected ; the face is flushed and swollen; albuminuria and leucopenia are
225
p resen t.
A fter two or three days the c h a r a c te r istic symptoms appear:
the skin has a yellow ish cyanotic p a llo r; the conjunctivas are yellow ;
the gums are dusky, sw ollen, and spongy; coffee-ground vomitus, which i s
due to p a r t ia lly d igested hemorrhagic blood, is common; tarry s t o o ls occur.
In severe ca ses hemorrhages from the nose, gums, stomach, in te s t in e s , ure­
thra, and ears may occur.
I f a p a tien t survives u n til the seventh day, h is chances for recovery
gen erally are good.
In fa ta l cases, death u su ally occurs between the f i f t h
and eighth days of i l l n e s s , following a coma which may la s t from tw elve to
twenty-four hours.
Period o f Convalescence.
Convalescence u su ally is rapid.
Complications and Sequelae.
Period o f Communicabllity.
These are rare.
The d isea se i s communicable during the f i r s t
three or four days a f te r a person has been b itte n by an in fected aegyp ti mos­
q u ito.
In areas where infected mosquitoes abound and where there are many
su scep tib le persons, the degree of communicability is high.
Prognosis and M ortality.
;
The prognosis of the disease depends to
degree upon how ex ten siv ely the kidneys are involved.
a great
The m ortality ra te
ranges from 5 to 75 per cent in epidem ics.
Treatment.
The treatment of yellow fe v e r is symptomatic.
During
the
f i r s t sta g e o f the d isea se aspirin may be given to reliev e the heqdaehe, tod
dextrose may be administered intravenously.
Food sometimes may be w ithheld
for several days.
Methods of Control:
Recognition and Reporting.
nized by the c lin ic a l symptoms.
The disease i s recog­
The most common conditions from which it
must be d iffe r e n tia te d are dengue and m alaria.
I t is a reportable d ise a s e .
:
u
f
:|
I
225
I s o la t io n .
The patien t
oughly screened foam for the
should be iso la ted from mosquitoes in a th or­
f i r s t fbur days
of the f e v e r .1
The house in
which he was taken i l l should be fumigated to destroy adult mosquitoes.
Quarantine.
Immunization.
This is not required in the United S ta te s .
The v a ccin e, which is used as an a c tiv e immunization
measure c o n sists of yellcw fe v er viru s rendered nonvirulent by prolonged
c u ltiv a tio n in tissu e c u ltu r e s.
I t cannot be made a v a ila b le for general
d is tr ib u tio n , as even when stored at low temperatures i t may become in a c t i­
vated in a short time;
in
for t h is reason i t is necessary to t e s t i t s a c t iv it y
su scep tib le animals every tim e it is used
At p resen t, the vaccine
i s availab le at
for human immunization.
the lab oratories of theIn te r ­
n a tio n a l Health Division of the R ockefeller Foundation in New York (where it
was f i r s t developed), in Rio de Janeiro, in Bogota, in London, and in P a r is .
In the United States a supply o f vaccine is kept ready for use by the quaran­
tin e o f f ic e r s at the South American a ir lin e term inals in Miami, Florida, and
in B row nsville, Texas.
The fly in g personnel of the a ir lin e s operating between
the United S ta tes and South America are vaccinated again st yellow fe v e r .
Transportation R egulations.
The o ffic e r s of the United States Public
Health S ervice are responsible fo r preventing the introduction of yellow fev er
into the United S tates,
'lihen a v e s se l vfoich i s known or suspected of being
in fe ste d with yellow fever a r r iv e s , i t is inspected to determine the presence
of m osquitoes, and a l l persons on board are examined.
Airplanes are examined
c a r e fu lly and are sprayed with in s e c tic id e s to k i l l the in sects i f found.
Persons who have no vaccination c e r t if ic a t e s when th ey arrive in the United
1,
Public H ealth Reports, L.'Washiugtqnj _D.Q«: United S tates Government
P rin tin g O ffice, August 9 , 1935, p. 48.
227
S tates by water or by air from l o c a lit ie s known tobbe in fected are held
under su rv eilla n ce for the remainder of the yellow fev er incubation period.
Everyone who expects to tr a v e l in regions where yellow fever is prevalent
i s urged to be vaccinated.
Elim ination of Breeding P la ces.
Aegypti mosquitoes breed not only in
the tr o p ic s, but in any region during th e warm summer months.
In order to
devise measures for the erad ication of the aegypti mosquito, it i s neces­
sary to understand i t s h a b its.
The in sect i s domestic, as i t breeds in and
around houses, and is found almost ex clu siv e ly in a r t i f i c i a l water containers,
such as buckets, cans, flow er va ses, c is te r n s , and roof g u tters.
The females
la y th eir eggs near the surface of clear water on the sid e s of the containers.
I f the eggs remain m oist, they w ill hatch in twenty-four to fo rty -eig h t hours;
i f they become dry, hatching w i l l be retarded.
The larvae grow for from seven
to nine days, when they reach the pupal sta g e; the adult mosquitoes emerge two
days la te r .
Thus, at le a s t ten days are required for the mosquitoes to reach
the adult sta g e .
I f containers are com pletely emptied a t lea st once a week,
reproduction of the in sects i s prevented.
employed in th e control of yellow fever.
This is the procedure generally
Breeding p la ces which cannot be
e n tir e ly elim inated may be rendered harmless by spreading o i l on the surface
of the water in order to k i l l the mosquito larvae.
Water tanks are sometimes
stocked with sp e c ia l v a r ie tie s o f small f is h which feed on the mosquito larvae.
Nursing Care
I s o la tio n .
A patient w ith yellow fev er should be iso la ted for the f ir s t
four days of the fever, in a room which is thoroughly screened.
228
Comfort of the P a tie n t.
Rest in bed in quiet surroundings i s e s s e n tia l.
A ll exertion should be avoided.
Personal Hygiene:
Care of the Skin.
A d a ily bath should be given.
cohol sponges are soothing, as the temperature may be as high as 103° F.
A l­
A
bed cradle should be used to keep the weight of th e bedclothing from the
s e n sitiv e skin.
Care of the Eyes.
The eyes should be protected from lig h t, a s they are
inflamed and s e n s it iv e .
Irr ig a tio n s of b oric acid solu tion may be ordered,
and co ld compresses may afford r e l i e f .
Care of the Mouth.
attacks of vom iting.
The mouth requires meticulous care, e sp e c ia lly a fte r
An a n tis e p tic mouthwash should be used before and a fte r
feeding, care being taken to avoid injury to the tender gums.
I f the gums
bleed, a 50 per cent so lu tio n of hydrogen peroxide provides an e ffe c t iv e
mouthwash.
E lim ination.
The p a tien t u su ally is constipated, and enemata may be
ordered to a lle v ia te t h is con d ition.
R esults should be secured with a m ini­
mum amount of exertion on the part of the p a tien t.
The nurse should watch
for symptoms of reten tio n or suppression of urine, as these conditions often
occur.
C atheterization frequently is necessary.
Elim ination must be care­
fu lly watched, and an accurate account should be kept of the intake and out­
put.
A specimen of urine should be examined d a ily .
D ie t.
Food is not given during the f i r s t three or four days of the
acute stage of the d ise a se , as hemorrhages from the stomach cause frequent
attacks of vom iting.
A fter th is period, a liq u id d iet low in c a lo r ic con­
tent u sually is ordered.
This may co n sist of barley water, rice water, and
other alkaline drinks, which should be given frequently in small amounts.
229
Milk should be excluded from the d i e t .. A fter vom iting, cracked ice w ill be
found h e lp fu l.
According to soma a u th o r itie s, many p atien ts die because of
feed in g, while few ever die from lack of food.
A fter the acute stage of the
disease has passed, a s o ft d ie t can be to lera ted .
Return to f u ll d ie t u su ally
is deferred u n t il the patient i s convalescent.
Convalescence.
The p atien t convalesces rap id ly, but return to f u l l
a c t iv it y should be gradual.
D is in fe c tio n : Concurrent.
As the p a tie n t’s sputum, f e c e s , u rin e, and
vomitus are not in fe c tio u s, and since the d isease cannot be contracted by
con tact, concurrent d is in fe c tio n is unnecessary.
Terminal.
The house which has been occupied by a p atien t in fected with
yellow fever should be fumigated to elim inate the p o s s ib ilit y of further in ­
fe c tio n by the aeg y p ti.
E sse n tia l Points to Remember:
1.
Do not overfeed the p a tien t; keep him q u iet; do not permit him to exert
h im self.
2.
Airplane tr a v e l has increased the danger of spreading the d ise a s e .
Community Protection
For the elim in a tio n of aegypti mosquitoes the health a u th o r itie s provide
in sp ectio n and sanitary control measures and an inspection service fo r persons
i l l with yellow fever.
A ll persons expecting to tr a v e l in regions where yellow
fever i s known to be endemic should be vaccinated.
230
Selected References
Bauer, J . H ., Yellow Fever, I ts H istory, Occurrence, and Control.
Health Reports, LV (March 1, 1940), pp. 362-71.
Public
Broadhurst, Jean, and Given, L eila I . , Microbiology Applied to Nursing.
4th Edition Revised. Philadelphia: J. B. Lippincott Company, 1939.
P. xix + 654.
Howard, Sidney C ., and DeKruif, Paul H ., Yellow Jack.
Brace & Co., I n c ., 1933. P. x i + 152.
New York:
Harcourt
Park, William H., and W illiams, Anna W., Pathogenic Microorganisms. 11th
Edition Revised. Philadelphia: Lea and Febiger, 1939. P. 1056.
Stimson, A. M,, The Communicable D iseases. M iscellaneous P u blication No.
30, Washington, D.C.: United S tates Public Health S ervice, 1939.
P. x ii-f - 1 1 2 .
Soper, Fred L ., The Newer Epidemiology of Yellow Fever.
of Public H ealth, XXVII (January, 1937), p. 1.
W illiams, C. L ., D isin sec tiz a tio n of A ircra ft.
(June 7, 1940), pp. 1005-10.
American Journal
Public Health Reports, LV
CHAPTER 5DC7I
MALARIA
D e fin itio n .
Malaria is a p a ra sitic disease o f the red blood corpuscles
characterized by c h i l l s of varying se v e r ity followed by interm ittent or
rem ittent fe v e r .
I t i s transm itted to man by the b it e of in fec ted anopheles
mosquitoes.
H istory.
The term malaria (meaning "bad a ir” ) was applied to th is d is ­
ease in ancient tim es, when i t was supposed to have been caused by gasebus
p o llu tio n o f the a ir in the v ic in ity of swamps and marshes.
described malaria as a type o f interm ittent fever.
Hippocrates
The p o s s ib ilit y th a t the
d isea se was transm itted by mosquitoes was mentioned by Varro two thousand
years ago, and during the time of Caesar swamp areas and swamp p arasites were
thought to have had a part in the transm ission of th e d ise a s e .
Malaria was
brought by sla v es and captives to Greece and Rome, where it became wide­
spread and helped to hasten the decline o f the Graeco-Roman c i t i e s .
I t prob­
a b ly was brought to America by slaves from A frica.
In 1880, in A lg eria , laveran was the f ir s t in v estig a to r who found para­
s i t e s in the red blood corpuscles of m alarial p a tie n ts, and who worked out
various sta g e s of t h e ir development in the human body.
In 1897, in In d ia ,
Ross suggested that anopheles mosquitoes were the a ltern ate h osts for human
m alaria.
In 1898, in I ta ly , and in 1900, in London, Grassi and Manson, rer
s p e e tiv e ly , found th a t the anopheles mosquito is d e f in it e ly the intermediate
(231)
232
h o s t.
In 1900, Manson shipped mosquitoes which had fed on malarial patients
from Rome to London (where the d ise a se was unknown) and allowed them to bite
h is son who, as a r e s u lt , contracted the d is e a s e .
In 1911, m alarial parasites
were a r t i f i c i a l l y grown by Bass.
Prevalence.
About 97 per cent of a ll m alarial ca ses which occur in the
United S ta tes are found in the southeastern se c tio n of the country, e sp e c ia lly
in the rural areas.
The disease occurs more frequently among children than
among adults; more o ften among Negroes than among the w h ite s.
a l l parts o f the world, and is both endanic and sporadic.
I t occurs in
In commenting on
m alaria, G r i f f i t t s shows that data about the time and p laces where cases of
the disease develop are d if f ic u lt to secure:
the m ajority of persons infected
with the d ise a s e are n o t seen by a physician, morbidity reports are scen t, and
1
death rep orts lack f u l l inform ation.
Malaria is a ser io u s disease in some o f the southern s ta te s , not only be­
cause of the number o f deaths th a t r e s u lt, but because o f great economic l o s s .
In a study made by the National Emergency C ouncil, malaria was reported as
second in a l i s t of f i v e d iseases considered partly responsible f o r the low
economic conditions o f the South.
The study revealed th a t the in d u stria l
output of th e South had been reduced one h a lf by th is d ise a se .
In 1935, reports from nine lumber companies owning fourteen sawmills in
f iv e southern sta tes showed that 7.6 per cen t of a ll h osp ital adm issions,
16.4 per cent of physicians* c a l l s , and 19.7 per cent o f dispensary drugs
d istrib u ted were for m alaria.
In Porto Rico and the P h ilip p in es, the disease
i s serio u s.
1.
T. H. D. G r if f it t s , Malaria Control - Comments on P ast and Future.
Anerlean Journal of public Health, XXVII (February, 1937), pp. ISO-124.
233
E tio lo g y .
The causative agent of malaria is a protozoan p a ra site.
In the United S tates three sp ecies of the p arasite produce the d isease:
(1) plasmodium vivax, which causes benign te r tia n malaria;
m alarias, which causes quartan m alaria;
causes estivo-autum nal malaria.
(2) plasmodium
(3) plasmodium falciparum, which
A ll three types have s im ila r itie s in ap­
pearance, h a b its, and cy d les, but they d iff e r in p e r io d ic ity of the d ev el­
opment of spores in the red blood corpuscles.
The m alarial organism has two la y ers, or organs.
The ch ief function
of the outer layer i s m o tility o f the organism; the function of the inner
layer i s d igestion and reproduction, during the processes of which toxin s
responsible fo r the symptoms ch a ra cteristic of the d isease are produced.
The l i f e cycle of the m alarial parasite co n sists of two phases:
the
sexual phase occurring in the anopheles mosquito, and the asexual phase
developing in the red blood corpuscles of man.
The spores (sporozoites)
of the p a ra site are in jected in to the human body by the b ite of an in fected
anopheles mosquito.
Each spore on entering the blood stream bores i t s way
into a red blood corpuscle, where i t develops to maturity and eventually
destroys the corpuscle.
The spores f ir s t appear as sm all, c o lo r le ss bodies
with ameboid movements.
During the process of development they increase in
s iz e and become pigmented, the pigment granules being derived from the red blood
corpuscles.
As the cy cle of development nears completion the pigment c o l­
le c ts in the center of the p a r a site .
The mature p arasite undergoes segmen­
ta tio n , each segment being known as a m erozoite.
The red blood corpuscle
ruptures and lib e ra te s the m erozoites with the m alarial to x in , causing the
generalized reaction of c h ills and fever;
thus the paroxysm occurs simul­
taneously w ith the lib e r a tio n o f the merozoites into the blood stream.
234
The merozoites then enter other red blood corpuscles and repeat the sporula tin g c y c le.
About one f i f t h o f the m erozoites develop into the sexual
forms (microgametocytes and macrogametocytes) and remain in the blood stream
for long periods.
During th is time the individual a c ts as a ca rrier of
m alaria, from whom an anopheles mosquito may become in fe c te d .
Each type of plasmodium d iffe r s in the time required for completion of
the asexual c y c le , and each produces a d iffe r e n t number of spores a t the
time of maturity.
The te r tia n parasite matures in fo r ty -e ig h t hours and pro­
duces from six teen to tw enty-four merozoites; the quartan parasite matures in
seventy-two hours, and lib e r a te s six to twelve m erozoites; the estivo-autumnal
p a ra site matures in twenty-four hours, and produces six teen to th irty-tw o mero­
z o it e s .
Each merozoite is then capable of repeating the asexual c y c le s in the
human body.
When a sin g le brood of tertia n p arasites is present in the blood,
c h ills occur every other day; a single brood o f quartan p arasites causes a
c h i l l every fourth day.
I f more than a sin g le brood are present, c h ills occur
more frequently.
When an anopheles mosquito in gests the blood of an individual, the sexual
phase of the plasmodium's l i f e cycle takas place w ithin i t s body.
The male
microgametocyte sends o ff sev era l spermatazoa-like projections which separate
and enter the female macrogametocyte, forming a zygote, or oOkinete.
The otfkinete enters the w a ll of the m osquito's stomach and grows into a
large oocyst; thousands of sporozoites may form in one oocyst.
The oocyst
ruptures and the lib erated sporozoites invade a l l the organs of the mosquito's
body, accumulating primarily in the salivary glands.
This cycle requ ires from
ten to fourteen days (twenty-one days for the quartan p a r a site ), a fte r which
235
the mosquito can i n j e c t the plasm odia and s t a r t the growth cy cle in a human
bein g .
Only the fem ale mosquito tra n sm its the d ise a se , as th e male is a
v e g e ta ria n .
Source of I n f e c tio n .
of the in fe c tio n .
The blood of an in fe c te d in d iv id u a l i3 the source
About 20 p e r cent of a p p a re n tly healthy n a tiv e s in most
m a la ria l reg io n s h a rb o r plasm odia, and as c a r r i e r s are im portant agents in
the sp read of m a la ria .
Mode of T ransm ission.
The d ise a se is tra n sm itte d by th e b ite of an in ­
fe c te d anopheles m osquito.
S u s c e p ti b i l i t y .
M alaria o ccurs in a l l r a c e s , during a l l ages, and in
both se x e s.
Negroes appear to s u f f e r le s s s e v e re ly than o th e r races from
the d is e a s e .
A person who has once had m alaria seems prone to subsequent
a tta c k s , but some r e l a t i v e immunity appears to follow rep eated attacks of
the d is e a s e .
P ath o lo g y .
P a th o lo g ic a l changes brought about by m a la ria include th e
d e s tru c tio n of re d blood c o rp u sc le s, throm bosis of the c a p i l l a r ie s by p a ra ­
s i t e s , enlargem ent of th e sp leen , and sometimes of the l i v e r .
The d e s tru c tio n
of red blood c o rp u sc le s causes anem ia, and soon a f t e r the o n set of the d ise a se
leucopenia is p re s e n t.
In acu te m alaria the spleen is m oderately en larg ed ; in
chronic m alaria i t may reach an enormous s iz e , e s p e c ia lly in n ativ e c h ild re n ;
in u n tre a te d m alaria th e e n tire sp leen may be f i l l e d with p a r a s itiz e d red
blood c o rp u sc le s.
In cu b atio n P e rio d .
This p e rio d v a r ie s , depending upon th e type of m alaria
and th e h e a lth of th e in d iv id u a l.
The usual p erio d s are a s follcw s:
in
t e r t i a n m alaria, from th ir te e n to fourteen days ( i t may be a s sh o rt as te n days,
,
M A L A R X A
(S in g le T e r t i a n Form )
A d m i tt e d
....
Fema l e ....................
M on th .
D a y o f M onth.
D a y o f Illn ess.
May
23
a*.
24
25
26
...16 y r s . ____Ca . e
27
28
10
n ».
29
11
H o u r o f D a y.
R esp. P
ulse
T
TEM P.
em p.
170
108 '
160
107 '
150
106 '
140
105'
130
104'
120
103 '
110
102 '
100
101
39°
100'
40
F ig . 13. Temperature ch a rt o f a p a tie n t w ith m a la ria ,
ty p e ) . (See page 236.)
(te rtia n
236
but r a r e ly exceeds tw enty d ay s);
in estivo-autum nal m a la ria , from e ig h t to
f i f t e e n days, av erag in g eleven days;
to fo rty -tw o d ay s.
M alaise and headache may be p r e s e n t.
Course o f th e D isea se.
groups:
in quartan m a la ria , from twemty-3even
M a la rial fe v e r p a tie n ts may be divided in to two
(1) th o se who have th e t e r t i a n o r quartan ty p e of in fe c tio n w ith
in te rm itte n t f e v e r, th e paroxysms c o n s is tin g of c h i l l s and fev er;
(2) those
who have the estiv o -au tu m n al type w ith re m itte n t f e v e r .
The on3et o f m alaria i s ab rupt and i s c h a ra c te riz e d by th e ty p ic a l cy c lic
paroxysms of th e d is e a s e .
Each paroxysm c o n s is ts o f th re e sta g e s:
In th e
f i r s t , o r co ld , sta g e th e p a tie n t has severe c h i l l s which may progress to a
d e f in ite r ig o r ; he becomes cy a n o tic, h is te e th c h a t t e r , and he q u iv ers w ith
c o ld , although h is tem perature is e le v a te d .
se v e re , and nausea and vom iting may o ccu r.
Headache and backache may be
This s ta g e may l a s t from tw enty
to s ix ty m inutes, when th e second, or h o t, stage im m ediately b egins. The
o
o
sk in becomes dry and h o t, and the tem perature r is e s r a p id ly to 105 o r 106 F.
o r h ig h e r.
Headache and backache a re a c u te , and th e p a tie n t complains o f in ­
te n se t h i r s t .
He may become d e lir io u s o r , in some c a s e s , comatose.
The hot
stag e l a s t s from one to s ix h o u rs, a f t e r which the t h i r ^ , o r sw eating, sta g e
o c c u rs.
The tem perature drops r a p id ly , fre q u e n tly becomes subnormal, and the
p a tie n t p e rs p ire s p ro fu s e ly .
In two o r th re e hours he f e e ls b e tte r and usu­
a l l y f a l l s a s le e p .
The paroxysm i s s im ila r in a l l ty p e s of m a la ria , d iffe rin g only in th e
time of occurrence o f th e c h i l l s and f e v e r .
occur every o th e r day;
In th e t e r t i a n type the c h i l l s
in the q u artan type they occur every fou rth day.
The sp leen i s e n la rg ed ; herpes is common.
MAL ARI A
( S i n g l e Q u a rta n Form )
A d m i tt e d .
Name..
-Male.
Age
25 y r s .
...Case No..
June
M onth.
20
D a y o f Month.
22
21
2 5
2 4
25
2 6
8
6
D a y o f Illness.
H o u r of D ay.
tem p.
R e s p . PULSE T e m p .
170
108° _
42°
160
107° _
150
106° _
140
105° _
130
104° _
120
103° _
110
102° _
100
101°_
90
100°_
80
99° _
70
98° _
41'
I
40°
f
I
39°
%
38°
u.
9
37°
t.
60
97° _
70
50
96° _
60
40
95°
36°
am :
50
136
40
30
20
V . Vl'Av-
*
F ig . 14. Temperature c h a rt of a p a tie n t w ith m alaria (q u a rta n type).
(See page 236.)
237
The estivo-autum nal type of m alaria, which occurs in th e la te summer
or autumn, i s characterized by a continuous rem ittent fe v e r .
The symptoms
are irregu lar, and the hot stage o f the paroxysm may la s t fo r twenty-four
hours; freq u en tly , there are no in term ission s, and the course of the d isea se
may simulate th a t of typhoid fe v e r .
called "pernicious malaria."
This severe form of malaria i s often
The symptoms vary with the lo c a liz a tio n of
the p a ra sites, and i f they accumulate in the cerebral c a p illa r ie s coma
develops, and th e attack may term inate fa ta lly ; i f they accumulate in the
g a s tr o -in te s tin a l tr a c t, p ro stration , vom iting, and diarrhea occur, and
the kidneys may be severely damaged.
Estivo-autumnal m alaria occurs in
trop ical and su b -tro p ica l co u n tries, but i t i s rare in th e temperate zone.
Com plications.
Complications sometimes occur.
They c o n sist c h ie fly
o f the development o f anemia and hemoglobinuria.
Period o f Oommunicability.
Malaria i s communicable fo r as long a
period as the sexual foims of the m alarial p arasite remain in the c ir ­
culating blood o f an individual in s u ffic ie n t q u an tities to in fe c t mosquitoes.
The sexual forms o f the p arasite may p e r s is t for months in individuals who
do not receive treatm ent.
Prognosis and M ortality.
In the tertia n and quartern types of malaria
the m ortality is low, and p r a c tic a lly a l l p atien ts w i l l recover i f treatment
i s started e a r ly in the d isea se; in the estivo-autumnal type i t may be as
high as 50 per c e n t, regardless of treatment.
Treatment.
Quinine i s the s p e c if ic treatment fo r malaria and, i f given
before a c h i l l i s expected, i t w i l l destroy the young p arasites as they are
liberated from the red blood corp u scles.
The liq u id form of the drug is
MALA R I A
(A e stivo-A utu m nal F o rm )
A d m itte d
_-Mckl.6.-_
Name
..........
-................ -.....................
Age
1 9 _ _ y H S - . ---------- Case No.
October
Month.
10
D a y o f M onth.
11
14
13
o
D a y of Illn ess.
15
10
H our of D a y.
RESP.
PULSE T E M P.
170
108 '
160
107 '
150
106 '
140
105 '
130
104 '
120
103 '
110
102'
100
101
100'
y ..e
weg-i-.a r
F ig . 15. Temperature c h a rt of a p a tie n t w ith m alaria ( e s tiv o autum nal ty p e .) (See page 237.)
238
preferred as it must be absorbed and enter the blood stream quickly to be
e f f e c t iv e .
Quinine in capsule form or fresh ly made p i l l s may be given i f
the ta ste of the drug i s ob jection ab le.
Before adm inistering quinine a
la x a tiv e dose of calomel i s given to f a c ilit a t e absorption of the drug.
In the paroxysmal stage of malaria 30 gr. o f quinine sulphate (three
doses o f 10 gr. each) are given for at le a st four consecutive days.
A s.the
p a ra sites may remain in the spleen and cause the d ise a se to recur when proper
conditions a r is e , 10 gr. of quinine should be given d a ily for eight weeks
a fte r a l l c lin ic a l tra ces o f malaria have disappeared.
taken by mouth, it may be administered by hypodermic.
I f quinine cannot be
The dosage of quinine
for children under one year o f age i s £ g r ., for each year up to the f i f t h ,
1 g r . , and a fter the fif t e e n th year, 10 gr.
When a patient has an id iosyn ­
crasy to quinine, atabrine and plasmochin (sy n th etic drugs) are used fo r
treatment of malaria.
Plasmochin appears to be s p e c if ic for the destruction
o f the adult sexual forms o f p a ra sites in estivo-autum nal malaria.
r e s u lts have been reported from the use of sulfanilam ide.^
E ffe c tiv e
During a paroxysm
the treatment is symptomatic.
Therapeutic m alaria, which i s a r t i f ic ia l ly acquired as a treatment for
general p a resis, is transm itted to paretic p a tien ts by the subcutaneous or
intramuscular in jec tio n of 2 to 5 cc. of blood serum from a malarial in fec ted
person, or by the use o f in fected mosquitoes grown in the laboratory; the in ­
cubation period for therapeutic malaria is the same as fo r naturally acquired
m alaria, and the treatment i s id e n tic a l.
1.
A. Diaz de Lion, Treatment of Malaria with Sulfanilam ide Compounds.
Public Health Reports, 1X1 (October, 1937), p . 1460.
239
Methods of Control; Recognition and Reporting.
The d isea se is recog­
nized by i t s c lin ic a l symptoms, but the d e fin ite diagnosis i s made only on
finding the p a ra sites in the blood, more of them being present during the
height of the fever than during the in term ittent period.
In estivo-autumnal
in fectio n the asexual forms are found in the peripheral c ir c u la tio n only
during the paroxysmal stage; therefore, the diagnosis of malaria may be missed
unless the blood smear is taken at the proper tim e.
Malaria is a reportable
d isea se.
I s o la tio n .
A person with m alarial p arasites in h is blood should be pro­
tected from the b ite s o f mosquitoes.
This is the only precaution which i s
of any a v a il.
Quarantine.
No quarantine i s necessary.
Immunization.
There i s no method of immunization again st m alaria.
Pro­
phylactic doses of quinine should be given to those constantly exposed to the
in fec tio n and to persons unable to p rotect themselves again st anopheles mos­
qu itoes.
The M alarial Commission of the League of Nations recommended giving
6 gr. d a ily as a preventive measure during the m alarial season.
In v e stig a tio n and Source of In fe c tio n .
Breeding p laces should be sought
and larvae and mosquitoes should be destroyed.
Carriers of the malarial micro­
organism should be treated u n til the p a ra sites can no longer be found in the
blood.
Prophylaxis.
Since prophylaxis depends upon the d estru ction of the
anopheles mosquitoes (which breed in stagnant w ater), th is i s c h ie fly a public
health problem.
To prevent larvae from maturing, swamp areas where the mos­
quitoes breed may be drained;
i f draining is not p o ssib le , breeding may be
240
prevented by covering the surface of the water with kerosene.
The drainage
o f swamps i s a sanitary engineering problem and an annual expenditure of
large sums of money i s required for the work involved.
Homes in m alarial d is t r ic t s should be screened, and beds should be
covered with mosquito n e ttin g , as the anopheles mosquitoes f ly at n ig h t.
The public should be educated in the mode 0 f spread of the disease and in
the methods of malaria prevention.
Nursing Care
I s o la tio n .
The p a tien t should be cared fo r in a screened room; i f th is
i s not p o ssib le, n ettin g should be placed over h is bed to prevent further a t ­
tacks o f anopheles mosquitoes and consequent spread of the d isease by them.
Comfort of the P a tie n t.
stage of a paroxysm.
The patien t requires s k ilf u l care during each
During the onset o f the cold sta g e , which i s character­
ized by nervousness, c h illy sen sation s, headache, and sometimes by nausea and
vom iting, the p atien t should be kept in bed, and external heat, such as blanl e t s and hot water b o t tle s , should be applied; a ls o , the patient should be
urged to take hot f lu id s .
As the hot stage (which immediately fo llo w s the cold stage) develops and
the p atien t begins to f e e l warm,the heat appliances should be gradually removed.
During th is sta g e, when the p a tie n t’s skin is dry and h6t, his pulse rapid, and
h is temperature high (sometimes as high as 106° F . ),
tepid sponges, alcohol
sponges, and the ap p lica tio n o f ice-caps to h is head w ill a lle v ia te h is discom­
fo r t; cold flu id s should be forced, and small p illow s should be used to r e lie v e
the ch a ra cteristic backache.
I f sign s of delirium are observed, and a nurse is
241
not a v a ila b le to remain constantly with the p a tie n t, sideboards should be
attached to h is bed, or he should be put into a bed with p ro tectiv e ad­
ju stab le s id e s .
Since polyuria u su a lly is present, indicating a great
d estru ction of red blood corpuscles by the malaria p arasites, the p a tie n t’s
urine should be ca refu lly observed for blood.
In th® sw eating stage, which fo llo w s the hot stage, the patien t begins
to p erspire and h is en tire body becomes bathed in perspiration;
ture drops rapidly and f a l l s to normal w ithin a few hours.
h is tempera­
To replace the
flu id s l o s t through the skin and kid neys, f r u it ju ice s and large q u a n tities
of water should be given.
To prevent the com plication o f b ro n ch itis, the
p a tie n t’s lin en should be changed freq u en tly , h is skin kept d iy , and d rafts
avoided.
A fter the sweating stage su b sid es, the patient f a l l s into a deep
sleep from which he awakens refreshed.
The e n tir e paroxysm la sts from ten to fourteen hours.
The tim e, dura­
tio n , and s e v e r ity o f the c h ills should be c a r e fu lly observed and recorded
on the p a t ie n t ’s c lin ic a l record.
The temperature, pulse, and resp ira tio n
should be reco rded at the beginning of the f i r s t c h ill and again every hour
u n til the temperature reaches 100° P ., then a t four-hour in tervals u n t il the
next c h i l l .
As the p atien t cannot hold the thermometer in h is mouth when
shaking with a c h i l l , the temperature should be taken by a x illa or rectum.
P a tien ts with quartan or te rtia n m alaria f e e l w ell and do not remain in
bed on the days when no c h ills occur.
The estivo-autumnal form i s much more
serious than the other forms, and the patient may develop severe anemia.
th is form o f malaria prostration i s always marked.
The c h ill and sweating
may occur as in the other forms, but u su a lly are milder and of shorter
In
24£
duration; the fever m y he continuous as in typhoid fe v e r .
P a tien ts with
t h is d isea se need constant care.
In any form of the d ise a se , the nurse should be on the a le r t fo r symptoms
of n e p h r itis or g a str o -in te stin a l disturbances, and should report them im­
m ediately i f they occur.
The urine should be watched c a r e fu lly , and any
d ev ia tio n from the normal quantity or appearance should be reported.
M edication.
Quinine should be given a t the exact time sp e c ifie d by
the p h y sicia n , and the patient should be watched ca refu lly for m anifestations
of id iosyn crasy to the drug, such as u r tic a r ia , coryza, and dyspnea;
other
symptoms, such as ringing in th e e a r s , temporary deafness, and d u lln ess of
v is io n , a f te r even a small dose of quinine, also frequently develop.
V'ihen quinine cannot be to le r a te d , atabrine is given.
The nurse should
watch fo r to x ic symptoms follow ing the adm inistration of th is drug, such as
yellow ap earance of the skin (due to absorption of the drug, which is a
yellow d y e), anorexia, ep ig a stric p a in s, and sometimes p sych osis.
Plasmochin, which sometimes i s used in the treatment of estivo-autum nal
m alaria, may produce toxic e f f e c t s such as cyanosis, methemoglobinuria, a l ­
buminuria, and coma.
Absolute r e st in bed i s e ssen tia l when t h is drug is
adm inistered.
Iron u su ally is given during convalescence to combat the anemia.
E lim in ation .
I f con stip ation i s present, enemata may be ordered to a l ­
le v ia t e the condition.
la x a tiv e s are given as ordered.
The urine output
should be accurately recorded.
D ie t.
During the acute stage the d ie t should co n sist of flu id s ; fr u it
ju ic e s and water should be given in abundance during the hot s ta g e .
During
convalescence a highly nourishing d ie t should be given to counteract the
anemia.
243
Complications.
The nurse should watch for symptoms of anemia, hemo­
g lob in u ria, and, in estivo-autum nal m alaria, for cerebral symptoms, which
may lead to coma.
D isin fe c tio n .
A ll observations should be accurately recorded.
Concurrent and term inal d isin fe c tio n are not necessary.
The spread of the disease i s prevented only by destruction of the anopheles
mosquito.
E sse n tia l Points to Remember:
1.
The prophylaxis of malaria i s a public health problem.
2.
Sleeping and liv in g quarters in sections in which malaria i s prevalent
should be screened.
3.
In endemic areas malaria is an economic and s o c io lo g ic a l problem.
4.
Qjuinine i s the s p e c ific drug given in malaria.
Home Care
Nursing In stru ctio n s.
The p a tie n t’ s room should be screened.
i s not p o ssib le, mosquito n ettin g should be put over the bed.
I f th is
The physician’s
d irectio n s should be c a r e fu lly follow ed in the adm inistration of quinine or
other drugs.
The time and duration of the c h ills should be carettilly noted.
Coirmunity Protection
Eradication of breeding places of anopheles mosquitoes and the use of
la r v ic id e s w ill reduce the incidence of the d isea se.
Provision should be
made fo r examination of the blood o f persons liv in g in in fec ted areas and
for the treatment o f in fe c ted in d iv id u a ls.
244
S elected References
B a ll, R. C ., The Treatment o f Malaria with Atabrine Followed by Plasmochin,
United S tates Navy Medical B u lle t in . 2X7 (October, 1937}, p. 418.
Broadhurst, Jean, and Given, L eila L ,, Microbiology Applied to Nursing. 4th
E dition Revised. Philadelphia: J, B, Lippincott Company, 1939.
P. x ix + 654,
H azelhurst, George H ,, Engineering Aspects of Malaria Control by State Health
Departments. American Journal of Public Health, XXX7II (March, 1937),
pp. 267-69,
Jordan, Edwin, A Textbook of General B acteriology. 12th E d ition .
delphia: W. B, Saunders Company, 1938. P. 808.
Marr, William L ., Malaria.
1936), pp. 969-75.
Phila­
American Journal of Nursing, XXX7I (October,
MacLeod, Dorothy, The Malaria P atient and the Nurse.
Nursing, XXX7I (October, 1936), pp. 976-78,
American Journal of
Park, William H ,, and W illiams, Anna lA'., Pathogenic Microorgani sms« 11th
Edition Revised. Philadelphia: Lea andF ebiger, 1939. P, 1056.
Rosenau, Milton J ., Preventive Medicine and Hygiene. 6th E ditioni
York: D. Appleton-Century Company, 1935. P. xxv + 1 4 8 2 ,
New
S tevens, Arthur A ., and Ambler, Florence A ., A Textbook of Medical Diseases
fo r Nurses. 4th E dition R evised. Philadelphia: W. B. Saunders Company,
1940. P. xyi -+ 551.
Sutton, Don C ., Introduction to Medicine.
Company, 1940. P. 642.
St. Louis:
The C. 7 , Mosby
I
PART
III
C01.MUNI CABLE DISEASES ATT) THT CCLJ.TKITY
CHAPTER XXVII
CASE OF COMMUNICABLE DISEASES IN THE HOME*
Since graduate nurses in the public h ealth f ie ld or in the private prac­
t ic e w ill frequently be c a lle d upon to care fo r p a tien ts w ith communicable
d isea ses in th e ir homes, the student nurse should be instructed in com­
municable d isease nursing tech n ics which may be applied in the horns, where
the nursing problems are very d iffe r e n t from those encountered in the hos­
p ita l.
In both h o sp ita l and home nursing "protection of others" i s the
b asic reason fo r employing s p e c ia l tech n ics in the care o f communicable
d ise a se s.
In the h o s p ita l, where the b est nursing f a c i l i t i e s are a v a ila b le ,
the spread o f in fe c tio n i s f a ir ly w e ll controlled by medical a sp e sis, and
the nurse u t i l i z e s every opportunity to in stru ot the p a tien ts and v is it o r s
in preventive measures; in the home, th e p a tien t and h is fam ily must be in ­
structed how to prevent the spread o f in fe c tio n in t h is individual situ a ­
tio n .
The fou rfold d u tie s o f the nurse in the care o f communicable d is ­
eases as outlined fo r h o sp ita l nursing (see page 43) w ill be found ap p li­
cable in the home, and fa m ilia r ity with the Sanitary Code o f the sta te or
c it y in which she i s employed w il l be of value to her in her teaching
cap acity.
*
This chapter i s intended f o r th e graduate nurse in p rivate practice who
may be c a lled upon to care f o r the p atien t with a communicable d is ­
ease in h is home, and who w il l be expected to in stru ct manibers o f
the p a tie n t’s fam ily In the sp ecia l tech n ics o f communicable disease
care. Public h ealth nurses follow the technic o f procedures a s out­
lin ed in manuals prepared by the organizations in which they are
employed.
(245)
246
Frequently p a tie n ts w ith communicable d ise a se s are cared fo r by a
member o f the household.
In such a case in stru ctio n s may be giren by the
fam ily physician, by a nurse from the Department of H ealth, or by a nurse
from a p rivate agency.
One member of the fam ily should assume resp on sib il­
i t y fo r the eare o f the p a tien t (preferably one who i s immune to the d is ­
e a se); only she and those se le c te d to r e lie v e her should enter the sick ­
room.
The nurse should demonstrate each procedure to the person who i s to
care fo r the p a tie n t, and t h is person & ould demonstrate several times in
the presence o f th e n u rse.
The nurse a lso should in str u c t the attendant
how to keep an accurate n otation of the p a tie n t's temperature, p u lse, re­
sp ir a tio n , general co n d itio n , treatments given , and other important fa c ts
concerning h is i l l n e s s on h is c lin ic a l reeord.
The P a tie n t's Room.
A sunny, w ell-v e n tila te d room in which the clean
and contaminated areas may be d e f in it e ly defined should be selected for the
p a tie n t.
(As d rop lets from a cough or sneeze may be carried a distance of
s ix f e e t , a t le a s t th at d istan ce from the p a tie n t's bed should be consid­
ered contaminated.)
I f the p a tien t remains in h is own room, i t is not neces­
sary to remove cu rta in s, rugs, and p ictu re s, as ch eerfu l surroundings con­
trib u te to h is happiness, and a t the termination o f h is i lln e s s these
a r t ic le s may be d isin fe c te d by exposure to su n ligh t and fresh a ir .
During
the warm months the windows should be screened with copper wire screening
or mosquito n ettin g to prevent f l i e s or other in s e c ts from entering the
room.
Arrangement o f th e room should be, f i r s t , fo r the p a tie n t's comfort,
247
then fo r th e convenience o f th e nurse*
In hones where th ere is hut one
hathroom (or where there i s no bathroom) nursing equipment should be kept
in the p a tie n t's roam*
'Toilet a r t i c l e s , books, equipment fo r treatm ents
and f o r b aths, and the thermometer are placed on the dresser top; clean
d re ssin g s, uncontaminated lin e n , and th e c lin ic a l chart are kept in one
o f the d resser drawers.
A scrub stand to be used by the doctor and the
nurse should be se t up; a ta b le fo r the convenience of the p a tien t and
th e nurse Ebould be placed a t the bedside; a waste p a il in to which the
bedpan and u rin al may be emptied should be provided.
Dresser and ta b le
tops may be protected by washable lin en covers, by o ilc lo t h , or by papers.
The Bathroom.
When a bathroom i s availab le fo r the ex clu siv e use o f
th e patient; the nursing care i s s im p lifie d , since a l l equipment may be
kept in t h is room. As in the p a tie n t's room, clean and contaminated areas
should be designated a lso ; the fa u c e ts , t o i l e t flu sh ers, doorknobs, and
e le c t r ic lig h t buttons should be considered clean surfaces.
U sually there is only one bathroom in a p a tie n t's home, and f o r the
s a fe ty o f the family a l l su rfaces should be kept free from contam ination.
When necessary fo r the nurse to touch anything in the fam ily bathroom;
paper squares (newspapers or t o i l e t t is s u e ) should be used to prevent con­
t a c t with clean areas.
Equipment.
Technics should be sim p lified so that only the minimum
amount o f equipment w ill be n ecessary fo r the care of the p a tie n t.
The
equipment needed includes:
Covered p a il (fo r flu id w aste)
Covered recep tacle (for the
p a tie n t's dishes)
Wash basin
P itch er and drinking g la s s (on
bedside tab le)
T o ilet a r t ic le s (fo r p a t ie n t 's
use
248
Tub or other la rg e receptacle
(fo r s o ile d clo th e s)
Thermometer (fo r ex clu siv e use
o f p a tien t)
Cotton (fo r clean in g p a tie n t's
nose and e a rs)
Paper handkerchiefs (fo r the
nose and th roat discharges)
Two p itch er s (fo r hot and cold
water) . Bedpan
Small basin (fo r oral discharges)
Paper squares (newspapers or d is ­
posable t is s u e s )
Cord (fo r ty in g waste parcels)
Band brushes (or a chemical d is ­
in fec ta n t i f lo c a l health de­
partment regu lation s so sp ecify)
A supply o f newspapers (which are
used to p rotect clean surfaces,
and to make in to paper bags)
Procedure To Be Followed in Caring fo r the P a tie n t.
The nurse assem­
b le s a l l necessary equipment in the p a tie n t's room in preparation fo r h is
care.
R eoeptacles fo r contaminated d ish e s, s o ile d lin e n , and waste water
are conveniently placed, newspapers being used to keep them from coming
in contact with th e f lo o r .
Bath water, the wash bowl, cup o f mouthwash,
an emesis b a sin , w ashcloths, and towels are placed on the bedside tab le;
bed lin e n and a clean gown (for the p a tien t) are placed on a chair nearby.
The nurse g iv e s the bath and treatm ents which have been ordered, spe­
c i a l a tte n tio n being given to cleansing th e mouth.
Mineral o i l may be ap­
p lied to the l i p s , n ose, eyes, and ea rs, as i t i s necessary to protect
them from i r r it a t io n .
Paper handkerchiefs, co tto n , or gauze which have
been contaminated with discharges from the nose and throat are deposited
in a paper bag, which has been attached to the bed or ta b le .
A fter com pleting the care of a patient, the s o ile d lin en is placed in
the covered recep ta cle provided fo r th at purpose.
The bath water, urine,
any liq u id nourishment which i s l e f t by th e p a tie n t, mouthwash, and so­
lu tio n s which have been used fo r treatments are emptied in to the waste
water p a i l .
I f the d isea se i s transm itted through the urinary or the a l i ­
mentary t r a c t , th ese discharges should be d isin fe c te d in a sp e cia l con­
tain er in a 5 per cent solu tion of chlorinated lime (see page 54) fo r a t
249
l e a s t one hour before being emptied into the t o i l e t .
The contaminated
d ish es are placed in the receptacle f o r b o ilin g .
The wash basin and mouthwash cup and basin may be plaeed on a ta b le
eovered with newspaper in the bathroom, washed thoroughly with soap and
w ater, Which may be emptied in to th e t o i l e t .
p o s s ib le , they are
I f t h is procedure i s not
washed in the p a tie n t's zoom.
t ie d in to the t o i l e t , washed
to th e p a tie n t's zoom.
The waste p a il i s emp­
thoroughly w ith soap and w ater, andreturned
The paper bagsof wastes are wrapped in clean news­
paper and secu rely
tie d with a cord; la t e r they are burned. The u te n s ils
(mops and brushes)
which are used by the nurse fo r cleaning the zoom
should be kept in the p a tie n t's room.
The MUrse's Uniform.
The nurse wears a short-sleeved gown over her
uniform; t h is may be made of paper or cotton m a teria l.
The outside of the
gown i s contaminated and the nurse washes her hands before and a fte r she re­
moves i t .
The gown may be hung on a clo th es rack or on an improvised c lo th e s
hanger, with the contaminated sid e o u t.
(See page 4 8 .)
I f a member o f
the household cares fo r the p a tie n t, she should wear a short-sleeved wash­
able dress over which a short-sleeved gown or a large apron should be
worn when in contact with the p a tie n t, and she should be taught how to
put on and how to remove th is gazment without contaminating h erse lf; i t
should be hung up before she lea ves the p a tie n t's room.
I f the phyaioian
requests th at a mask be worn, a clean handkerchief or c lo th may serve the
purpose•
The P h ysician 's Gown.
A gown should be provided fo r the physician.
This may be kept in a paper bag made from hewspapers with the contaminated
sid e folded in .
250
Hand. Cleansing.
A table with e wash bowl, p itch er, soap, orangewood
s tic k , and paper (or cotton) tow els i s provided far the use of the nurse
and p h y sicia n .
As the inside o f th e wash bowl i s contaminated, the pitcher
i s not put in to i t .
Paper squares should be used when grasping th e handle
o f the p itch er and when l i f t i n g covers o f th e p a ils .
A bag far discarded
squares and tow els may be propped a t th e back of th e stand, against the
w a ll, or pinned to th e paper cover.
I f paper tow els are used, they should
be unrolled, separated, and kept in a neat p i l e .
A cake of bland soap, a
tube o f shaving cream, or a b a ttle of liq u id soap may be used for hand
clea n sin g .
The tube or b o ttle may be picked up w ith paper squares.
The
water i s poured in to the basin by covering th e handle of the pitcher with
a paper square.
(The basin is emptied a fte r each handwashing.)
After wash­
ing her hands and arms (to the elbows), the nurse r in se s them by pouring
water over them, then dries them with a paper to w el.
(When cotton towels
are used, the samepart i s not used tw ice; they should not be used i f w et.)
The waste water may be poured into th e bathroom t o i l e t or into the waste
p a il.
The nurse should wash her hands frequently in the bathroom with
soap and hot -punning water; always b efore going to meals the hands should
be thoroughly cleansed.
Taking the Temperature, P u lse, and R espiration.
The p a tien t’s temper­
ature i s taken by mouth or by rectum, as ordered by the physician or as
in d icated by the age and condition o f th e p a tie n t.
(The thermometer is
kept in a clean container, such as a drinking g la s s .)
When about to take
the temperature, p u lse, and resp ira tio n of th e p a tien t, the nurse proceeds
as fo llo w s:
She places her wstch on a clean paper square on the bedside
ta b le ; dry cotton or cleansing tis s u e and a cotton sponge moistened with
green soap a lso are placed on the square; she then takes the thermometer
and holding i t over a basin, pours water from a pitcher over i t .
After the
251
temperature, p u lse, and resp iration sare tak en ,th e thermometer i s removed
from the p a tie n t's mouth and wiped o f f with th e dry cotton or tis s u e to
remove s a liv a and mucus; i t i s then cleaned with the soapy sponge, rinsed
(by pouring water from the cold water p itch er over i t ) , and returned to
the con tain er.
I f a r e c ta l temperature i s taken, v a selin e on cotton or
cleansing t is s u e (to be used as a lu b rican t) i s added to the equipment.
Serving the Tray.
I f i t i s necessary f o r the nurse or attendant to
prepare the food fo r the p a tie n t, she should wash her hands before lea v ­
ing th e p a tie n t's room (in the bathroom) and again in the kitchen before
handling the food*
(The importance of frequent hand washing, using fresh
water each tim e, i s thus impressed upon the fam ily by the nurse's example.)
For serving th e food, a framed p ictu re , a cookie pan, the top of a bread
box, or a sim ila r fla t-su rfa ce d a r t ic le may be used as a tray ( i f a regu­
la r tray i s not a v a ila b le ).
The tray may be prepared in the kitchen and
brought to the p a tie n t's bedside.
I t should be properly d isin fecte d or
b o iled w ith th e d ish es a fte r the meal.
I f th e tray i s kept in the p a tie n t's
room, the food may be brought from the k itch en in recep tacles and trans­
ferred to i t before serving the p a tie n t.
S a lt , pepper, and sugar contain­
ers may be kept in the p a tie n t's room and b o iled with the dishes whenever
necessary.
Care o f Contaminated D ishes.
A covered container in which d ish es are
to be b o iled i s brought to the p a tie n t's room and placed on a tab le or
ch air p rotected by the newspaper.
kept fr e e from contamination.
The ou tsid e o f the container should be
Remnants o f food from the p a tie n t's tray
are scraped in to a paper bag which i s placed on a newspaper, and the dishes
252
are then put into the container (the cover being handled with a paper
square) .
The nurse then washes her hands and wraps the paper bag in a
clean newspaper, securely ty in g th e package with cord.
The package i s
burned and th e container is taken t o the kitchen, where the dishes are
b oiled in i t for fiv e minutes; a fte r b o ilin g they are washed and placed
in the cupboard or upon a tra y .
For sc*ne communicable d iseases certain
a u th o rities recommend washing dishes with soap and water in place of b o il­
in g .1
Care of Contaminated Linen.
The s o ile d lin en should be kept in the
p a tie n t’ s room u n til i t i s ready to be laundered.
A covered receptacle
may be brought t o the room and placed on a surface covered with a news­
paper.
The clo th es are put in to th e recep ta cle.
A fter washing her hands
the nurse tak es the receptacle to th e kitchen, where the clothes are boiled
for ten minutes; the cloth es may then be dried and sent to be laundered.
Another method frequently employed i s to r o l l the lin en in a neat bundle
in th e p a tie n t’ s room, then carry i t to the kitchen and put i t in to the re­
ceptacle in which i t i s to be b o ile d .
taken to avoid touching anything.
This procedure i s safe i f care i s
The lin e n should be immersed immediately
in hot water and soap-suds, and b o iled .
Thorough w etting of m aterials should
be made cer ta in by s tir r in g them with a wooden rod or s tic k , and th e lin en
should remain in the recep tacle f o r te n minutes a fter b o ilin g temperature
i s reached.
1.
Some a u th o rities recommend e ith e r washing lin en in soap-suds
Manual o f Communicable D iseases fo r Public Health Nurses, New York S tate
Department o f Health, Albany, 1959, p. 31.
253
and hot water or b o ilin g * 1
I f f a c i l i t i e s f o r b o ilin g are not a v a ila b le ,
lin e n may be soaked in a 2§ per cent c reso l so lu tio n a fte r which i t i s
laundered or hung up to dry before being sent to th e laundry.
Some com­
m ercial laundries make provisions fo r the care o f contaminated lin e n . The
lin e n i s wrapped in clean paper before being sent to the laundry.
D isposal o f Wastes.
Methods for the d isp o sa l o f waste m aterials
are described in paragraph under "Procedure To Be Followed in Caring for
the P a tien t," page 248.
Care o f Dairy Milk B o ttle s.
In some communities the b o ttle s in which
m ilk has been l e f t a t the p atient *s home are not c o lle c te d u n t il the p lac­
ard has been removed and the iso la tio n period term inated.
Milk b o ttle s
should be washed and b o iled fo r f if t e e n minutes b efore being placed outsid e fo r c o lle c t io n .
2
The nurse should acquaint h e r s e lf with the lo c a l
h ealth ordinances concerning milk b o ttle s .
Post Mortem Care.
The lo c a l health department s e ts up sp e c ia l regula­
tio n s regarding the bodies of persons who d ie of certa in communicable d is 3
e a s e s. The Sanitary Code o f the City of New York s tip u la te s th at morti­
cian s must not expose or hold the bodies of persons who d ie of cholera,
bubonic plague, d ip h th er ia ,p o llia a y elitis, s c a r le t fe v e r , and smallpox.
These bodies must be placed in coffirisi, which Immediately ai® sea le d .
In
such cases p rivate fu nerals only are perm itted.
1,
Manual o f Communicable D iseases,
Albany, 1939, p . 32
New York S ta te Department of H ealth,
2,
Ib id .
3,
Sanitary Code o f th e City of New Yoric. New York C ity.
254
Terminal P is in fe c tio n * The p a tien t should be given a tub bath (or a
bed bath i f t h is is not p o s s ib le ); h is h air should be washed and fresh
clo th es put on; he i s then removed to another room.
Tie contaminated room
should be given a thorough clean in g; washable surfaces and o b jects should
be washed with soap and hot water; u te n s ils should be b oiled f o r tan min­
u tes; m attresses should be aired and sunned fo r s ix hours.
Books should
be exposed to su n lig h t and a ir and kept out of circu la tio n fo r two weeks.
A ll bed lin en should be b o iled and washed; blankets should be washed and
dried in th e sun, or aired fo r s ix hours before being sent to the clean er.
Curtains should be washed, and rugs should be exposed to sunlight and aired
fo r s ix hours.
Fumigation fo r c e r ta in d isea ses i s required by lo c a l h ealth
ordinances.
E ssen tia l Points to Remember:
1.
The p a tie n t’s fam ily must see the n ecessity fo r carrying out e f fe c t iv e
control measures, and must understand the reasons fo r them.
They a lso
must understand the importance o f nursing ca re, as w ell as prevention
and co n tro l.
In stru ctio n s must be sim ple, c le a r , reasonable, and adapt­
able to the in d iv id u a l s itu a tio n .
2.
The nurse should grasp every opportunity to teach th e prevention and
control o f communicable d ise a se s to the patien t and his fa m ily .
should remember th a t she w i l l teach b est by example.
She
255
Selected References
Bureau o f Nursing, Manual - Communicable D isea ses.
York, Department o f Health, 1938, p. 28.
New York:
City of New
Department o f Health, The Sanitary Code o f the C ity o f New York.
Department o f Health, 1939. P . 156.
F r o st, H arriet, Nursing in Sickness and in H ealth.
Company, 1939. P. x i i + 218.
New York:
New York:
The Macmillan
Habel, Mary L ., and Milton, Hazel D ., The Graduate Nurse in the Home.
Philadelphia; J . B. Lippincott Company, 1939. P. x v ii +• 290.
Harraer, Bertha, and Henderson, V irg in ia . Textbook of the P rin cip les and
P ractice o f Nursing. 4th E d ition . New York: The Macmillan Company,
1939, P. x + 1048.
Manual o f Communicable D iseases for Public Health Nurses.
S ta ts Department of Health, 1939. P . 84.
Albany:
McChesney, Emma H ., What i s Communicable D isease Nursing?
o f Nursing, XL (March, 1940), pp. 266-72.
American Journal
Nursing I so la tio n Procedures.
XL (A pril, 1940), pp. 378-82.
New York
American Journal of Nursing,
McCulloch, Ernest C,, D isin fec tio n and S t e r iliz a t io n .
and Febiger, 1936. P. 526.
Philadelphia:
Lea
National Organization far Public Health Nursing, Manual of Public Health
Nursing. 3rd E dition. New York: The Macmillan Company, 1939.
P. xv + 530.
Z in sser, Hans, and Bayne-Jones, Stanhope, A Textbook of B acteriology.
Edition Revised. New York: D. Appleton-Century Company, 1939.
P. x x v iii + 990.
8th
CHAPTER H 7 I I I
the; communicable disease nurse in the community
"Preparedness" i s America’ s watchword, gen erally speaking (today more
than ev er), and th e trend o f the sciences in a l l f ie ld s o f endeavor is
toward t h i s end.
Accordingly, hospital adm inistrators are aware of the
importance o f th e ir p rofession al part in th e country’ s h ealth program; in
th e ir appreciation of the fa c t that as graduate nurses th e ir students must
assume a large share o f th e r e sp o n sib ility for the n a tio n ’s health* these
adm inistrators aim con tin u ally to widen th e scope o f th e ir teaching cu rric­
ula and to prepare the student nurse for the op p ortu n ities th at await her in
the various nursing f i e l d s .
Because i t i s tru e, th erefo re, that knowledge
o f the p r in c ip le s and tech n ics o f communicable disease nursing w ill be o f
sp e cia l value to th e nurse in any health situ a tio n , schools of nursing in
increasing numbers are seeking a f f ilia t io n with communicable d isease hos­
p it a ls , where th e ir students may secure experience in t h i s work.
Nursing O pportunities.
Conditions growing out o f wars in the past
have proved there is a sp e cia l need for th e nurse tra in ed in methods of
prevention and control o f d isease; through the influen ce o f the World War
several movements d irected toward ra isin g nursing standards and toward
increasing vocational opportunities for the nurse have evolved.
The hos­
p ita l and th e public health f ie ld , with i t s unlim ited range of a c t iv it y in
so c ia l hygiene, school nursing, in d u strial nursing, parent education and
guidance, and preventive nursing, represent many op portun ities for the
nurse; in each o f th e f ie ld s the technics of communicable d isea se nursing
(256)
25?
nay be e f fe c t iv e ly ap p lied .
In rural areas, e s p e c ia lly , where the "back-to-
the farm" movement has created, as never b efo re, an awareness of health pro­
blems, and where provisions are being made fo r the care of persons liv in g
in rural se ctio n s, p o sitio n s fo r the q u a lifie d nurse are increasingly a v a il­
a b le .
H ospital Nursing.
For the nurse, h o s p ita ls , whether supported by pub­
l i c or private funds, represent the f ie ld o f experience and b asic in stru c­
tio n in application o f the nursing a r t s .
To assure sa fety for the p atien t
each h o sp ita l includes on i t s s t a f f a certa in number o f bedside nurses,
head nurses, supervisors, in str u c to r s, and adm inistrators (the number of
s t a f f members varies with th e capacity of the h o sp ita l and the nursing
lo a d ).
In h o sp ita ls with approved sch o o ls, where students receive both
th e ir th e o re tica l and p r a c tic a l experience in nursing care, a w ell sele cted
s t a f f o f health educators and in stru cto rs i s necessary, and sin ce, a s a
preventive measure, m edical a se p sis has been w idely adopted in the care o f
maternity p a tie n ts, in fa n ts, and children in general h o sp ita ls, teaching
opportunities for the nurse w ith a knowledge o f a sep tic technic are in creas­
ing; th is i s e sp ec ia lly so sin ce the concerted e ffo r ts of a l l e x istin g
h ealth organizations to reduce the maternal and in fant m ortality ra te o f
the country has led to the s t r i c t use of a sep tic technic on maternity wards
and in n u rseries,
Bie o u t-p a tien t departments of h o sp ita ls a ls o , Where ob­
servation of the patients* symptoms are most valuable in the prevention and
con trol o f disease, provide many opp ortun ities as teacher and a s sista n t to
the physician fo r the nurse with s p e c ia l preparation in communicable^ d is ­
ease nursing.
258
Public Health Nursing.
The work of public health nursing i s impor­
tant because o f i t s scope and i t s far-reaching r e s u lts in the prevention
and control of d isease through education of the p u b lic.
Because o f her
closen ess to the home and to the community, the prepared nurse in th is
f ie ld i s in valu ab le.
is
Her opportunity here for e ffe c t iv e teaching o f health
g rea ter, perhaps, than in other situ a tio n s; fo r,
as Dr. Haven Emerson
has sa id , "The most e ffe c tiv e permament education service for public health
is
that d elivered in person and by word of mouth by the public h ealth nurse
to
the family and in the home."1Public Health includes a l l phases of nursing being done under the aus­
p ices o f the United S ta tes Public Health S erv ice, the s ta te and lo c a l health
departments, the Red Cross Nursing S ervice, v is it in g nurse a sso cia tio n s,
school and in d u str ia l nursing groups.
In t h is f ie ld the opportunities in
adm inistrative and teaching p o sitio n s for those nurses with communicable
d isea se experience are innumerable.
(The q u a lific a tio n s fo r public health
nurses as sp e c ifie d by the Education Committee o f the National Organization
of Public Health Nursing include:
". . .
in stru ctio n and experience in the
acute communicable d isea se, as w ell as in tu b ercu lo sis, s y p h ilis , and
gonorrhea."2 )
Public health nursing i s administered by tax-supported agencies,
by private con tribu tion s, or by a combination of these two means.
Voluntary A gencies.
Voluntary agencies u su ally supply bedside nursing
serv ice to the community; they may a lso supply other serv ices for which tax
1.
Haven Emerson, Scope and Form of Local O ffic ia l Health S ervices, New
York S tate Journal o f Medicine, XXXVTII (May 15, 1938), pp. 796-802.
2.
Manual of Public Health Nursing, p . 496.
259
funds are not a v a ila b le .
Their generalized programs include the care o f pa­
t ie n t s with communicable d is e a s e s .
The Henry S treet V isitin g HUrse S erv ice,
one of the b est known voluntary agencies in the United S ta te s , reported
19,740 communicable d isea se v i s i t s including tuberculosis and s y p h ilis by
i t s nurses in 1939.
O ffic ia l A gencies. O ff ic ia l agencies which o ffer opportunities for the
q u a lified public h ea lth nurse are: the fed eral nursing serv ices and the s ta t e ,
county, and municipal h ea lth departments.
An important function o f the nurses
employed by these agen cies i s to educate the public in the prevention, care,
and con trol o f communicable d is e a s e s .
Indicating the trend toward o f f i c i a l
control of the h ealth of the p u b lic, o f f i c i a l agencies employed 13,349 nurses
in 1938 as a g a in st 9,724 in 1931; the voluntary agencies throughout the
United S ta tes employed 6,004 nurses in 1938 as against 6,167 in 1931,
School Nursing.
Various methods for the control of communicable d is ­
eases have been s e t up in the sch ools throughout the country and the school
n urse's part in them i s a very important one.
Her ch ief function i s h ealth
teaching and, more than any oth er person in the school system, She may, through
education, reduce the incidence of d isease in a community.
The h ealth pro­
gram which she h elp s to plan includes the home, the school, and the com­
munity in both urban and rural areas.
Through her understanding o f com­
municable d ise a se s she can d istin g u ish between those which can be com pletely
co n tro lled , those which can be p a r tia lly con trolled , and those which cannot
be con trolled with the information now a v a ila b le .
She in terp rets the lo c a l
health regulations to the school p rin cip als and teachers,and In stru cts
parents in h ealth p r a ctice s which w ill reduce the dreaded sequelae which
260
may fo llo w a communicable d isease, as w ell as in prevention, care, and con­
t r o l o f tiie d ise a se .
(Immunization against diphtheria and smallpox i s the
r e su lt o f parent education.)
In secondary schools the nurse teaches Home Hygiene and Child Care to
students; in c o lleg e s she has the rare opportunity, e sp e c ia lly in teachers
c o lle g e s , to a s s is t in the planning of h ealth control programs by impart­
ing a u th o rita tiv e information to prospective teach ers.
In d u strial Nursing.
The in d u stria l op p ortun ities for the nurse per­
mit her to reduce the incidence of d isease through her observation of symptoms,
and her teaching o f employees the importance of personal hygiene as a pre­
v en tive measure against colds and other communicable d ise a se s.
Gonorrhea,
s y p h ilis , and tu b ercu losis present sp e cia l problems to the in d u stria l
nurse.
The American Red Cross.
At the present time about s ix hundred Red
Cross nurses in rural communities, towns, and c i t i e s carry on a public
h ealth program, and a valuable contribution to the prevention and control
o f communicable d iseases i s made by t h is organ ization .
Under i t s auspices
c la s s e s in Home Hygiene and Care of the Sick are given by q u a lifie d nurses.
During any d isa ste r s and wars th e ir work cannot be overestim ated.
P rivate P r a c tic e .
Private p ractice o ffe r s many opportunities to
nurses with experience in communicable d isease nursing, e s p e c ia lly in
the care o f children.
The teaching o f preventive measures i s an impor­
tant part o f th e ir duty.
The Nurse o f Tomorrow.
As has been said previously in t h is book,
the p rofession o f nursing goes forward w ith the progress of medicine, and
261
i s influenced, as are a l l other p rofessions, by th e con stan tly changing so­
c ia l and economic ord ers.
Opportunities for th e nurse change accordingly,
and nursing le a d e rs, through education, must help her to keep abreast of
the tim es.
More and more, s o c ia l planning includes th e control o f disease
and care of the sick on extensive bases, and thus d ir e c ts the a tten tio n of
nursing outside th e h o sp ita l in to th e home and the community.
In community
nursing, where great r e s p o n sib ility for prevention of the spread o f disease
f a l l s upon the nurse, a knowledge of communicable d ise a se s and a sep tic
technic i s paramount.
Because of th ese changing s o c ia l conditions the pro­
fe ssio n already i s making those changes in nursing schools which w ill f i t
nurses in to the community sphere.
In the adjustments tak in g place in the
nursing school programs, the study o f communicable d isea ses has an important
p lace.
For th e nurse of tomorrow - the community nurse - the knowledge of
communicable d isea se prevention, care, and control w il l be a requirement i f
she i s to embrace th e many opportunities which await her in nursing service
and in health education.
Selected References
Amberson, Katherine Gr., Surgery, Medicine, and Communicable D isea ses.
The American Journal o f Nursing, XXXVI (March, 1936) pp. 267-74.
Andrus, Ruth, and Garrison, John M., The Nurse-Teacher.
Nursing, XXVII (May, 1935), pp. 260-62.
Public Health
Axelson, A lfh ild J . , Preparation o f the Nurse for Nursery School.
Public Health Nursing, XXVII (September, 1935), pp. 479-82.
Brown, Josephine, The V is itin g Nurse: What Happened on One Day. The
American Journal o f Nursing, XXXVI (A pril, 1936), pp. 360-62.
Hodgson, V io le t, Public Health Nursing in Industry.
Macmillan Company, 1933. P. x x li + 249.
New York:
The
262
Johnson, L ily M., Student Health and the C ollege Nurse.
Nursing, XXVII (September, 1935), pp. 474-76.
Public Health
Manual o f Public H ealth Nursing. Prepared by the National Organization
for Public Health Nursing. 3rd E d itio n . New York: The Macmillan
Company, 1939. P. x v i t 529.
Mclver, P earl, Public Health Nursing, Washington, D.C; United S ta te s
Government P rin tin g O ffic e , 1937. Supplement No. 133 to the Public
Health Reports. )
Nursing Information Bureau. Facts About Nursing. New Yoric C ity: The
Nursing Information Bureau of the American NUrses A sso cia tio n , 1939.
P. 60.
Spalding, Eugenia, P r o fessio n a l Adjustments I I .
Lippincott Company, 1939. P. x v i * 436,
Philadelphia:
J . B.
Strong, Leora B ., What C on stitu tes the Camp Nurse’s Job? Public Health
Nursing, XXVT (J u ly , 1934), pp. 381-85.
The American Red Cross: I t s Organization and A c t iv it ie s .
American Red C ross, May, 1938.
Washington, D.C.:
Townsend, J . G ., M edical and Health Work Among the North American Indians.
Health O ffic e r , II (December, 1937), pp. 350-52.
W etzel, Marion, and Tremper, B ea trice, A Community Nursing S e r v ic e .
Journal o f N ursing. XL (January, 1940), pp. 40-6.
American
APPENDICES
A.
NURSING PROCEDURES
B.
LIST
OF DISEASES
APPENDIX A
ADMISSION TECHNIC
When a p atien t i s admitted to a communicable d isease h o sp ita l, sp e c ia l
procedures are carried out to aid in esta b lish in g or confirming the diag­
n o sis .
The adm itting room i s a clean area, and contamination i s lim ited
to the stretch er on which th e p atien t is placed.
Only one p atien t a t a
time i s allowed in the adm itting room; others w aiting to be admitted are
placed on stretch ers o u tsid e the room.
This i s to prevent the p o s s ib il­
it y o f c r o ss-in fe c tio n s occurring.
Routine admission in clu d es the follow ing laboratory procedures:
Culture taking
Nose and throat, for
KLebs-Loeffler; other
cu ltu res as ordered
A ll p a tien ts
Dick control t e s t
Right forearm, proximal
A ll p a tien ts
Dick te s t
Right forearm, d is t a l
A ll p a tien ts
Schick control t e s t
L eft forearm, proximal )
)
Schick t e s t
L eft forearm, d is t a l
Schultz-Charlton t e s t
Right lower quadrant
)
A ll p a tien ts not re*
ceiv in g diphtheria
a n tito x in
As ordered
Wassexmam t e s t
As ordered
Vaginal smear
A ll female p a tien ts
Tmmurift serum may be g iv en a t the time of admission.
A clean nurse prepares the admission tab le.
(See page 3 9 .)
The cover in which the
s t e r ile syringes have been wrapped serves as the f i e l d on which she places
*In many cases th e procedures which have been described in th is book o rig ­
in a lly were prepared by the author fo r use in the Willard Parker
H osp ital. Other h o sp ita ls have found them adaptable for use on both
th eir general and communicable d isease se r v ic e s.
(263)
264
the equipment to be used, such as th e s t e r ile syringes, n eed les, and c o t­
ton p led g ets.
V ia ls containing the various t e s t m aterials are ca re fu lly
wiped o f f with alcohol and hypodermic solu tion s are prepared, a fte r which
one v i a l i s placed a t the l e f t o f each 2 c c . syringe, fo r id e n tific a tio n *
Only the rubber caps of the v ia ls are placed on the s t e r ile f i e l d .
s t e r i l e set-up includes t e s t m aterials fo r :
The
the Dick con trol t e s t , the
Dick t e s t , the Schick control t e s t , the Schick t e s t , the Schultz-Charlton
t e s t , and a 5 or 10 co. syringe fo r th e Wassermann test*
Equipment which i s arranged on the u n ste r ile table s h e lf in clu d es:
Bowl with green soap so lu tio n
and a lco h o l, 70 per cent
(for discarded need les)
(cu ltu re tubes
(tongue depressors
Container w ith (s te r ile ap p licators
( in g la ss tubes
(Wassermann tube
Jar with 2§ per cent c r e so l
so lu tio n and forceps
Container with water (fo r r in sin g
the syringes)
Iod in e, 3§- per cent
F la sh -lig h t wrapped in paper
towel
Small enamel basin
Jar with a lc o h o l, 70 per cent
Otoscope wrapped in a paper towel
Mercurochrome, 2 per cent (to
mark s i t e o f the S ch u ltzCharlton t e s t )
Tourniquet
Bag fo r discarded paper tow els
Compress saturated with alcoh ol
Admission Procedure* A contaminated nurse takes the temperature, p u lse,
and resp iration ; when necessary she undresses th e patient and a s s i s t s the
physician w ith the p h ysical examination*
The clean nurse a s s i s t s the p hysician by passing such a r t ic le s as are
needed in making th e examination and in givin g the te s ts *
The f l a s h - l i g h t ,
265
protected with a paper tow el, i s handed to the p h ysician .
After use, he
hands i t back to the nurse, who r e c e iv e s i t in an alcohol sponge; he drops
the paper towel into the bag.
otoscope i s used.
A sim ilar procedure i s repeated when the
The clean nurse a lso hands the syringes containing the
t e s t m aterials to the physician.
A fter in je c tin g the p a tien t, he separates
the used syringe and discards i t in to the enamel b asin , dropping the needle
in to the container of green soap and a lco h o l.
When a Wassermann t e s t i s ordered, the nurse a s s is t s by handing the
physician an applicator, the iod in e, the alcohol sponge, the tourniquet,
and a syringe; she holds a container w hile he c o lle c t s the blood from
the p a tie n t.
Having completed taking the blood, the physician rin ses the
syringe and the needle in the bov/1 o f water and p laces the used tourniquet
in the b a sin .
procedure.
Nose and throat cu ltu res a lso are taken as an admission
(See page 287.)
I f in d icated , the contaminated nurse takes
a vaginal smear.
A fter the physical examination and admission procedures have been eonp leted , the physician discards h is gown, scrubs h is hands, and washes h is
steth escop e.
Before taking the p a tien t to the room or cubicle assigned,
the nurse covers him completely with a sheet to reduce the p o s s ib ility o f
spreading the in fe c tio n .
(Infants may be carried by the nurse to the u n it.)
A fter pu ttin g the patient to bed and carrying out any orders the physician
may have prescribed, the nurse scrubs her hands and removes her gown in
the routine manner.
(See pages 45, 4 8 .)
The contaminated lin en on the
stretch er i s discarded into the hamper, a fte r which the nurse again scrubs
her hands.
The equipment used in the admission procedures i s replaced.
266
and culture tubes and other speeiments are properly lab eled and sent to
the laboratory fo r examination.
A ll contaminated a r t ic le s are oared fo r
as indicated on pages 52-54.
I f more than one p a tien t at a time i s admitted (u n less they come from
the same home or i n s t it u t io n ) , the contaminated nurse and doctor change
th e ir gowns and scrub th e ir hands a fte r each admission procedure.
A new
set-up i s used in each ca se.
Recording.
A complete record i s made concerning th e admission pro­
cedures, in clu d in g a d escrip tion of the patient *s condition on admission.
A notation i s made in d ica tin g the names and numbers of the preparations
used fo r th e sk in t e s t s and the s it e s of in jection *
An accurate record
i s a lso made o f any clo th in g or valuables the p a tien t may have brought
with him.
(See page 5 0 .)
AMBULANCE TECHNIC AND REGULATIONS
When a p a tien t w ith a communicable disease i s to be brought to the
h o sp ita l by ambulance, the ambulance nurse is n o tifie d o f the sex , age,
and d iagnosis o f the ca se , and she then obtains the fo llo w in g equipment
to take with her on the c a ll:
Pajamas of s u ita b le s iz e
Blankets
Sheets
S afety-p in s
Rubber-covered p illo w in
p illow case
Two gowns (fo r emergency)
Ambulance bag w ith standard
equipment
An ambulance porter accompanies the nurse on the c a ll; each wears a gown
and a cap*
A p hysician accompanies the nurse and porter i f the p a tien t
has croup, o f i f he i s a moribund or wforced -in w ease*
Upon en terin g the home or in s titu tio n from which th e p atien t is to
be taken, the nurse and porter proceed according to the prescribed routine;
The porter holds the ambulance bag w hile the nurse removes from i t paper
towels on which i t i s then p laced .
The necessary a r t ic le s fo r examination
of the p a tien t are next removed by the nurse.
She p la ces the h istory card
on a paper tow el and records the p atien t*s h isto r y , a f te r which she wraps
i t in a clean paper tow el and puts i t into the pocket o f her gown.
A fter examination of the p atien t i s made, he i s dressed in th e h o sp ita l
clothin g by a member o f th e fam ily or by the ambulance nurse.
I f the
p atien t i s a c h ild , a name tag i s fastened to h is w rist and he i s wrapped
in blankets; the porter holds a clean sheet across h is arms to receiv e the
child*
The nurse ( i f contaminated) washes her hands and wraps the sheet
(267)
268
around the ch ild and he i s then carried to the ambulance*
I f the p atien t
i s an a d u lt, he i s placed on a str e tc h e r , and th e large 3heet with which
i t i s draped i s wrapped around him.
He i s carried to the ambulance by the
p orter, a ssiste d by the ambulance d riv er.
The d iagn ostician 's card, which
i s contaminated, i s wrapped in a paper towel by the nurse and i s put in to
the pocket o f her gown.
She ca r r ie s the equipment bag to the ambulance
when ready to return to the h o s p ita l.
Upon a rrival a t the h o sp ita l th e patient i s taken to the admitting
TO<m o f the assigned ward and placed on the stretoher* The nurse removes
her gown, then submerges the d ia g n o stic ia n 's card (taken from her gown
pocket) in 2^ per cent c r e so l so lu tio n fo r d isin fectio n * The card i s then
b lo tted on a paper towel and placed with the h isto ry card fo r the p h y sicia n 's
use*
Before the ambulance i s returned to the garage or is sent out fo r an­
other p a tie n t, the in sid e o f i t i s scrubbed by the porter with soap and
w ater.
Unless from the same home or I n s titu tio n , not more than one pa­
t ie n t at a time i s brought to the h o sp ita l in the ambulance.
MORNING CARE CF THE PATIENT
Preparations fo r morning care depend upon whether the in d ividu al equip­
ment i s kept in the p a tie n t's unit or in the u t i l i t y roam.
a t th e b ed sid e, th e procedure i s as follow s:
I f i t is kept
The nurse en ters the u nit
and arranges conveniently on the bedside ta b le th e u t e n s ils she i s about
to u se , then scrubs her hands.
She brings warm water fo r the bath in a
large p itc h er and pours i t into the basin; the mouthwash (prepared in the
u t i l i t y room) i s brought to th e unit in a con tain er and poured into a cup
on th e ta b le .
(In cubicled u n its a second p itc h e r of water i s needed fo r
clean in g th e u n it.)
fo o t o f the bed.
The necessary lin en i s brought in and placed at the
(Procedures suoh as temperature, p u lse , and resp ira tio n ,
and the g iv in g o f medications or treatments are carried out when morning
care i s g iv en , i f p r a c tic a l.)
The nurse puts on a gown, then removes the p illo w case from the pa­
t i e n t ' s p illo w and fa ste n s i t to the fo o t o f the bed or crib with a s a fe ty pin (or she may hang i t over a chair back) to r eceiv e the s o ile d lin e n .
(The spread or a sheet may be tie d to th e fo o t o f the bed or crib fo r the
same purpose.)
A clean pillow case i s put on the p illo w , which i s than
placed on th e chair or on the tab le; t h is prevents contamination i f the
p illo w i s dropped*
The nurse proceeds with the care of th e p a tien t; and when she has f in ­
ished mwiri ng the bed she tucks the covers in at both s id e s so th at uncon­
taminated persons in the ward w ill not brush again st them*
The cubicle
w a lls and fu rn ish in gs are then cleaned with wet and dry d u sters, a fte r
270
which the nurse pours the bath water and mouthwash in to the large p itch er .
The p illow case (or folded sheet) with so iled lin e n i s then placed a t the
foot o f the bed w ith the used fa c e -c lo th and dusters on to p .
When t h is
part o f the routine care i s fin ish e d ,th e nurse, a f te r pu ttin g the fa c e ­
clo th s and dusters in to mesh bags, empties the contaminated lin en in to
the hamper bag or down the clo th es chute.
The contaminated u te n s ils are
brought to th e u t i l i t y room, where they are s t e r iliz e d .
The nurse then
scrubs her hands and rep laces th e used u n it equipment with clean a r t i c l e s .
The procedure is sim p lifie d i f a l l equipment is kept in the u t i l i t y room,
since the nurse may then carry clean equipment d ir e c tly to the bedside.
METHODS OF GIVING MEDICATEOW3
Administration o f M edications:
Oral.
Medications frequently are given
o r a lly , and various methods are devised to make them palatable and e a s ie r
to ta k e.
For example, when ta b le ts are given to children they may f i r s t
be crushed and d issolved in water; drugs with an unpleasant ta ste may be
given in syrups or f r u it j u ic e s , or they may be prepared as e l i x i r s or in
capsules; the disagreeable nature of o i l s may be overcome by c h illin g and
adding f r u it ju ice s to them; drugs such as hydrochloric acid and d iu r e tic s
should be w ell d ilu ted in a g la s s of water before being given; drugs that
ir r it a t e the mucous membrane, such a s io d id es, Should be given in milk;
and drugs which may s ta in or otherwise damage the teeth should be given to
a p atien t through a drinking straw.
Cough syrups, to have th e ir f u l l e s t
e f f e c t , should be adm inistered undiluted; they should never be follow ed
by a drink o f water.
When only a few drops of a so lu tio n , such as a v ita ­
min concentrate, are adm inistered, they may be dropped d ir e c tly upon the
tongue w ith the medicine dropper; the t ip o f the dropper should be protected
w ith a short piece of rubber tubing.
R ectal.
The r e c ta l route of medication may be preferred i f the pa­
t ie n t i s vomiting or i f f lu id s by mouth are not permitted fo r other reasons.
Large doses o f s a lic y la t e s or ch loral hydrate frequently are d issolved in
a starch retention enema, and paraldehyde d ilu ted in water or o i l may be
given r e c ta lly .
Medicated su p p o sitories a lso may be employed, the cone
being inserted w ell into the rectum.
V aginal.
Drugs may be given o cca sio n a lly by the vaginal route,
(271)
272
medicated s o lu tio n s or sup p ositories being used*
The suppositories should
be in serted blunt-end f i r s t .
Nasal*
Nasal packs are ordered f o r t h e ir lo c a l e f fe c t on the mucous
membrane, the in h alation o f various drugs, such as eth er, to control con­
v u lsio n s, and s p ir it s o f ammonia, to overcome v ertig o ; steam inhalations
containing v o la t ile drugs, such a s menthol or tin ctu re o f benzoin, may be
used to r e lie v e congestion in the naso-respiratory tr a c t.
(A sp e cia l ket­
t l e or in h alator should be used fo r benzoin in h a la tio n s, sin ce th e sta in
and d ep o sit from the drug are d i f f ic u lt to remove from any u t e n s il.)
Subcutaneous.
Drugs are administered subcutaneously when rapid ab­
sorption i s d esired , or when they cannot be swallowed*
Medication Equipment: For Oral Adm inistration:
Medicine g la sse s graduated in
m etric or apothecary system
Minim g la ss e s
Medicine Droppers
Teaspoon
Drinking straws
For R ectal Administration:
Retention enema s e t
For Medicated Inhalation:
Mask fo r giv in g ether
Croup k e t t le fo r steam
in h alation s
S p ecia l mask and breath­
ing bag ( i f carbogen i s
given)
For Subcutaneous Administration:
Medication
S t e r ile 1 - 2 c c . hypo­
dermic syringe and No. 24
gauge needle
S t e r ile d i s t i l l e d water
Alcohol compress
S t e r ile medicine g la s s (fo r
d isso lv in g ta b le t
Alcohol lamp
Spoon (in which d i s t i l l e d
water i s b oiled and tbs
ta b le t d issolved )
27?
Procedure.
Before g iv in g any medication i t i s the n u rse's responsi­
b i l i t y to check th e order sh eets and the treatment sheets (or cards, i f
a system o f medioine cards i s employed).
A fter preparing the drug prescribed th e nurse proceeds to the pa­
t ie n t ' s u n it, carrying th e medicine g la s s , which she p laces on the bed­
sid e stand.
She than puts on a gown and adm inisters th e m edicine, a fte r
which she scrubs her hands and removes her gown.
( I f the p atien t r e ­
quires no a ssista n ce in taking m edication the gown need not be w orn.)
The contaminated u t e n s ils are rinsed at th e hopper, then they are s t e r il*
ized .
For subcutaneous m edication, given hypodermically, the so lu tio n is
prepared, then th e nurse proceeds to the u n it and p laces the s t e r i le
syringe, wrapped in an a lco h o l compression the bedside ta b le .
Before in ­
je ctin g the n eed le, the p a tien t should be warned o f the s lig h t pain which
may be caused.
The s i t e o f in je c tio n i s cleaned with the a lco h o l com­
press before g iv in g the hypodermic.
Following the removal of the n eed le,
the area i s g en tly massaged to stim ulate circu la tio n and to aid absorption.
The nurse then removes her gown, r in se s the syringe and needle a t the
hopper, and p laces them in the instrument s te r iliz e r *
Recording.
Rotation should be made on the chart in d ica tin g the medi­
cation given , the time and the manner of adm inistration, and the reaction
o f the p a tie n t.
Symptoms o f any to x ic e f fe c t s a lso must be reported.
If
treatment sh eets are employed, in d ication that the order has been carried
out should be made*
I f a narcotio has been used, i t must have been signed
fo r as stip u la te d by Federal a u th o r itie s.
FILLING AND APPLYING A HOT WATER BOTTLE
When the ap p lication o f a hot water b o t t le has been ordered, the nurse
proceeds as follow s:
She ob tains and takes in to the p a tie n t's u n it a
p itch er o f hot water and a clea n cover fo r the water b o t tle , i f necessary.
The temperature o f the water should be 120° F. for adults (110° F. fo r
children or unconscious p a tie n ts) and i t should be tested with a bath
thermometer when put in to th e p itc h e r .
On entering the unit the nurse
p laces the pitch er on the bedside ta b le and puts on a gown.
I f the hot
water b o ttle has been in use and the water has cooled, she empties i t in ­
to the face basin in the u n it, then r e f i l l s i t with the hot water; the
cap i s screwed on t ig h t ly to prevent leak age, and the cover is replaced
before applying i t to the p a tie n t.
The discarded water in the basin is
then poured into the p itc h e r and the b asin put back in place on the bed­
sid e stand, a fte r which the nurse scrubs her hands and removes her gown.
The p itch er o f water taken from the u n it i s emptied in to the hopper in
the u t i l i t y zoom, then s t e r iliz e d .
Hot water b o ttle s are not f i l l e d with tap water in the room because
the bath thermometer w ith which the water i s te ste d i s not a part of th e
room equipment.
Hot water b o t t le s which are removed from the unit are
washed thoroughly with soap and w ater.
Recording.
R e fillin g is clean procedure.
When a hot water b o t t le has been applied to a p a tie n t,
the temperature o f th e water should always be indicated on the chart.
(274)
FILLING AND APPLYING AN ICE-COLLAR OR ICE-CAP
For f i l l i n g and applying an ic e - c o lla r the procedure i s as fo llo w s:
The nurse obtains and takes in to the p a tie n t's u n it some f in e ly chopped
ice in a sm all container) a ls o a clean cover for the c o lla r , i f necessary.
She p la ces the a r t ic le s on th e bedside tab le and puts on a gown.
She then
removes th e ic e - c o lla r from the p a tie n t's throat, takes o ff the cover, and
empties th e con ten ts in to th e face basin on the ta b le b efore r e f i l l i n g i t
with the i c e .
A fter r e f i l l i n g , the metal cap i s screwed on t ig h t ly , and
the ic e - c o lla r (covered) i s properly adjusted to the p a t ie n t 's th roat.
The discarded water i s poured into the bowl or contain er used fo r bring­
ing in th e i c e , and the b asin is put back in the stand.
i s emptied in to the hopper, then s te r iliz e d .
The bowl of water
I f the ic e - c o lla r i s taken
from the u n it to be f i l l e d , i t 1b thoroughly washed w ith soap and water.
Care should be taken to avoid f i l l i n g the c o lla r with to o much i c e .
ing an ic e - c o lla r i s a clean procedure.
F ill­
The procedure used in f i l l i n g an
ice-cap when ordered i s the same as f o r an ic e -c o lla r .
In h o s p ita ls equipped with refrig era tio n s p e c ia lly designed fo r fr e e z ­
ing ic e - c o lia r s and ice-ca p s f i l l e d with solu tion s of g ly cerin e or a lco h o l,
the procedure d if f e r s somewhat from the above.
These ic e - c o lla r s and i c e ­
caps are s e a le d , and when necessary to r e f i l l them they are washed with
soap and water in th e u t i l i t y roam, then placed in the f r ig id a ir e fo r a
period o f two hours.
Recording.
Comments on the chart include: the procedure, the time
applied, and th e p a tie n t's rea ctio n .
(2 7 5 )
TRANSFERRING A PATIENT FROM ONE WARD TO ANOTHER
When transferring a p a tien t from one ward to another sp ecial measures
are taken to prevent the spread o f in fe c tio n .
The follow in g equipment i s
necessary:
Stretcher
Clean sheet
Clean gown fo r nurse
A r tic le s fo r terminal d is in
fa ctio n o f the u n it (se e
page 52)
Preliminary Measures.
P a tie n t's chart and bedside card
(wrapped in paper)
P a tie n t's clothing and personal
property, (wrapped in
paper)
An order i s w ritten by the physician fo r the
tran sfer o f a patient from one ward to another.
The nurse responsible for
carrying out the order n o t if ie s the a d m in istra tio n .o ffice and the ward to
which the patient i s assign ed , then Checks and completes the p a tie n t's
c l in ic a l record and wraps i t , together with the ward or treatment card,
in a paper tow el.
Before entering the p a tie n t's cu b icle or u n it, the nurse a lso f i l l s
out a irin g s lip s to be attached to the contaminated m attress and p illo w s,
in d icatin g the tim e, d ate, and ward in which they have been used.
She
then prepares a large basin o f green soap so lu tio n in the u t il i t y room,
(in to whioh such contaminated a r t ic le s as cannot be b oiled are to be
placed) and a smaller basin (fo r th e discarded thermometer)« The
stretch er i s then wheeled to the entrance o f the un it and draped w ith a
clean sh e e t.
A clean gown i s placed beneath the stretch er m attress.
The Transfer.
gown.
The nurse en ters the contaminated unit and puts on a
She wraps the p a tien t ( i f a ch ild ) in a blanket from the bed and
277
and p laces him on the str e tc h e r .
I f th e p a tien t i s an a d u lt, he i s placed
on th e stretch er and i s covered with a blanket.
(An attendant remains at
the sid e o f the stretch er i f the p a tien t i s a ch ild or an irresp onsible
a d u lt.)
While in her contaminated gown, the nurse prepares the unit fo r te r ­
minal d is in fe c tio n , a fte r which she d iscard s her gown and scrubs her hands,
then puts on a clean gown.
Next, she wraps a clean sheet about the patient
and, carrying the ch art, accompanies th e p a tien t (wheeled by the p orter,
a lso properly gowned) to the assigned ward.
I f the p atien t i s a small
ch ild ,h e may be carried in the arms of the p o rter.
The p a tie n t's per­
sonal a r t ic le s may be placed in a paper bag and transferred at the' same
tim e.
The porter p laces the p atien t in the c u b ic le , d iscard s h is gown, and
scrubs h is hands; the nurse g iv e s any necessary care to the p a tie n t, a fte r
which she scrubs her hands, removes her gown, and returns to the f i r s t
ward.
TAKING PATIENT TO X-RAY ROOM
When a patient i s taken to the x-ray room, care is taken to prevent
the spread o f in fe c tio n .
The follow ing equipment is necessary:
Stretcher draped with clea n
sheet ( i f p atien t i s an
adult)
Clean gown fo r nurse
Preliminary Measures.
Clean sheet ( i f patient is a
small ch ild and may be car­
ried in the anas of the
porter)
A r e q u isitio n fo r x-ray of a patient i s brought
to the ward, and the nurse proceeds to carry out the order; a porter (prop­
e r ly gowned) a s s is t s her in conveying the patient from the ward to the x-ray
room.
I f the patient is a c h ild , the nurse drapes a large sheet over the
p o rter's arms, then en ters the u nit and puts on the contaminated gown.
She wraps the ch ild in a blanket from the bed, then places him in the
p o rter 's arms.
The nurse next removes her gown in the routine way, scrubs
her hands, and, a fte r p u ttin g on a clean gown, fo ld s the sheet about the
p a tie n t, tucking up the ends.
I f the patient is an a d u lt, the nurse before entering the unit spreads
a clean sheet over the str e tc h e r .
She then puts on a contaminated gown,
places the patient on the str e tc h e r , and covers him with a blanket, a f te r
which she again changes to a clean gown and fo ld s the sheet over the pa­
t i e n t , to prevent spreading o f the in fe c tio n .
Taking P atien t to X»ray Room.
the
The nurse (in a clean gown) accompanies
patient and porter (who wheels the p a tien t) to the x-ray room; the
(278)
279
porter p laces th e patien t on the x-ray table*
Before going near the pa­
t ie n t , the nurse removes her gown to ad just a heavy rubber apron (worn as
a p rotection against x -r a y s).
She again puts on her gown and unfolds the
sheet which covers the p a tie n t, keeping the ou tsid e o f i t fr e e from con­
tamination*
She a s s i s t s with the x-ray procedure by undressing the pa­
t ie n t , supporting him w hile the technician ad ju sts the covered x-ray p la te ,
and p la ces th e p a tien t in p o sitio n as directed*
For x-ray of th e mastoid region the nurse p resses the p a tie n t's ear
forward and downward and fa sten s i t in th a t p o sitio n w ith a s tr ip of ad­
h esive ta p e.
I f i t i s not necessary fo r the nurse to remain with the pa­
t ie n t w h ile th e x-ray i s being taken, she may step behind the leaded
p a r titio n in th e room.
A fter th e x-ray i s taken the nurse a s s i s t s by removing the covered
p la te s , slip p in g the cover p a r tia lly o f f so th a t th e tech n ician may grasp
the p la te without contaminating h im self.
She then d resses th e p atien t and
wraps him securely in the blanket, a fte r which she discards the contamin­
ated gown, scrubs her hands, and removes th e rubber apron; then, in a
clean gown, die covers the patient with a sh eet, and he i s taken back to
the ward by th e porter and placed in bed.
The porter then discards h is
gown and scrubs h is hands; the nurse g iv e s any necessary care to the pa­
t ie n t .
Recording.
x-rayed.
A notation i s made on the ch art, in d icatin g the parts
COLLECTION OF SPECIMENS
For the c o lle c tio n o f specimens the nurse secures su ita b le clean con­
ta in e r s, la b e ls to be attached fo r id e n tific a tio n , and r e q u isitio n s l i p s .
A container i s placed upon a clean area, and the outside o f i t i s kept
free from contamination.
Every specimen sent to the laboratory should
be recorded in th e p a tie n t's c lin ic a l record.
Urine specim ens.
A fter bringing the bedpan to the u t i l i t y roam the
nurse pours the specimen in to a clean b o t tle , with th e aid of a funnel;
she scrubs her hands fo r two m inutes, covers the b o ttle (using a stopper
or standard ca p ), and attach es the la b e l bearing the p a tie n t's name, the
ward, and the d a te .
A r e q u isitio n s lip in d icatin g the laboratory examina­
tio n desired i s held in place with a rubber band. A p a rticu la r notation
in d ica tes whether the specimen i s ro u tin e, admission, or s t e r i l e .
Fecal Specimens.
Fecal specimens are co llected in the u t i l i t y room.
The nurse f i r s t p ro tects the u t i l i t y s h e lf with a newspaper before p lac­
ing the waxed cardboard container upon i t .
She also p laces the bedpan up­
on the newspaper and tra n sfers a sm all portion of the feces to th e s p e c i­
men cup by means o f a clean spatu la.
container, and th e bedpan i s emptied.
The spatula i s dropped into the
The nurse then scrubs her bands for
two minutes, p la ces a cover on the container, and attach es the la b e l and
re q u isitio n s l i p .
S to o l specimens should be sen t to the laboratory at
once.
Sputum specim ens.
The most d esirab le m aterial f o r sputum specimens
comes from the bronchi, uncontaminated by the sa liv a and discharges from
(280)
281
the nose and throat*
The p a tie n t's mouth f i r s t should be rinsed with an
a n tis e p tic solu tion before he expectorates in to the con tain er, which may
be a waxed cup or a b o t t le .
To avoid surface contam ination, the specimen
may be transferred to a clean container.
The nurse scrubs her hands be­
fo re covering the container and attaching the la b e l and r e q u isitio n s li p .
I f g la ss b o t tle s are used, the outside surface may be cleaned by washing
with soap and water*
Blood Specimens.
Blood specimens taken fo r c u ltu r e , chem istry, typ­
in g , Wassermann, Widal, or Weil F elix t e s t s are c o lle c te d in s p e c ia lly
provided con tain ers.
These are la b eled , and the r e q u isitio n s lip s are
attached before the specimens are sent to th e laboratory fo r examination.
')
THROAT IRRIGATION
Throat ir r ig a tio n s freq u en tly are given in the care of communicable
disease p a tie n ts.
The fo llo w in g equipment is used:
Throat ir r ig a tio n can with
rubber tubing and clamp
Glass ir r ig a tin g t ip or g la ss
elbow tube (45° angle) protected w ith rubber tubing
Basin (fo r return flow )
Rubber cape or dressing rubber
Dressing tow el
standard on which the t r r igation can i s hung
Prescribed so lu tio n (110° 120° F .)
Bath thermometer
A fter preparing the so lu tio n ordered and te s tin g i t w ith the bath
thermometer, the nurse takes the necessary equipment to the bedside stand,
then puts on a gown*
She turns the patient on h is sid e and supports h is
head comfortably w ith a folded p illo w .
(The patient may s i t up in bed for
the treatment i f i t has not been sp e c ifie d that he remain ly in g f l a t . )
The rubber cape o r dressing rubber i s then adjusted,
and a tow el is placed
across the p a tie n tf s ch est; th e basin fo r the return
flow i s placed w e ll
under h is ch in .
A fter hanging the irrig a tin g can (which contains the so­
lu tion ) on the standard, the nurse regulates the force o f the flow o f the
so lu tio n , d ir e c tin g the stream toward the back of the mouth and s lig h t ly
moving the ir r ig a tin g t i p to reach a l l parts o f the pharynx.
ment i s stopped a t in te r v a ls to allow the patient to
re st.
The t r e a t­
Care is taken
to avoid injury to the mucous membranes, and to prevent the patient from
gagging.
A fter th e treatment 1b completed and the p atien t i s made com­
fo r ta b le, the nurse scrubs her hands and removes her gown*
i s taken to the u t i l i t y room, then sterilized *
(2 8 2 )
The equipment
283
Solutions used fo r throat ir r ig a tio n s are:
g lu c o se , 10 per cent;
normal sa lin e ; sodium bicarbonate (l|r drams to 1 quart o f w ater); sodium
chloride and sodium bicarbonate solu tion (1 dram o f each to 1 quart o f
water) .
Recording.
The treatm ent, tim e, and solu tion used are charted,
sp e c ia l mention being made of the nature of the return flow and of the
p a tie n t's reaction*
ADMINISTRATION OF ANTITOXIN AND IMMUNE SERUM
Immune serum and a n tito x in may be administered as a therapeutic or
prophylactic measure.
Before any immune serum (other than con valescen ts'
serum) i s given, ophthalmic and intracutaneous s e n s it iv it y t e s t s are made.
For t h is procedure the nurse prepares the admission ta b le w ith s t e r ile
equipment and the u n ste r ile equipment as follow s:
Jar with a lc o h o l, 70 per cent
B o ttle with io d in e ,
per cent
Container w ith fo rcep s in c r e s o l,
per cent
Small basin (fo r used syringes)
Container with green soap and
alcohol (fo r used needles)
Tourniquet
Basin with water 100° F. (for
warming v ia ls o f serum)
V ials of immune serum
V ials of horse serum or rabbit
serum (fo r s e n s it iv it y t e s t )
S te r ile ap p licators in g la s s
tube containers
The cover in which the s t e r ile syringes had been wrapped serves as
the f ie ld on which the nurse p laces the s t e r ile syrin ges, n eed les, and
cotton p led g ets.
Preparation fo r the S e n s it iv ity T ests.
The nurse prepares fo r the
s e n s it iv it y t e s t s as prescribed by the physician.
serum may be ordered.
Horse serum or rabbit
I f horse serum i s ordered (using the 1:10 d ilu tio n
for the intracutaneous t e s t and the undiluted serum fo r the ophthalmic
t e s t ) , the nurse has 5 minims o f each prepared in hypodermic syringes; she
places each v i a l b esid e th e resp ective syringe in to which she has drawn
i t s contents, f o r th e purpose o f id e n tific a tio n .
I f the undiluted rabbit serum i s ordered, 5 minims o f the t e s t m aterial
are prepared in a sy rin g e.
I f the 1:10 d ilu tion i s to be used, the nurse
draws o A c c . o f the rab b it serum into a syringe and in je c ts i t into a v ia l
(284J
containing 0 .9 ,c c . o f normal s a lin e ; from the d ilu ted solu tion she prepares
5 minims in a syringe to be used by th e physician.
Giving the S e n s itiv ity T e sts.
The nurse hands the physician a cotton
pledget wet with a lco h o l, with which the skin a t the s it e of in jec tio n i s
cleaned.
He in je c ts the 3erum intracutaneously (into the aim), removes
the n eed le, then i n s t i l s a drop o f the serum into the eye.
accurately the time of ad m in istration.
The nurse notes
The physician discards the syringe
in to the basin and drops the needle in to the container of green soap and
a lco h o l.
A hypodermic syringe containing an ampoule o f adrenalin 1:1000
i s always kept in readiness fo r emergency when giving a s e n s it iv it y t e s t .
Giving the Immune Serum.
A fter an in te r v a l o f a t le a st twenty minutes
a fte r adm inistration, the p hysician reads the s e n s it iv it y t e s t s .
I f the
reading i s n egative, the serum i s given , the nurse handing the physician
an ap p licator dipped in io d in e, a cotton pledget wet with alco h o l, a tou rn i­
quet ( i f necessary), and the syringe containing the immune serum; she tim es
the rate o f adm inistration a ccu ra tely .
I f the s e n s it iv it y t e s t s are p o s it iv e , the serum may be given by the
physician in fra ctio n a l doses at in te r v a ls of twenty to th ir ty minutes;
the nurse remains with the p a tie n t u n til the s e r ie s is completed, and c lo s e ­
ly observes him fo r symptoms o f r e a ctio n .
Care of the P a tie n t.
The p a tien t must be watched c lo s e ly at le a s t
on e-h alf hour fo r any unfavorable rea ctio n .
The syringe with adrenalin
i s placed in a convenient place f o r immediate use, i f necessary.
Recording.
In recording the procedure, the nurse notes p a rtic u la rly
the l o t and preparation numbers o f the serum, the route of adm inistration,
and the amount given . The p a t ie n t 's reaction a lso i s noted and f u ll y de­
scribed O
(2 6 5 )
MUMMY RESTRAINT
A mummy r e str a in t i s used to r e s t r ic t th e movements of a c h ild dur­
ing a p ain fu l examination or treatm ent.
I t i s accomplished by fold in g
a sheet so that i t s width w i l l extend from a point midway between the
elbows and shoulders to the f e e t :
With the patien t lyin g on h is back on
the folded sheet and h is rig h t arm held c lo se to h is s id e , the righ t sid e
o f the sheet is pulled across the ch est and under the l e f t arm and sid e .
The l e f t side o f the sheet i s then drawn over the l e f t arm, pu lled t ig h t ly
across the c h e st, and pinned with a sa fety -p in d ir e c tly below the rig h t
shoulder.
A second sa fety -p in i s used to fa sten the sheet a t the righ t
w r is t, to immobilize the arms.
The r ig h t lower portion of the sheet is
now tucked securely under the ex trem ities; the l e f t is mitred above the
k n ees, pulled tig h t ly around the ex tr e m itie s, and pinned to a f o ld in
the dart thus made.
(2 8 6 )
CULTURES OF THE NOSE AND THROAT
Cultures are taken for the purpose of d ia g n o sis, fo r d etection of
c a r r ie r s , and fo r determining the viru len ce of organisms.
The procedure
requires the follow in g equipment:
A small portable tab le
S t e r ile ap p licators (in tube
containers)
Culture tubes with L oeffler
serum agar
Flash-light(wrapped in a
paper towel)
Tongue depressor
Alcohol sponge
Alcohol lamp
Matches
Paper bag (fo r contaminated
a r t ic le s )
The ta b le on which the equipment i s assembled i s wheeled by the nurse
to a convenient p o sitio n in the ward, and she a s s i s t s the physician who
takes th e c u ltu r e s.
She f i r s t removes the cotton plugs from the tube con­
ta in in g a p p lica to rs; he removes th e s t e r i le a p p lic a to r s.
The nurse then
hands a tongue depressor to the p hysician and removes the cotton plugs
from th e cu ltu re tubes, holding th e tubes w hile the physician plants the
nose and throat cu ltu res.
replaced by th e nurse.
The tubes are then flamed and the cotton plugs
The tongue depressor and the app licators are d is ­
carded in to the paper bag.
When the fla s h -lig h t i s used i t i s handed to the physician in a
paper tow el; a fte r u se , the nurse r e c e iv e s i t in an alcoh ol compress; she
wipes i t o f f c a re fu lly and places i t upon th e ta b le .
discarded into the bag by th e p h ysician .
I f h is gown becomes contaminated,
he d iscard s i t into a hamper, then scrubs h is hands.
(287)
The paper towel i s
Rapid Cultures for Diphtheria B a c i l l i .
Instead o f L o effler serum agar
media, which requires twenty-four hours for the growth o f diphtheria b a c i l l i ,
a more rapid method has been devised1 : S te r ile cotton ap p licators are sat­
urated w ith s t e r i l e undiluted, unheated horse serum to which no preservative
has been added, then are flamed s u ffic ie n tly to coagulate the surface pro­
t e in .
The p a tie n t's nose and throat cultures are then taken in the routine
manner, a fte r which these sp e c ia lly prepared a p p lica to rs are replaced in
the s t e r i l e g la s s containers and incubated for from two to four hours.
The horse serum w ith which the applicators are saturated serves as the
culture media.
Smear preparations are made d ir e c tly from the ap p licators.
Reports o f the r e s u lt s are available w ithin a period o f four hours.
C ultures for Determination of Virulence o f Organisms.
are employed to d etect diphtheria ca rriers.
Virulence t e s t s
The L o e ffle r ’ s blood serum
agar media or the s p e c ia lly prepared app licators fo r rapid cultures may be
used.
A fter the nose and throat cultures are taken, they are sent t o the
laboratory and placed in the incubator.
The viru len ce t e s t i s made by in ­
je c tin g 2 c c . o f a forty-eigh t-h ou r broth culture in to each o f two guinea
p ig s, one o f which has been immunized with diphtheria a n tito x in .
I f the
organisms are v ir u le n t, the susceptible animal w ill d ie w ithin three to
f iv e days.
1 . M. Bernard Brahdy, M. Lenarsky, Lawrence W. Smith, and C. A. Gaffney,
A Rapid Method fo r the Id e n tifica tio n o f Diphtheria B a c illi,
Journal o f the American Medical A ssociation , CIX (May 25, 193§),
pp. 1881-1883.
LUMBAR PUNCTURE AND ADMINISTRATEON OF IMMUNE SERUM
A lumbar puncture may be done to r e lie v e in tracran ial pressure or to
secure spin al flu id fo r d ia g n o sis.
a lso be given in tr a th e c a lly .
Therapeutic immune serum or drugs may
In s e ttin g up fo r a lumbar puncture, a nurse
obtains the s t e r i l e tr a y , which includes the follow ing s t e r i l e equipment:
For lumbar puncture:
For lo c a l a n e sth e tic :
Large and small lumbar puncture
needles
3 test-tu b es (fo r sp in a l f lu id )
Spinal manometer
3-way stop-cock
Lumbar puncture sheet
Cotton pledgets
Gauze compresses
Rubber gloves (fo r the physician)
Hypodermic syringe
No. 24 gauge needle
Medicine g la ss
For giving Serum
Gravity se t
Syringe (for adrenalin)
No. 24 gauge needle
The u n ste r ile a r t ic le s needed include:
For lumbar puncture:
For giving serum:
Dressing rubber and tow el
Container with green soap and
alcohol
Iodine, 3§ per cen t
A lcohol, 70 per cen t
Jar with c r e s o l, 2§- per cent
(for forceps)
S t e r ile cotton ap p lica to rs in
g la ss tubes
Hack or oontainer (fo r used t e s t tubes)
la b e ls
Alcohol compress
Adhesive s tr ip s
Paper bag
V ials of serum
Cup of warm water (fo r v ia ls )
Cup of cold water fo r used
syringe)
V ial of adrenalin, 1:1000
Alcohol lamp
Matches
(289)
For lo c a l a n esth etic:
Flask of s t e r ile d i s t i l l e d water
Novocains t a b le t s , 0*02 gm«
290
Preparation of the P a tie n t.
The patient i s placed on the ward str e tc h e r ,
covered with a blanket, and h is gown removed*
He i s taken to the treatment
room i f privacy cannot be provided in h is u n it and i s restrained during
treatment by a nurse.
(The physician and those who a s s is t him are properly
gowned and observe the usual care to prevent th e spread of in fe c tio n .)
The
p a tie n t's spine i s fo r c ib ly fle x e d , and a dressing rubber and towel are
placed at th e p a tie n t's back; the bed blanket i s folded to expose the lumbo­
sa cra l region , including the i l i a c crests*
Procedure of the Lumbar Puncture.
The clean nurse hands the physician
the applicators dipped in 3*j- per cent iodine and an alcohol sponge with
which to clean the s i t e o f in je c tio n .
A fter use the physician discards
them into a paper bag, puts on s t e r i l e gloves, and drapes the p a tie n t.
If
a lo c a l an esth etic i s needed, the nurse prepares the 1 per cent novocaine
in the s t e r ile medicine g la s s by adding 0*02 gm. novocaine ta b lets to 4 c c . o f
s t e r i l e w ater.
A fter in je c tin g the lo c a l an esth etic, the physician in s e r ts
the lumbar puncture needle through the interspace above the fourth lumbar
vertebra into the subaraohnoid space.
w hile the reading i s taken.
The nurse holds the spinal manometer
As the physician takes a s t e r ile test-tu b e
from the ta b le, the nurse removes the co tto n plug from i t with forceps, and
p laces i t on the s t e r ile f i e l d .
When the specimen o f spinal flu id i s ob­
ta in ed , the nurse receiv es th e te st-tu b e from th e physician in an alcoh ol
compress; she replaces the cotton plug and puts the tube in the rack. Three
specimens are obtained and lab eled No. 1 , No. 2 , No. 3 , respectively*
I f iTtwmwft serum i s giv en , the nurse removes the v ia l from the warm
water, wipes o f f the top w ith an alcoh ol compress, removes the cork, and
291
flames the rim o f the v i a l , a fte r which she pours the serum into the gradu­
ated container o f the gravity s e t held by th e p h ysician .
The used gravity
se t i s discarded in to th e container of cold water, and the needle i s
dropped in to the container o f green soap and a lc o h o l.
The physician cleans
the s i t e of th e puncture with a lco h o l, then he d r ie s th e area and a p p lies
a s t e r i l e d ressin g to i t .
The specimens are lab eled by the nurse and sen t,
with the r e q u isitio n s l i p s , to the laboratory.
Care o f th e P a tie n t.
The patient is taken to h is u n it and kept f l a t
in bed w ith no p illow under h is head fo r a period o f time designated by
the physician; t h is i s to esta b lish equal pressure in the cerebro-spinal
c a v ity .
The syringe o f adrenalin i s kept a t the bedside of the p a tie n t,
who is c a r e fu lly observed fo r serum reaction .
Recording.
Notation of the procedure in d icatin g the amount and ap­
pearance o f the flu id withdrawn, the pressure, and any unfavorable reaction
o f th e p a tie n t i s made on the c lin ic a l record.
When Immune serum or a n ti­
to x in i s adm inistered, the s e r ia l number a lso should be recorded.
LARYNGOSCOPY' AND SUCTION
When a p atien t i s su ffer in g from severe respiratory embarrassment, a
laryngoscopy may be performed by the p hysician .
to r e lie v e the respiratory d is t r e s s .
Suction may be necessary
For these procedures i t i s b est to
have a room s p e c ia lly equipped as follow s:
Examining ta b le w ith :
Rubber-covered foundation
Large sheet
Draw-sheet (fo r mummy r e str a in t)
Sand-bag with removable cover
Three sa fety -p in s
Tongue depressors
Dry c e l l b a tte r ie s with
rheostat and cord a tta ch ment (fo r laryngoscope
lig h t)
Suction apparatus Including:
Suction pump w ith rubber conn estin g tube and adaptor
fo r metal suction t i p
Paper bag (fo r waste)
Small bowl o f warm water
(fo r flu sh in g the suction
tube)
Supplies fo r laryngoscopy and su ctio n :
Culture tubes
Alcohol lamp and matches
Spectacles (for physician
and nurse)
Masks
Gauze squares
No. 12 Chevalier Jackson
laryngoscopes
No. 6 Chevalier Jackson
laryngoscopes
Tongue depressors
Metal su ctio n t ip s (various
s iz e s )
S te r ile cotton ap p licators
(in tube containers)
S olu tion s fo r contaminated a r t ic le s :
C resol, 2§- per cent (fo r
used instrum ents)
Tincture o f green soap (fo r
masks and sp e cta cles)
A lcohol, 70 per cent ( f 0r
lig h t bulbs and h o ld e r s)
(292)
293
Other equipment:
Oxygen tanks with gauge
and n asal cath eter
S t e r ile tracheotomy se t
Stimulants
Hamper bag in conveyor (for
contaminated lin en )
S t e r iliz e r (fo r instruments)
Low s to o l
The equipment i s always kept in readiness f o r emergency.
Preparation o f th e P a tie n t.
The p atien t i s placed on the ta b le fo r
examination by the p h ysician , and a mummy restra in t app lied.
(See page 20L )
The p a tie n t's shoulders are placed on the sand-bag, with the head dropped
back in the m id lin e.
The nurse leans across the p a tie n t's chest and grasps
h is head, firm ly placin g her palms on th e sid e s (fin g ers extended and thumbs
on the forehead).
A s lig h t turn of th e p a tie n t's head backward permits a
more d ir ec t view o f the larynx.
Two nurses may be needed to com pletely re­
str a in th e p a tien t.
A ssistin g with Laryngoscopy and S u ction .
A clean nurse a s s is t s the
physician w ith su ctio n , cu ltu r e s, and in other ways as may be necessary.
The a r t ic le s to be used are arranged on a email stand with the suction ap­
paratus.
The clean nurse hands th e physician a tongue depressor, laryn­
goscope (proper s i z e ) , and su ction t ip .
The suction apparatus i s te ste d
before i t is used.
The physician laryngoscopes the p atien t (using the suction pump to
remove lo o se membrane from the larynx) and takes the cu ltu res.
The clean
nurse holds the culture tubes w hile the physician plants the cultuxes; she
then flames th e rims o f the tubes and rep laces th e cotton plugs which she
has removed from the tubes.
A fter the laryngoscope has been removed by the
p h ysician , the contaminated nurse immediately turns the patient on his sid e
294
and wipes out h is mouth with gauze squares*
The p a tien t i s then placed
f l a t on th e t a b le , the r e str a in t is loosened, and he i s examined by the
physician before being returned to h is unit*
Care o f Contaminated JEquipmant.
A fter each treatment a l l contamin­
ated instrum ents, with the exception of the lig h t bulb and holder (which
are placed in a lc o h o l, 70 per c e n t), are b o iled in the instrument s t e r i l i z e r .
The contaminated sp e c ta cle s and masks are washed in the green soap so lu tio n .
The su c tio n apparatus i s cleaned by flushing the connecting tubing f i r s t
with a d ilu ted so lu tio n o f green soap, and then with cold w ater.
When the
membrane i s to be saved fo r examinatloni the return flow i s strained through
gauze and th e m aterial thus c o lle c te d plaoed in form alin, 10 per ce n t.
Recording.
S u itab le notation indicating the r e s u lt s o f the treatm ent,
the tim e, and the p a tie n t's reaction is made on th e ch art.
INTUBATION
An intubation may be done to r e lie v e resp iratory d istr e ss caused by
edema o f the larynx, by pseudo-membrane, or by other abnormal co n d itio n s.
The d ir e c t or in d irect method may be employed.
An 0 'Dwyer hard rubber tube
adapted to the siz e o f the larynx (which v a r ie s according to age, from in ­
fancy to adulthood) i s used.
Indirect Method.
When th e in d ir e c t method of intubation is u se d ,,th e
clean nurse prepares the fo llo w in g equipment:
Mouth-gag
Ind irect intubator
O'Dwyer tube w ith lin e n
thread attached
Tongue depressors
S cisso rs
Gauze squares
Rubber catheter (fo r su ctio n
i f desired)
The p a tien t i s placed on a treatm ent ta b le and examination made by th e physi­
cian (properly go w e d and wearing a mask and sp e c ta c le s).
i s then applied by th e contaminated nurse.
(See page286.)
A mummy r e s tr a in t
The nurse holds
the p a tie n t's head from above w hile the physician adjusts the mouth-gag and
with the in d irect intubator in s e r ts th e 0 'Dwyer tube.
When the tube is in
place, the physician cuts th e lin e n thread, discards i t , and removes the
mouth-gag.
The p atien t i s immediately turned on h is side to prevent aspira­
t io n , and, i f necessary, the mouth i s wiped out with gauze.
As soon as
p o ssib le the restra in t i s loosen ed.
D irect Method.
When the d ir e c t method of intubation i s used,the clean
nurse assembles the follow in g equipment!
(295)
296
Chevalier-Jackson laryngoscope
D irect intubator
O'Dwyer tube with lin en thread
attached
S cisso rs
Gauze squares
Tongue depressors
Suction t ip ( i f desired)
Rubber catheter ( i f desired)
The contaminated nurse holds the patien t a s f o r laryngoscopy and with the
d ir e c t intubator the physician In se r ts the tube d ir e c tly througi the
laryngoscope.
As soon as th e tube is in place the lin en thread is cu t and
discarded, and the laryngoscope i s removed.
The patient i s immediately
turned on h is sid e to prevent a sp ir a tio n , and the restra in t i s loosened.
The physician and the nurse each wears a gown and sp e c ta c le s.
The patient
i s put to bed a fte r the treatm ent; he must be c a r e fu lly watched fo r any
respiratory d if f ic u lt y .
Recording.
In recording the procedure p articular notation is made o f
the s iz e of tube in serted , and of the p a tie n t's appearance (coloi), p u lse,
and r esp ir a tio n ,
EXTOBATIGN
When an intubation tube becomes blocked or when resp iratory enfcarrassment no longer requires an O'Dwyer tube, an extubation i s done.
E ith er the
d ir ec t or in d irect method o f procedure is employed.
D irect Method.
For d irect extubation the clean nurse assembles the
fo llo w in g a r t ic le s :
C hevalier Jackson laryngoscope
Tongue depressors
Wire extubator or laryngeal
forceps
Gauze squares
Suction apparatus
Curved b asin
The contaminated nurse ap p lies a mummy restra in t then holds the p a tien t in
p o sitio n (as fo r laryngoscopy) while the p h ysician , using the wire extubator
or laryn geal forcep s, removes the hard rubber tube through the laryngoscope
and, i f n ecessary, uses the suction apparatus to remove mucus or membrane.
(The physician wears a clean gown, mask, and g la s s e s .)
carded in to the enamel b a sin .
The tube is d i s ­
As the tube i s removed the p a tien t i s turned
on h is sid e to prevent asp iration ; h is mouth i s wiped with a gauze square
and the r e str a in t i s loosened.
An intubator and a tube (the same size as th e one the patient is wear­
ing) are kept in read in ess for any emergency.
In d irect Method. For the ind irect method o f extu b ation , an extubator,
mouth-gag, and gauze are needed.
The p o sitio n o f the p a tien t is the same
as fo r the in d irect in tu b ation .
After the removal o f the tube the p atien t
i s turned on h is sid e by the contaminated nurse; th e mouth i s d ried , i f
n ecessary, and the r e s tr a in t i s lossened.
b a sin .
The tube i s discarded into the
296
Care of the P a tien t.
The nurse tak es the patien t hack to h is u n it and
p la ces him in bed, watching c lo s e ly fo r retra ctio n s or fo r any symptom o f
respiratory d is tr e s s , such as change in co lo r or pulse ra te.
Care of Equipment.
The instruments used are washed and b o ile d , and the
contaminated lin en i s discarded.
The Intubation tube is washed w e ll with
soap and water and allowed to remain in a lco h o l, 70 per cen t, fo r a t le a s t
h a lf an hour.
Recording.
I t should not be b o ile d .
The procedure i s noted on the p a tie n t's c lin ic a l record,
and a description o f the p a tie n t's condition follow ing the treatment i s
given.
CHANGING THE TRACHEOTOMY TUBE
When a p a tien t i s wearing a tracheotomy tube, a s t e r ile tube and tracheal
d ila to r should always be in readiness to replace i t i f necessary*
A tube
i s changed by the physician; the nurse prepares the follow ing a r t ic le s on
a s t e r i l e f ie ld fo r the procedure:
Tracheotomy tube w ith obdura to r , tap es, dressing
Inner tube
Tracheal d ila to r
Gauze compresses
Lubrajel
Tongue depressors
Paper bag
The necessary u n sterile equipment includes:
A lcohol, 70 per cent
Hydrogen peroxide
Boric ointment
S cisso r s
Curved basin
Procedure:
Suction apparatus
Bowl o f cold water
Bowl o f warm sodium bicarbona t e , 2 per cent
Rubber catheter
The contaminated nurse a s s is t s the physician as needed*
A sm all curved basin is placed at the fo o t of the treatment ta b le to re­
c eiv e contaminated a r t i c l e s .
The su ction apparatus with s o ft rubber
ca th eter attached i s kept in readiness fo r emergency.
A fter the physician cu ts the tapes attached to th e tracheotomy tube
BTid d iscard s the tube in to the curved b a sin , the nurse hands him alcoh ol
compresses (to clean the area around the in c is io n ) , dry compresses, and
boric ointment as he req u ests.
With the obdurator in place, the nurse
lu b rica tes the t ip of the tracheotomy tube with lu b r a je l, then hands the
(2 9 9 )
300
tube w ith tapes and dressing attach ed, to the p h ysician .
A fter in sertin g
the tube the physician discards the obdurator and adjusts the tap es.
Suction may be necessary i f th e mucus discharge i s profuse.
The nurse
then hands th e physician the inner tube.
Care o f the P a tien t.
The contaminated nurse takes the patient back
to h is u n it and places him in bed, observing him ca refu lly fo r any re­
sp iratory d is t r e s s .
She makes cer ta in that the small key holding the
inner tube in place i s turned.
Care of th e Equipment.
Contaminated dressings are discarded in to
the paper bag, and used lin en i s placed in the hamper bag.
The tracheot­
omy tube i s ca refu lly cleaned and freed from any dried mucus (peroxide may
be used for t h i s ) .
Recording.
The instruments are b o iled fo r ten minutes.
The treatment i s recorded in the p a tie n t's c lin ic a l record.
DISCHARGE BATH
Before a p a tien t i s discharged from th e h o sp ita l a complete bath and
shampoo are giv en .
The follow ing equipment i s assembled in the bathroom
fo r the procedure:
Enamel cup fo r mouthwash
Enamel cup fo r soap solu tion
Cotton p led gets on paper towel
Orangewood s tic k
S c isso r s
Coarse and fin e combe
Soap and dish
P itch er o f warm water (for
rin sin g the h air)
A n tisep tic mouthwash
Tincture o f green soap (for
shampoo)
Bath thermometer
The follo w in g containers are placed in the u t i l i t y room to receive the
contaminated a r t ic le s when they are removed from the p a tie n t's unit:
la r g e b asin (with soap solu tion
f o r a r t ic le s which cannot be
b o iled )
Sm all curved basin (with soap s o lu tio n fo r the thermometer)
Procedure.
Small basin w ith ere s o l, 2^
per oemt /fo r d is in fe e tin g bedside eard'
The nurse prepares a stre tc h e r by draping i t with a large
sh e e t, and fanning the sheet a t the sid e s; over t h is she places a rubber
s h e e t, covered with a draw-sheet.
Then a face tow el i s placed a t the head
o f th e str etch er and a bath towel and sm all blanket are fanned (together)
to the f o o t o f i t .
A second large sheet (fanned a t the sid es) i s used to
cover th e previously arranged a r t ic le s , and a clean gown i s placed under
th e m attress.
The nurse then wheels th e stretch er to the entrance of the
p a t ie n t 's u n it.
Returning to the bathroom the nurse pours a small supply of mouthwash
(3 0 1 )
302
in to one o f the cups and green soap and warm water into the oth er.
She
then f i l l s the p itch er with water (105° F . ) and draws the bath water
(100
o
- 105
o
F.).
S u itable clothing for the p a tien t i s conveniently
placed on the tab le top; the wash-cloth i s dropped in to the tub.
In the u n it, a irin g tags (with a n otation o f the tim e, d ate, and
ward) and a supply o f sa fety -p in s are placed on the p a tie n t's bedside ta b le .
The nurse then puts on a gown and assembles the p a tie n t's ind ividual equip­
ment in the face basin.
The patient i s then undressed, placed on the
s tr e tc h e r , and taken to the bathroom ( i f a c h ild , he i s wrapped in a
blanket from the bed before being placed upon the s tr e tc h e r ).
(An a t­
tendant remains with an in fant or with an irresp o n sib le p a tien t while he
i s on a s tr e tc h e r .)
The bed i s then stripped by the nurse, and a spread
or sh eet i s tie d to the fo o t o f the bed to r eceiv e the contaminated lin en;
the rubber bed sheet i s placed in th e face basin; the a irin g s lip s are
fastened to the m attress and p illow s; the contaminated lin en i s discarded
into th e hamper, and the nurse removes her gown.
The p a tie n t's contaminated equipment i s then taken to the u t i l i t y room;
the toothbrush and cotton from the thermometer ja r are discarded (the th er­
mometer i s placed in a solu tion in the sm all curved basin; the enamel ware
i s placed in the u te n s il s t e r iliz e r ; a l l other equipment is placed in the
large basin o f soap solu tion ; the bedside card i s dipped in
per cent
c r e so l so lu tio n and dried with a paper tow el; toys ( i f any) are washed or
discarded.
The nurse then scrubs her bands and puts on the gown v&ich she
removes from beneath the stretch er m attress, r o l l s up her sle e v e s, covers
the p a tien t on the stretch er with a sh e e t, and wheels him to the bathroom.
303
The Bath (Child P a tie n t).
The patient is uncovered and l i f t e d into
the tub, the contaminated sheet and blanket being discarded into the hamper.
The bath i s given and the hair shampooed (the hair i s rinsed by pouring
warm water from th e p itch er over i t ) .
A fter the b ath, the ch ild i s lif t e d
onto th e s tr e tc h e r , covered with the blanket, and d ried ;
the wet draw-
sheet i s discarded, and the rubber sheet i s l e f t a t the sid e o f the tub.
The ch ild i s then dressed, h is ears and nose are swabbed w ith cotton
p le d g e ts, and h is mouth rinsed out with an a n tis e p tic so lu tio n (the emdsis
basin i s used to receiv e the used so lu tio n ); h is h a ir is combed with a
fin e comb and c a r e fu lly inspected fo r n its and p e d ic u li.
ton p led g ets are discarded into a paper tow el.
The s o ile d co t­
Covered with a clean sh eet,
the p a tien t is then taken into a clean unit, placed in bed, where he con­
tin u es to be cared fo r with medical aaaptic technic u n t il he i s discharged
from the ward.
A fter the p a tien t has been put into bed, the ward maid washes the used
tub and ta b le thoroughly with soap and water, s t e r i l i z e s th e contaminated
a r t i c l e s , and leaves th e bathroom in order.
The Bath (Adult B a tle n t).
somewhat from the c h ild 's .
The procedure fo r an a d u lt's bath d iffe r s
In the bathroom,a ch air (covered with a clean
blanket) i s placed a t the sid e o f the tub, and a clean folded draw-sheet
i s placed on th e flo o r as a bath n e t.
The stre tc h e r i s draped with a
sh e et, a blanket folded a t the foot of i t , and over th ese another sheet
i s p la ced .
In th e u n it, the nurse puts on the contaminated gown and a s s i s t s the
p a tien t onto Hie str e tc h e r , then covers him with a blanket from the bed.
304
She discards th e gown, scrubs her hands, and puts on a clean gown.
Tbe pa­
t ie n t i s then covered w ith the stretch er sheet and wheeled to the sid e of
the tub, where he i s screened.
He i s then instructed by the nurse to remove
h is clo th in g , to drop i t onto the flo o r , and to use i t to stand on before
stepping into the tu b .
The ad u lt takes h is own bath, washes h is h air ( i f
able to do t h i s ) , and d resses h im self, a f te r which the nurse removes the
contaminated sheet from the s tr e tc h e r .
She then a s s is t s the p atien t onto
the stretch er and covers him with a b lan ket.
She i s responsible fo r the
p a tie n t's proper mouth care and f o r in sp ection of h is hair for n i t s and
p e d ic u li.
The patien t may walk to and from the bathroom (with a clean sheet
wrapped about him) i f he has p reviously been allowed out o f bed.
Clean
slip p ers are provided for h is return to the clean unit i f he walks.
The Bath Given on S tre tc h er .
When fo r any reason a tub bath may not
be given to a patient about to be discharged,he is bathed on the str e tc h e r .
The procedure i s as fo llo w s:
The bathroom equipment is prepared in the
routine manner, with the ad d itio n of a large bath basin o f warm water (105° F . ),
and a clean cotton blanket*, the clo th in g , tow els, and fa ce-clo th are ar­
ranged conveniently.
The s tr e tc h e r i s draped with two cotton b lan k ets, fan­
ned a t the sid e s, and a sheet i s fold ed a t the fo o t; a K elly pad (covered
w ith a draw-sheet) i s placed a t the head; a gown fo r the nurse i s placed
under the m attress.
The nurse then wheels the stretcher to the u n it, puts
on the contaminated gown, covers the p a tien t with a blanket from the bed,
aM a s s is t s Him Onto the s tr e tc h e r .
The contaminated lin en i s then discarded,
the contaminated in d ividu al equipment removed, and the unit l e f t ready to be
cleaned* (See page 56*)
A fter scrubbing her hands and putting on a clean
gown (r o llin g up the sleev es) the nurse covers th e p a tien t with the clean
sheet (from the fo o t o f the stretch er), then wheels him to the bathroom.
In the bathroom the nurse removes the sh eet and discards i t into the
hamper and the stretch er i s placed beside th e tu b .
The K elly pad (a fte r
the draw-sheet which covers i t i s removed) i s adjusted to hang over the
tub so th a t the water used f o r washing and rin sin g the p a tie n t's hair may
be d irected into the tub.
A fter the shampoo the K elly pad i s removed and
the h a ir i s d ried .
The p a tie n t's fa ce i s then washed and the contaminated top blanket is
folded downward, exposing the arms, c h e s t, and abdomen, the areas next
washed.
Then the p a tien t i s turned on one sid e , h is back i s washed, and
the upper part of the blanket on which he i s lyin g i s fold ed inward and
underneath h is body.
The ex trem ities are then washed, and the r e s t of the
blanket folded inward, leaving a clean area on which the patient l i e s when
he i s turned on h is other sid e for the bath to be completed.
While turned
on h is other s id e , the contaminated blankets are drawn o f f the str e tc h e r ,
away from the p atien t; he is then placed on h is back and covered with a
clea n cotton blanket.
hamper.)
(The contaminated blankets are discarded into the
The p a tie n t's mouth and ears are cared for in the routine manner;
then he i s taken to a clean u n it.
Recording.
N otation o f the discharge bath is made on the ch a rt.
Spe­
c i a l mention i s made o f any discharges, eru p tion s, or unusual symptoms, a lso
o f th e presence o f n it s or p e d ic u li.
APPENDIX B
LISTS OF DISEASES1
A
•List of Communicable D iseases for Which N o tific a tio n
I s U sually Required in the S tates and
C itie s o f the United S tates
Actinomycosis
Ancylostom iasis (hookworm
d isease)
Anthrax
Chicken pox (v a r ic e lla )
Cholera
C o n ju n c tiv itis, acute
in fe c tio u s
Dengue
Diphtheria
Dysentery, amebic
(amebiasis)
Dysentery, b a c ilia r y
E n cep h a litis, in fe c tio u s,
le th a r g ic and nonleth a r g ic
Favus
German m easles (rubella)
Glanders (farcy)
Gonorrhea
Influenza
Leprosy
Malaria
Measles (rubeola)
Meningococcus m en in gitis
Mumps (p a r o titis)
Paratyphoid fever
Plague, bubonic, septicem ic,
pneumonic
Pneumonia, acute lobar
P o lio m y elitis
P s itta c o s is
Puerperal in fe c tio n (puerperal
septicem ia)
Sables
Rocky Mountain spotted (or
tic k ) fever
S carlet fever (sca rla tin a )
Septic sore throat (streptococ­
cus throat in fec tio n )
Smallpox (variola)
S y p h ilis
Tetanus
Trachoma
T rich in osis
Tuberculosis, pulmonary
T uberculosis, other than
pulmonary
Tularaemia
Typhoid fever
Typhus fev er
Undulant fev er (b ru c e llo sis)
Whooping cough
Yellow fever
1 . Public Health Reports, L. Washington, D. C.: United S tates Government
P rin tin g O ffice, August 9 , 1935, pp. 2-3.
B
Communicable D iseases or In festa tio n s Occurring In the
United S ta tes and Insular P o ssessio n s, but fo r Ufoich
N o tifica tio n to th e Health A u th orities
i s Not Everywhere Required
A scariasis
Common cold
Coccidioidal granuloma
F ila r ia s is
Icterohemorrhagic jaundice
(W eil(s disease)
Impetigo contagiosa
Lymphogranuloma venereum
(inguinale) and clim a tic
bubo-*-
P ed icu lo sis
R at-bite fever (sodoku)
Relapsing fever
Ringworm
Scabies
Schistosom iasis
V incent’s in fe c tio n (angina,
sto m a titis)
Yaws
C
D iseases o f Concern to Health O fficers because of Their Croup
or Epidemic Occurrence and the P r a c tic a b ility of Their
Prevention, and fo r ThCae Beesons Often Included
Among Those N o tifia b le to the Health Authority,
but Not Considered Communicable in the
Usual Sense o f th e Teim
Botulism
Food in fe c tio n s and poisonings
1.
P ellagra
This t i t l e does not include granuloma venereum (in g u in a le), which
i s a d ifferen t c l i n i c a l con dition.
(307)
GLOSSARY
GLOSSARY*
Aerobe - A micro-organism which can liv e only in a ir or in oxygen.
A gglutinin - An antibody which causes clumping or agglu tin ation o f the
b acteria or other c e l l s which hsve acted as an tigen .
Anaerobe - An organism which th r iv e s b e s t, or only, when deprived o f oxygen.
Angina - Any disease characterized by su ffocation , as quinsy, croup, e t c .
Anorexia - Loss o f a p p e tite .
Antibody - A body, e ith e r n aturally e x is tin g or a r t i f i c i a l l y introduced in­
to th e blood, which i s an tagonistic to other bodies or substances
in ju rio u s t o th e animal organism.
Antigen - Any substance which, when introduced in to the animal organism, causes
the production o f an antibody.
A ntiseptic - D estruction to the germs of d isease, ferm entation, or putrefaction .
A ntitoxin - A substance, formed in the liv in g t is s u e s of a plant or animal,
which n e u tra liz e s th e b a cteria l poison that produced i t .
A sepsis - A condition in which liv in g pathogenic organisms are absent.
Aspirate - To remove by su ction or asp iration .
♦For d e fin itio n s of selected words in t h i s Glossary Steadman’ s Medical
Dictionary and Funk and Wagnall’ s Standard D ictionary have been consulted
or quoted a s a u th o r itie s.
309
A spiration - The withdrawal, by su c tio n , o f a ir or flu id from any of the
body c a v itie s .
Atrophy - A wasting cf th e t is s u e s o f a part or of the en tire body.
Attenuation - 1. D ilu tio n , th in n in g.
2. Dimunition o f virulence in an
organism, obtained through heating, c u ltiv a tio n on certain media,
and other ways.
Avirulent - Not v ir u le n t.
Bacterlemia - The presence o f liv in g b a cteria in the circu latin g blood.
B ronchiectasis - D ila ta tio n o f a bronchus or of the bronchial tubes.
B rudzinski's Sign - 1 . C ontralateral r e f le x ; when the thigh in a child, i s
fo rcib ly flexed again st th e abdomen there is a movement - sometimes
o f extension, sometimes o f fle x io n - at th e opposite hip*
2. Neck
sign; i f th e neck i s p a ssiv ely bent forward, fle x io n of th e th ig h s
and le g s occurs, as in m en in g itis.
Carrier - Vector, b e c illi- c a r r ie r , a person in apparent health who i s in ­
fected with sane pathogenic organism to which he him self, for the
time being at l e a s t , i s immune, but which, tihen accidentally tran s­
ferred to another, may produce an attack o f the sp e c ific d isea se.
Clrcumoral - Encircling the mouth.
C istern al Puncture - Introduction of a needle through the intravertebral
opening and into the subarachnoid space (cistern ) of the brain fo r
the purpose of in je c tin g m edication or withdrawing spinal f lu id .
Clean - Free frau the organisms of d isea se; uncontaminated by d irect or in ­
d irect contact with an in fe c te d p atien t or h is environment.
Cleaning - Removal (by scrubbing with soap and water) of a ll matter in which
micro-organisms may fin d favorab le conditions far growth; also removal
(by sim ilar means) o f micro-organisms adherent to surfaces.
310
Communicable - Capable o f being transm itted from boat to b ost.
Contact - A person (or animal) wbo bas been exposed to d irect or in d irect
tr a n sfe r o f in fe c tio u s m aterial.
Contagious - Capable o f being transm itted from one person to another by direct
or in d ire ct con tact, or from animal to anim al, or animal to human. (See
page 2 0 .)
0ontamination - P o llu tio n , s o ilin g vdth in fe c tio u s m atter.
Coryza - Cold in th e head.
C r is is - A sudden change in th e course of an acute d isea se; abrupt d eclin e,
w ithin a few hours, o f a continued fe v e r .
C ro ss-in fectio n - An in fe c tio n of a new type superimposed upon a patient with
a p rior in fe c tio n of a d ifferen t type (u su ally carried from one patient
to another through a break in asep tic te c h n ic ).
Dermographism - A condition in which tracin gs made by pressure on the skin
lea v e a d is tin c t elevated mark, white or reddish in co lo r, and which
may p e r s is t for some minutes.
Desquamation - Peeling or shedding of the sk in .
Diaphragm - An important muscle used in resp ir a tio n , situ a te d between the
th o ra cic and abdominal c a v it ie s .
Dick Test - The t e s t fo r a person’s s u s c e p tib ility to sc a r le t fev er.
Diplococcus - Biscuit-shaped bacteria appearing in p a irs when stain ed .
P isc r e te - Made up o f separate p arts, or characterized by le s io n s which do
not jo in w ith others.
311
D isin fectio n - The d estru ction of pathogenic micro-organisms. Concurrent
d is in fe c tio n - D isin fe c tio n of in fectio u s m aterial as soon as i t
occurs. Terminal d isin fe c tio n - D isin fectio n of a person’s immediate
e f f e c t s and environment as soon as he has ceased to be a source of
in fe c tio n in h is person.
D isin festin g - Any p rocess, p hysical or chem ical, such as trapping, shooting,
poison, gas, h ea t, e t c . , by which animals or in s e c ts capable o f trans­
m ittin g d isea se are destroyed.
Disphagia - D iffic u lty in swallowing.
/
Enanthem - A rash on a mucous membrane.
Endemic - The con d ition in which a d isease is continuously present in a com­
munity in season, as d istin g u ish ed from an epidemic or sporadic form.
^Endotoxin - A to x in or poison that i s retained w ithin the body o f th e invad­
ing organism and i s not released except by the d isin teg ra tio n o f said
organism, wherein i t d iff e r s from the e x tr a -c e llu la r or true to x in
(ex o to x in ).
Epidemic - A con d ition in which a d isease attacks a large number of people in
a community at the same tim e, or during th e same season, and tends to
x spread rap id ly to o th ers.
v
Eruption - A breaking out, e s p e c ia lly th e appearance o f le s io n s on the skin;
a rash on the skin or mucous membrane.
Erythema - An abnormal redness of the skin (many v a r ie t ie s ) , due to congestion
o f the c a p illa r ie s ; rose rash.
E tiology - That department of various sciences which has to do w ith the in ­
q u iries as to causes, as o f d isea se.
Exanthem - A skin eruption occurring as a symptom of a general d ise a s e , such
as sc a r le t fever or m easles.
Excreta - M aterials cast o ff from the body; waste m atter.
Exotoxin - A soluble to x in excreted by an organism into the surrouding medium.
312
Extubate - To remove an in tu b ation tube from the larynx.
Exudate - Any abnormal substance deposited in or on a tissu e by a d isea se
or v it a l p rocess.
Eastigium - The acme, or h igh est p o in t, of a fever; th e period of f u l l de­
velopment o f an in fe c tio u s d ise a s e .
Eauces - The space between th e c a v ity o f the mouth and the pharynx.
Eamites - Substances or m ateria ls other than food (such as clo th in g , hard
surfaces, e t c . , ) th a t may harbor, carry or transmit pathogenic organisms.
Eixed Virus - Virus o f ra b ies o f th e utmost viru len ce, obtained by numerous
passages through r a b b its . (See page 12.)
Hemorrhagic - R elating to or marked by hemorrhage; discharge of blood from
a ruptured blood v e s s e l.
Herpes - An inflammatory eruption o f the skin, forming groups of small b l i s t e r s .
Host - The organism at the expense o f which a parasite liv e s .
Hydrocephalus - Enlargement o f th e head w ith prominence of the forehead due to
an abnormal increase in the amount of contained f lu id .
Hyperemia - An unusual amount o f blood in any part of the body.
Hyperesthesia - E xcessive s e n s ib ilit y totouch, pain, or other sensory s tim u li.
Hypostatic - A con d ition in which the blood, influenced by gravity, s e t t l e s
in a part, due to feeb len ess of c ir c u la tio n .
- A s ta te , natural or acquired, in which the body is r e s is ta n t to
d isease.
Tmmiinity
313
In clu sion Bodies - Round, oval, irregu lar bodies which have been observed
in sid e the t is s u e c e l l s in many v iru s d is e a s e s . They are found in
th e cytoplasm, in the nucleus, or both, in the d ise a s e s in which
they have been reported; they may be in terp reted e ith e r as stages
or mass growth o f the viru s, or as rea ctio n o f the c e l l to the in ­
vading viru s; th e ir nature s t i l l i s uncertain, but t h e ir sig n ifica n ce
i s important as a sign o f in fe c tio n . Valuable in d iagn osis.
In fe c tio u s - Capable o f being transm itted by in fe c tio n , with or without
actu a l con tact. (See page 20.)
In ocu lation - The in ten tio n a l introduction o f the viru s o f a disease in to
the body. Curative in oculation - In jectio n o f a p rotective serum
fo r curative purposes. P rotective in ocu lation - In jectio n of a
serum t o protect against d isease; vaccin ation .
Intubation - In sertion o f a tube in to any canal or other part; used in
laryn geal diphtheria.
Invasion - The a tta ck or onset of a d isea se.
I s o la tio n - Separation from others i l l with a contagious d ise a se , or from
ca r r ie r s of the in fe c tin g organism.
K eraig’ s Sign - A symptom o f m eningitis; when a patient l i e s upon h is back,
and h is thigh i s flex ed to a r ig h t angle with th e a x is o f th e trunk of
h is body, complete extension o f h is le g on h is th ig h i s im possible.
Koch’ s P o stu la tes - Koch’s low: to e s ta b lish th e s p e c if ic it y of a micro­
organism, i t must be present in a l l cases of the d ise a se , inocu lations
o f i t s pure cu ltu res must produce the same d isea se in animals (when i t
i s transm itted to such^, and from th ese i t must be again obtained and
be propagated in pure cu ltu res.
K oplik’ s Sign (or Spots) - A diagnostic sign in m easles; small bluish-red
spots on the mucous membrane' o f th e cheeks and l i p s before the rash
appears.
L* - That dose o f to x in which when mixed with one unit of a n tito x in w ill
have ju st enough t o x ic it y to k i l l a 250-gram guinea p ig in four days.
314
Lumbar Puncture - The in trod u ction of a needle between th e second and f i f t h
lumbar vertebrae in to the subdural space of the spinal cord for the re­
moval o f sp in a l f l u i d , for diagn ostic or therapeu tic purposes.
Lysis - The gradual subsidence o f th e symptoms o f an acute d isease; a form of
the curative p rocess, d istin guished from c r i s i s .
Macule - A spot on the sk in , d ifferin g in color from the surrounding area but
not elevated above the general su rfa ce.
Minimum Lethal Dose - The sm allest amount o f toxin which w ill k i l l a 250-gram
guinea pig in four d ays.
Morbidity - The r a tio o f s ic k to w e ll in a community; the sick r a t e .
M ortality - The r a tio o f the number of deaths to the t o t a l population; the ra tio
of the f a t a l ca ses to the t o t a l number cf cases a t any d ise a s e .
Mucopurulent - Containing both mucus and pus.
M ultllocular - Having many c e l l s , or lo c u li.
Myoclonic - R elating to m yoclonia, an interm ittent clo n ic spasm or tw itching
of a muscle or m uscles.
Hares - The n o s t r ils .
Opisthotonos - A te ta n ic spasm in which th e spine and extrem ities are bent with
convexity forward, th e body re stin g on the head and the h e e ls .
O titis Media - Inflammation of the middle ear.
Pandemic - A wide-spread, or world-wide, epidemic.
Papule - A small circumscribed ele v a tio n of the skin ; a ra ised sp o t.
Parenteral - In some other way than by th e in te s tin a l canal, referrin g e sp e c ia lly
to the a ssim ila tio n o f nutritWre m aterial introduced in to th e v e in s or sub­
cutaneous t is s u e s .
Parkinsonian (or P arkinson^) Syndrome - A condition characterized by immobile
fa c ie s , muscular r i g i d i t y , tremor which tends to disappear on v o litio n a l
movement, lo s s of a sso cia ted or automatic movements, cramps, and some­
tim es s a liv a tio n ; frequently seen as 8 sequel to epidemic en cep h a litis;
a lso known as p a r a ly sis a g itan s.
Parotid - The large salivaiy gland situ a ted in front o f , and beneath, the ear.
315
Paroxysm - A p eriod ic attack o f d isease; a f i t or convulsion of any kind.
P a s tia 's S im - Transverse lin e s appearing at the bend of the elbow in sc a r le t
fev er. At f i r s t , they are rose-red ; la te r , dark red or wine colored;
they may be v i s i b l e before the rash appears, remain through th e eruptive
stage, and continue a fter desquamation.
Pathogenic - Able to produce d isea se.
Pathology - The scien ce o f change in stru ctu re, and m odification in fu n ctio n ,
due to d ise a se .
Petechia - Small p u rp lish spots on the skin which appear in certa in severe fe v e r s.
Placard - A printed or w ritten poster p u b licly displayed; used t o in d ica te the
presence of a communicable d isease in a home.
Placental Extract (Immune glo b u lin - Human) - A preparation made tram human
placen tal blood which has been used as a substitute for sera in the
prophylactic treatment of m easles.
P ort-holes - Openings in the side o f a resp irator (iron lung) through which
a p a tie n t's needs are attended t o .
Prodromal - Indicating an impending attack of a d isease.
Prognosis - A fo reca st concerning th e course, duration, andterm ination
d isea se.
of a
\
Prophylaxis - Measures taken for the prevention of the development or spread
o f a d isea se.
Pseudo -membrane - A f a ls e membrane;
sim ulating a true membrane, as in dip h th eria.
P to sis - Dropping o f an organ or p art, as of upper ey elid from p a r a ly sis , or of
the v is c e r a l organs from weakness o f the abdominal m uscles.
Pustule - An elevated skin le s io n containing pus.
Quarantine - A term applied to the sanitary regulations which r e s t r ic t the fr e e ­
dom of those who have been in contact with communicable d is e a s e s , fo r a
period o f time during whifeh they may be a menace to others; a period
(o rig in a lly fo rty days) o f detention of ships and th e ir passengers com­
ing from a port where smallpox, yellow fev er, or some in fe c tio u s
disease p r e v a ils.
Relapse - Recurrence o f the d isease in a patient during h is period of con­
valescence.
Renovation - The treatment, other than clean in g, that i s needed to place rooms
or houses in a sa tisfa cto ry sanitary con d ition .
R eticu lo -en d o th elia l System - That system o f th e body (including the bone
marrow, spleen, liv e r , lymphoid stru ctu res, e t c .) which i s the source
o f c e llu la r and humoral elements o f the blood .
R etraction - Drawing backward. As used in connection with laryngeal diph­
th e r ia , i t re fer s to the p u llin g -in o f th e supraclavicular fossae
(the, muscles between the rib s and o f th e abdomen beneath) due to the
action o f the diaphragm in the attempt to in sp ire a ir .
Schick Test - The te st for s u s c e p tib ility to d ip hth eria.
Schultz-Gharlton Test - A te s t to show the presence o f sc a r le t fev er. The
intracutaneous in jectio n o f a serum s p e c if ic fo r sc a r le t fever produces,
in a true sca rlet fever eruption, a lo c a l area of blanching.
Septicem ia - The presence in the blood o f growing micro-organisms and their
to x ic products.
Sordes - Foul accumulations on l i p s and t e e th in fe b r ile d ise a s e s .
Sporadic - S cattered , or occurring in freq u en tly.
S treet Virus - The virus o f rabies present n atu rally in rabid dogs, le s s potent
than fixed v ir u s.
S usceptible - Not known to be immune to a given communicable d isease.
Symbiosis - The growth together o f d ifferen t micro-organisms, to th e ir mutual
advantage. Example: the growth together o f cholera b a c illu s , an ameba,
and the lepra b a c illu s, although th e la t t e r cannot be cu ltivated alone.
Syndrome - A ll the symptoms of a d isease considered as a whole; a s e t of
symptoms which con stitu te a u n it.
Terminal - (See D isin fectio n .)
Toxemia - A condition resu ltin g from the absorption o f th e poisonous products
o f b a cteria .
Toxin. - A poison produced by growing micro-organisms.
T oxin-antitoxin - A mixture of diphtheria to x in and a n tito x in used for immuniz­
ing su scep tib le persons against dip h th eria.
317
Toxoid - Toxin attenuated by h ea t, aging, or chemicals.
Tracheotomy - Operation o f cu ttin g in to the trachea u su ally for in se r tio n of
a tube to overcome trach eal obstruction; often done in severe laryngeal
diphtheria.
Unilocular - Having but one compartment.
Unit - In medical a se p tic te ch n ic , a sharply defined zone o f contamination.
U rticaria - H ives, an eruption o f th e skin by the sudden appearance o f w e lts,
or wheals, o f irreg u la r o u tlin e , accompanied by in ten se itc h in g .
V esicle - A b l i s t e r - l i k e 'small elev a tio n on the skin containing a serous f lu id .
Virulent - Exceedingly poisonous.
Virus - Any to x ic agent capable of producing disease; a micro-organism or i t s
toxin*
Wheal - The c h a r a c te r istic skin le s io n of u rtica ria ; elev a tio n o f the sk in ,
white in the center with pale red periphery, accompanied by itc h in g .
I NDE Z
i
INDEX
Acute a n terio r p o lio m y e litis.
See P o lio m y e litis
A d e n titis , c e r v ic a l. See
Cervical a d e n titis
Admission ta b le , 263
equipment, 264
Admission tech n ic, 263
clo th in g record, 50, 266
cu ltu re taking, 263
immune serum, 263
laboratory procedure, 263
procedure, 264
recording, 266
ro u tin e, 263
te sts:
Schick co n tro l, 263
Schultz-C harlton, 263
vaginal smear, 263
Wassermann, 263
v a lu a b les, record o f, 50, 266
Adults
care o f , 15
convalescence o f, 15
African sleep in g sick n ess, refer­
ence t o , 182
A gencies, health
county, 30
Federal, 28
m unicipal, 30
nursing, 259
o f f i c i a l , 259
p r iv a te , 31
s t a t e , 29
u n o f f ic ia l, 31
voluntary,
and care o f ch ild ren , 15
and nursing, 258
(318)
Agents, in fe c tiv e
l i s t e d , 20
number o f , as fa cto r in flu ­
encing in fe c tio n , 21
period of communicability, 24
p o r ta ls o f en try, 21
Ages, Middle, 5
A gglu tin in s, as in tern al
d efen se, 25
A gricu lture, Dept, of:
Bureau o f Animal Industry, 29
Bureau o f Chemistry, 29
P ath ological Survey, 29
Air-borne m icrobes, 43
A iring, 52. See a lso Sunshine
c lin ic a l records, 52
clo th in g and valu ab les, 50
m a ttresses, 56
p illo w s, 56
porches f o r , 52, 56
rubber s h e e ts , 52
A lastrim . See Smallpox
A lcohol, rubbing, 47
A lien s, examination o f , by
U .S .P .H .S ., 28
Ambulance techn ic and regula­
t io n s , 267
at home o f p a tie n t, 267
d is in fe c tin g ambulance, 268
equipment, 267
gown and cap, 267
p h ysician , 267
p o rter, 267
str e tc h e r , 268
tr a n sfer of p a tie n t, 267
America, progress o f d isease
con trol in , 9
319
American Public Health A ssocia­
tio n , 31
American Red Cross. See Red
Cross, American
American S o cia l Hygiene Asso­
c ia tio n , 31
Amyl n i t r i t e , fo r resp iratory
d is t r e s s , 41
Anaphylaxis
rea ctio n , 41
symptoms and treatm ent, 41
Anemia, fran prolonged in fe c ­
tio n s , 22
Angina, Vincent’ s . See V incent’ s
Angina
Animals
and a n tib a c te r ia l sera, 40
examination and supervision
o f, 35
sources o f in fe c tio n , 20
Anthrax, in Middle Ages, 6
A n tibacterial serum. See Serum,
a n tib a c te r ia l
Antibodies
and p assive immunity, 26
as in tern al defense, 25
r e s u lt o f in fe c tio n , 22
s p e c if ic , from sera o f convales­
cent p a tie n ts , 40
Antigens, and d ip h th eria, 39
A ntisera, in war, 9
A ntitoxin, 9 , 26
adm inistration o f , 284
d e fin itio n o f , 39
diphtheria
adm inistration o f, 120, Ap­
pendix A
as p rop h ylactic, 40
discovery o f , 9
how produced, 39
recording, 285
sca r let fe v e r , d e fin itio n o f
unit o f , 40
s p e c ific
in dip h th eria, 40
in sc a r le t fe v e r , 40
tetanus, as p rop h ylactic, 40
to x in . See T oxin -an titoxin
Antonine plague, 4
Areas
clean , in h o s p ita ls , 47
contaminated, in h o s p ita ls , 47
A rth r itis
and sc a r le t fe v e r , 108
and sep tic sore th ro a t, 133
A r tic le s , s t e r iliz a t io n o f contam­
in ated , by spore-forming
organisms, 52
AsepSis. See a lso Medical a sep sis;
Surgical a sep sis
medical. See Medical a se p sis
p rin cip les o f , applied by nurse, 14
su r g ica l. See Surgical a se p sis
Aseptic tech n ic
importance o f , 18
m edical. See Medical a se p tic technic
A ssociations
fo r cure o f sic k , establishm ent
o f, 7
p rivate, 31
Athens, plague in , 450,B .C ., 4
Autoclaving, fo r d isin fe c tio n and
s t e r iliz a t io n , 52
B a c illi
diphtheria, growth o f , 22
tu b ercle, e f fe c t o f protein
products, 22
B a cillu s
diphtheria, discovery o f , 9
tu b ercle, discovery o f , 9
B acteria. See a lso Germs; Microbes
as in fe c tiv e agent, 20
as vaccine, 38
k ille d , f o r acquired immunity, 26
B acterial to x in s . See Toxins,
b a c te r ia l
B a cterio lo g ica l d ia g n o sis, f i r s t
laboratory f o r , 12
Bacteriology, modem, and Mosaic
law, 4
B a cterio ly sin s, as in tern a l defense,
25
Bags, ;
diaper, 51
for s o ile d paper t is s u e s , 54
hot water, washing o f , 52
Bands, rubber, fo r gown, 47
Bath, discharge, 301
adult p a tie n t, 303
child p a tie n t, 303
equipment, 301
on stretch er, 304
Bathroom, in home, 247
330
Bedpan
d isin fe c tio n o f con ten ts, 54
s t e r iliz a t io n o f , 53, 55
Beds, d istance between, 58
Bedside stand, item s on, 47
B iologic products, supervision
and c o n tr o l, 29, 40
Black Death, 6
Blood serum, as in ter n a l defense,
25
Blood specimens, 281
Body d efen ses, d e fin itio n o f , 24
Body discharges, viru len ce o f , 21
Body f lu id s , as in tern a l defense,
25
B o ilin g , fo r d is in fe c tio n and
s t e r iliz a t io n , 52
Books
d isin fe c tio n o f
contaminated, 54
in s c a r le t fe v e r , 110
from v i s i t o r s , 57
B o ttles
hot water. See Hot water
b o ttle s
m ilk, d is in fe c tio n o f , in
home, 253
nursing, s t e r iliz a t io n o f, 53
Bowls, s o lu tio n , s t e r iliz a t io n
o f, 53
Breeding p la c e s, elim in ation o f
mosquito, 227
B ronchiectasis and whooping
cough, 156
Broncho-pneumonia, 72-9 2
and diphtheria, 116
and laryngeal diphtheria, 129
and m easles, 72
and sep tic sore th ro a t, 135
and smallpox, 89, 92
and whooping cough, 155
Brushes
hand, b o ilin g , 52
hopper, s t e r iliz a t io n o f, 53
B u lletin s o f S ta te Health Dept., 30
Can
garbage, 55
refu se, 51, 57
Cans, ir r ig a tin g , s t e r iliz a t io n
o f, 53
Cappadocia, f i r s t h o sp ita l estab­
lish e d in , 7
Caps, ic e , washing o f , 52
Cardiac involvement and sc a r le t
fev er, 109
Care, home. See Home care
Care, morning, o f p a tie n t. See
Morning care
Carrier, is o la tio n o f , in
epidemic, 35
Carriers
and b io lo g ic a l in fe c tio n , 24
as source o f epidem ics, 21
control o f, 21
d efin itio n o f , 21
diphtheria, 119
in te r sta te , sup ervision o f,
by U.S.PoH .S., 28
o f pathogenic microorganisms, 14
Census, Bureau o f , s t a t i s t i c s
a v a ila b le , 35
Centers, h ea lth , 30
Cervical a d e n itis
and dip hth eria, 116
and nasal diphtheria, 122
and m easles, 72
and sca rlet fe v e r , 108
and sep tic sore th ro a t, 135
Chapin, D r., method o f medical
a se p sis, 12
Charter, Children’s . See Children’ s
Charter
Chemical d is in fe c tio n , 53
Chest, x-ray report o f nurse’ s , 16
Chickenpox, 80
and active immunity, 25
and c o n ju n c tiv itis , 82
and e n c e p h a litis, 82
and e r y sip e la s, 82
and gangrene, 82
and la r y n g itis , 82
and skin in fe c tio n , 82
communieability, period o f , 82
community p ro tectio n , 84
com plications, 82
confusion with smallpox, 84
con trol, 82
convalescence, period o f , 81
course o f d ise a se , 81
d ie t, 84
d isin fe c tio n , 83
321
Chickenpox - continued
eruption, period o f , 81
e s se n tia l p oin ts, 84
hone care, 84
hygiene, personal, 83
incubation, period o f, 81
in vasion , period o f , 81
is o la t io n , 82
mucous membrane, care of in , 83
nursing care, 83
nursing in stru ctio n s, 84
p a tie n t, comfort o f , 83
prevalence, 80
prognosis, 82
prophylaxis, 82
quarantine, 82
reco g n itio n , 82
rep ortin g, 82
sequelae, 82
skin , care o f, 83
s u s c e p tib ility , 80
synonym, 80
transm ission, mode of, 80
treatm ent, 82
Children
care o f , 15
entertainment of, 15
Children’s Charter, as Twentieth
Century id e a l, 15
China, smallpox innoculation in , 3
Chinese
and smallpox, 3
m edicine, b asis o f , 3
Cholera, in d irect contact, 24
Clean, d e fin itio n o f term, 46
Clean areas, in h o sp ita ls, 47
Cleaning, d e fin itio n of, 41
C leanliness
fundamental principal of medical
a s e p s is , 44
personal, and indirect c o n ta c t,
24
C lin ica l records
contaminated, a irin g o f, 52
how carried , 57
where kept, 58
C lin ic s , sp e c ia l, 30
Clothing
care o f, 50
n u r se s', 17
Code, sanitary, of sta te s, 29
Colds, of nurses, 17
Combs, washing o f , 52
Communicable d isea se, d efin itio n
o f, 20
Communicable d isea ses, l i s t o f,
31, 306
Communieability, period o f. See
under disease
Community and nurse, 256
Community protection from d isea ses,
74, 79, 84, 93, 111, 116, 131,
136, 141, 158, 166, 207, 215,
218, 229, 243
Complications of diseases
chickenpox, 82
d iph theria, 116
laryn geal, 129
n a sa l, 122
pharyngeal, 125
epidemic en cep h a litis, 185, 187
lep rosy, 193, 194
m alaria, 237, 243
m easles, 65, 71
meningococcus m eningitis, 162, 165
mumps, 144, 145
p o lio m y e litis, 173, 179
p s it t a c o s is , 219
ru b ella , 77
sca b ies, 197
s c a r le t fev er, 102, 108
sep tic sore throat, 133, 135
smallpox, 89, 91
smallpox vaccination, 96
tetan u s, 206
V in cen t's angina, 138
whooping cough, 151, 155
yellow fe v e r , 225
Concurrent d isin fe c tio n . See
D isin fection
Conference, White House, and care
of child ren , 15
Contact, d irect
d e fin itio n o f , 23
in transm ission of disease, 23
Contact, in d irect
d e fin itio n o f , 24
l i s t e d , 24
in transm ission o f d isease, 23
Contact, nurse with p atien ts, 14
Contacts, o f infected individual, 32
Contagium animatum, doctrine o f , 7
322
Contagious. See In fectiou s
Contagious d isea se , d efin itio n
o f , 20
Contagious d ise a se s, recognition
o f, 5
Contaminated, d e fin itio n o f term,
46
Contaminated areas, in h o sp ita ls,
47
Contamination. See a lso In fection ,
prevention o f, by paper towel,
54
Contents, v
C ontrol, 28
of c a r r ie r s, 21
d iscrepan cies in the d ifferen t
s t a t e s , 29
item s considered important in,
32
methods o f
chickenpox, 82
dip h th eria, 123
epidemic e n c e p h a litis, 185
lep ro sy , 193
m alaria, 239
m easles, 68
meningococcus m en in gitis, 163
mumps, 144
p o lio m y e litis , 174
p s it t a c o s is , 219
ra b ies in man, 213
r u b e lla , 78
sc a b ie s , 198
s c a r le t fev er, 105
s e p tic sore th roat, 134
smallpox, 89
teta n u s, 204
V in cen t’ s angina, 139
whooping cough, 152
y ello w fev er, 225
nurse as teacher o f, 19
public h ea lth , and l i f e insur­
ance companies, 31
Convalescence
a d u lts, 15
ch ild ren , 15
C onvalescents’ serum, d efin itio n
o f , 39
Convulsions, and whooping cough,
156
Cooperation, fed er a l, s ta te , and
lo c a l a u th o r itie s, 28
Cough, whooping. See Whooping Cough
Count
d if f e r e n t ia l, importance o f, 22
leu co cy te, importance o f, 22
County health u n its , 30
Cowpox, 93
Cowpox v ir u s, 38
and smallpox, 39
Cresol so lu tio n , in s te r iliz a t io n , 54
Cross in fe c tio n . See In fection , Cross
Croup. See Diphtheria, Laryngeal
Crusades, and lep rosy, 5
C ubicle, care o f , 56
Culture media, a r t i f i c i a l , 22
Culture takin g, admission tech n ic, 263
C ultures, nose and th roat, 287
diphtheria b a c i l l i , 288
equipment, 287
procedure, 287
Cups, sputum
m etal, s te r iliz a t io n o f, 53
metal holder fo r , b oilin g o f, 54
paper
d isp osal o f , 54
and sawdust, 54
Cupfcy mouthwash, s te r iliz a t io n o f , 52
Curriculum, guide for, schools of nursing,
ii
D efenses, body. See Body Defenses
Defensive powers, of h ost, as factor
in flu en cin g in fec tio n , 21
D e fin itio n s. See also Glossary
ant ito x in s , 39
b a c te r ia l s p l it p rotein s, 22
b a cte r ia l to x in s , 22
b io lo g ic a l tran sfer, 24
body d efen ses, 24
c a r r ie r s, 21
clean , 46
clean in g, 46
communicable d isea se, 20
communieability, period o f , 24
contact
-:i i d i s t c t , 23
in d ir e c t, 24
contaminated, 46
d is in fe c tio n , 46
concurrent, 46
term inal, 46
fum igation, 46
323
D efin itio n s - continued
h o st, 20
immunity, 24
incubation period, 23
in fe c tio u s d ise a se , 20
la te n t ca se, 21
mechanical tra n sfer, 24
p a tien t u n it, 46
renovation, 46
s t e r i l e , 46
u n it, 46
v iru len ce, 21
D erm atitis, nurse subject t o , 17
Department o f A griculture, See
A griculture, Department of
Department o f Health
fe d e r a l. See Public Health
S erv ice, U.S,
m unicipal. See Health Depart­
ment, municipal
s t a t e . See Health Department,
sta te
Department o f In te r io r . See
In te r io r , Department o f
Department o f Labor. See Labor,
Department o f
Desquamination, period o f, in
sc a r le t fev er, 100
Detention period, Black Death, 6
Diagnosis
b a c te r io lo g ic a l, f i r s t labora­
tory fo r , 12
laboratory, in recogn ition , 32
leucocyte and d iffe r e n tia l
counts in , 22
Diaper bag, 51
Diapers, s o ile d , disposal o f, 51
Diarrhea, and m easles, 73
Dick Control T est, and admission
te c h n ic , 263
Dick T est, 39
and admission tech n ic, 263
for s u s c e p tib ility to sca rlet
fev er, 103
Diet
chickenpox, 83
diphtheria
laryn geal, 128
n a sa l, 122
pharyngeal, 125
D iet - continued
epidemic e n c e p h a litis, 187
lep rosy, 194
m alaria, 242
m easles, 71
meningococcus m eningitis, 165
mumps, 145
ru b ella , 78
s c a r le t fev er, 107
sep tic sore th roat, 135
smallpox, 91
tetan u s, 206
V incent’s angina, 140
whooping cough, 154
yellow fe v e r , 228
Diphtheria, 113
and albuminuria, 116
and broncho-pneumonia, 116
and cerv ica l a d e n itis, 116
and fe v e r , 22
and heart f a ilu r e , 116
and heart involvement, 116
and m yocarditis, 116
and n e p h r itis, 116
and n e u r itis , 116
and o t i t i s media, 116
and p a la te , s o f t , p aralysis o f, 116
and s p e c ific a n tito x in s, 40
a n tito x in
ad&dminiStratton o f, 120, Appendix A
d e fin itio n o f, 40
un it o f, 40
b a c illu s , discovery o f, 9
c a r r ie r s , 119
communieability, period o f , 116
community p ro tectio n , 131
com plications, 116
co n tro l, 120
cu ltu res
for b a c i l l i , 288
fo r determining virulence of
organisms, 288
d e fin itio n o f , 113
d is in fe c tio n , 129
endotoxins in , 22
e s s e n tia l p o in ts, 130
e tio lo g y , 114
growth o f b a c i l l i , 22
h isto r y , 113
home care, 130
324
Diphtheria - continued
immunization, 121
a c tiv e , 117
of nurse, 16
p a ssiv e, 118
in Middle Ages, 6
incubation, period o f, 115
innoculation a g a in st, 25
in fe c tio n , source o f , 114
is o la t io n , 120
laryngeal
and broneho-pneumonia, 129
com plications, 129
d e fin itio n o f, 126
d ie t , 128
hygiene, personal, 127
intubation in , 128
m edication, 127
mouth, care o f , 127
nursing care, 126, 127
su ffo ca tio n , acu te, 129
tracheotomy, 129
treatm ent, 127
mask, use o f , 50
m o rta lity , 116
n a sa l, 121
and cerv ica l a d e n itis , 122
and o t i t i s media, 122
and s in u s i t i s , 122
com plications, 122
d e fin itio n o f, 121
d ie t , 122
hygiene, personal, 121
nose, care o f , 1212
nursing care, 121
p a tie n t, comfort o f, 121
pathology, 115
pharyngeal
and m yocarditis, 125
and p a ra ly sis
e x tr e m itie s, 126
ocu lar, 125
p a la ta l, 125
resp iratory m uscles, 126
com plications, 125
d e fin itio n o f , 123
d ie t , 125
elim in ation , 124
ey es, care o f , 124
hygiene, p erson al, 124
mouth, care o f , 124
Diphtheria - continued
pharyngeal - continued
nose, care o f , 124
nursing care, 123
p a tie n t, comfort o f , 123
sequelae, 125
skin, care o f , 124
th roat, care o f , 124
prevalence, 114
prognosis, 116
prophylactic, 40
prophylaxis, 116
quarantine, 121
recogn ition , 120
reporting, 120
sequelae, 116
serum r e a c tio n s, 120
Schick T est, 116, 118
s u s c e p tib ility , 115
to x in , unit o f , 38
to x in -a n tito x in , 26, 117
d e fin itio n o f , 39
toxoid, 26, 117
d e fin itio n o f , 39
transm ission, mode o f , 114
treatment, 119
types o f, 113
vaccine, use o f , 39
Discard tech n ic, 48
Discharge bath* See Bath, discharge
Discharges,
body, viru len ce o f , 21
disposal o f , 54
respiratory tr a c t and mask, 50
wound, disposal o f , 54
Disease
and s u p e r stitio n s, 3
communicable. See Communicable
D isease
contagious. See Contagious disease
in fe c tio u s. See In fectio u s disease
preventable. See a lso Preventable
disease
men of genius who died from, 36
prevention, measures, 35
production, means o f , 22
types o f. See Types o f disease
D iseases, communicability of
chickenpox, 82
diphtheria, 116
epidemic e n c e p h a litis, 188
325
D iseases, communicability o f continued
leprosy, 193
malaria, 237
m easles, 66
meningococcus m en in g itis, 162
mumps, 144
p s it t a c o s is , 219
rabies
in dog, 210
in man, 211
ru b ella, 77
scab ies, 197
sca r let fev er, 103
sep tic sore th ro a t, 133
smallpox, 89
tetanus, 203
Vincent’s angina, 139
whooping cough, 151
yellow fev er, 225
Dish s t e r i l i z e r , 53
Dishes
contaminated, 55
in home, 251
soap, s t e r liz in g , 52
s t e r iliz in g , 53, 55
washing, 55
Dishwashing machine, 55
D isinfectant
action o f, 33
quantity in r e la tio n t o con­
ten ts o f bedpan or u r in a l,
55
D isin fec tio n . See a lso S t e r iliz a ­
tio n
and Mosaic laws, 4
ambulance, 268
bedpan, contents o f , 54
books, in sc a r le t fe v e r , 110
b o ttle s , milk, in home, 253
chemical, 33
concurrent
and prevention o f cro ss in ­
fe c tio n , 45
d e fin itio n o f, 34, 46
* ".important, 32
d efin itio n o f, by U .S .P .H .S ., 33
excreta, 54
equipment, extubation, 298
fumigation, 34
gaseous, p o lio m y e litis, 30
D isin fectio n - continued
heat, 33
leprosy, 194
malaria, 243
meningococcus m en in gitis, 166
methods o f, 52
s to o ls , formed, 55
su n ligh t, 33
term inal, d e fin itio n o f, 34, 46
tetan us, 206
u rin a l, contents o f , 54
x-ray, 34
Dogs, rabies in . See Rabies in the Dog
Dressings, Wound, d isp osal o f , 54
D uties, nurse, fo u rfo ld , 43, 245
Dysentery
anabic and b a c illa r y , 21
carriers as source o f , 21
E ncephalitis
and chickenpox, 82
epidemic. See Epidemic e n c e p h a litis
leth a rg ica . See Epidemic e n cep h a litis
von Economo *s • See Epidemic encepha­
litis
Endocarditis
and meningococcus m en in g itis, 182
and se p tic sore th roat, 133
Endotoxins, 22
Engineering, sanitary, and war, 9
Entry, portals o f . See P o rta ls of
entry
Environment, of in fected in d iv id u a l, 32
Epidemic en cep h a litis, 182
c lin ic a l recording, 188
communicability, 185
com plications, 185, 187
con trol, methods o f, 18S
convalescence, 188
course o f d isease, 184
d e fin itio n , 182
d ie t, 187
elim ination, 187
e s se n tia l p o in ts, 188
etio lo g y , 183
eyes, care o f, 187
h isto ry , 182
home care, 188
326
Epidemic en cep h a litis - continued
hygiene, personal, 186
immunization, 186
incubation period, 184
in fe c tio n , source o f, 183
is o la t io n , 186
mouth, care o f, 187
nursing
care, 186
in stru ctio n s in home, 188
pathology, 184
p a tie n t, comfort o f, 186
prevalence, 183
prognosis, 185
quarantine, 186
reco g n itio n , 185
rep ortin g, 185
sequelae, 185
sk in , care o f, 186
synonyms, 182
transm ission, mode o f , 183
treatm ent, 185
Epidemic p a r o t it is . See Mumps
Epidemic, p o lio m y e litis, Los
Angeles H osp ital, 1935-6, 18
Epidemic sore th ro a t. See S ep tic
Sore Throat
Epidemics
Black Death, 6
ca rriers as source o f , 21
character of early, 6
d isea ses occasio n a lly occurring
in , 31
immunization o f population, 35
measures of co n tro l, 32, 35
Middle Ages, 6
quarantine of those exposed, 35
Rome, 4
smallpox. See Smallpox epidemics
surpression o f in te r s ta te , 28
Equipment
adm inistration
o f a n tito x in , 284
o f immune serum, 284
admission table
s t e r i l e , 264
u n S ter ile, 264
ambulance, 267
changing tracheotomy tube, 299
c u ltu r e s, nose and th ro a t, 287
discharge bath, 301
Equipment - continued
extubation
d irect method, 297
d isin fe c tio n o f , 298
in d irect method, 297
in d iv id u a l, 47
intubation
d irect method, 296
Ind irect method, 295
laryngoscopy and suction , 292
care o f contaminated, 294
lumbar puncture and adm inistration
o f immune serum, 289
m edication, 272
needed in home, 247
taking patient to x-ray room, 278
throat ir r ig a tio n , 282
tra n sfer o f p atient frdm ward to
ward, 276
Eruption,
period of
chickenpox, 81
m easles, 65
ru b ella , 77
s c a r le t fev er, 100
smallpox, 88
vaccin ation , smallpox, 96
E rysipelas
and chickenpox, 82
in Middle Ages, 6
E sse n tia l points
chickenpox, 84
diphtheria, 130
epidemic e n c ep h a litis, 188
home, care in , 254
lep rosy, 194
m alaria, 243
m easles, 74
medical asep tic tech n ic, 59
meningococcus m en ingitis, 166
mumps, 147
p o lio m y e litis, 180
p s it t a c o s is , 220
r a b ies, 215
ru b ella , 79
sca b ies, 199
sc a r le t fev er, 110
sep tic sore th roat, 136
smallpox, 92
tech n ic, 59
tetan u s, 206
32?
E s se n tia l p oin ts - continued
V incent’ s angina, 140
whooping cough, 157
yellow fe v e r , 229
E tiology
d ip h th eria, 114
epidemic e n c e p h a litis, 183
lep ro sy , 191
m alaria, 233
m easles, 61
meningococcus m en in gitis, 160
mumps, 142
p s it t a c o s is , 218
r a b ie s, 209
r u b e lla , 76
sc a b ie s, 196
s c a r le t fe v e r , 99
se p tic sore th ro a t, 132
smallpox, 87
teta n u s, 201
V incent’ s angina, 137
whooping cough, 148
y ello w fe v e r , 223
Europe
and Black Death, 6
progress o f communicable disease
co n tro l in , 5
Examination, p h y sica l, of nurse,
16
Example, se t by nurse, 19
Excreta
d is in fe c tio n o f , 54
and Mosaic law, 4
as p o rta l o f e x it , 23
E x it , p o r ta ls o f. See P ortals of
E x it
E xotoxins, 22, 38
Experience, in preparation for
communicable disease nursing,
14
External d efen ses, 24
E x trem ities, paralysis o f . See
P a r a ly sis, E xtrem ities
Extubation, 297
equipment, care o f , 298
method
d ir e c t, 297
equipment, 297
in d ir e c t, 297
equipment, 297
p a tie n t, care o f , 298
Face, keeping hands away from, 17
Fecal specimens, 280
Federal, See a lso Government
See also United S ta te s
Federal h ealth agen cies, 28. See
a lso Public h ealth service
Federal se c u r ity agency
and U ,S ,P ,H ,S ,, 28
com position o f , 29
o f f ic e of education, 29
s o c ia l secu rity board, 29
Fever
a s reaction to in fe c tiv e agent, 22
degree as in d ica tio n of sev erity of
in fe c tio n , 22
p arrot. See P s itt a c o s is
F ir e , great, o f London, and the plague,
8
F l a s h l i g h t , p rotection from contam­
in a tio n , 54
F la s h lig h ts , s t e r iliz a t io n o f , 54
Floors
care o f , 57
m a teria l, 57
F luids
body. See Body flu id s
k itch en , d isp osal o f , 55
Fom ites, as in d ir e c t con ta ct, 24
Food
and Mosaic law, 4
a s in d irect con ta ct, 24
in v e s tig a tio n o f, fo r source of
in fe c tio n , 35
sup ervision o f , 35
Food handlers, supervision o f , 35
Formaldehyde, fo r fum igation, 56
Fumigation, See a lso S te r iliz a tio n
d e fin itio n o f , 46
when required, 34
Furnishings
care o f , 56
ward, washing, 52
Games fo r convalescents
a d u lts , 15
ch ild r e n , 15
Gangrene
and chickenpox, 82
and smallpox, 91
g a s, p ortal o f e x it , 23
328
Gas, d isin fe ctio n by, fo r
p o lio m y e litis, 30
Gastric ju ic e s, as in tern a l
defense, 25
Gauge, oxygen tank,
s te r iliz a tio n o f, 54
Gavage s e ts , s t e r iliz in g , 53
General h o sp ita l. See H o sp ita ls,
general
Genito-urinary tr a c t, as p o r ta l
of entry, 21
German measles. See Rubella
Germany, progress in 17th
century, 7
Germs. See a lso B a c illi; Microbes
discovery o f, 7
Pasteur’ s theory, 9
Glands, cer v ica l. See C ervical
glands
G lass, window, e f fe c t on su n lig h t,
34
G lasses, medicine, s t e r i l i z i n g , 53
Globulins, immune, and m easles, 67
Glossary, 308
Government agencies. See A gencies,
government
Gowh. See also Linen
kitchen maid, 55
physician’s , in home, 249
porter’ s , 56
putting on, 48
removing, 49
rubber bands fo r , 47
v i s i t o r ' s , 57
ward porter, 56
when taking temperature, p u lse,
and resp ira tio n , 51
where kept, 48
Gown tech n ic, 44, 48
Graeco-Roman world, and communicable
d isea ses, 4
Greeks, th e, and communicable
d isea ses, 4
Hair n et, worn by nurses, 17
B air, nurses, care o f , 17
Hamper, so ile d lin e n , 51
Hand brush, 49
Hand blushes, b o ilin g , 52
Hand lo tio n , use by nurse, 17
Handbooks, far h o sp ita ls,
e a r lie s t, 11
Hands
a fte r taking temperature, p u lse,
and resp iration , 51
care o f, 17
and in d irect contact, 24
clean , 49
cleaning
in heme, 250
in preventing spread of
in fe c tio n , 45
methods o f, 45
contaminated, 50
as in d irect contact, 24
nurse, care o f, 17
scrubbing, 49, 50
kitchen maid, 55
ward porter, 56
v is it o r s , 57
washed a fte r each p a tien t, 14
washing, 17
and puerperal fever, 9
f i r s t s c ie n t if ic experiment, 9
Head m irrors, s te r iliz a t io n o f , 54
Health
agencie s
municipal, 30
u n o ff ic ia l, 31community
and law, 12
and pUblic opinion, 12
cen ters, 30
departments
and c a rriers, 21
county, 30
m unicipal, 30
s ta t e , 29, 30
s t a t i s t i c s availab le, 36
nurse, safeguarding, 16
u n its , county, 30
Hearing, impairment o f, and mumps, 144
Heart, involvement, and dip htheria, 116
Heat
as d isin fe c ta n t, 33
dry, fo r valuable papers, 50
Heine-Medin d isease. See P o lio m y e litis
Hernia, and whooping cough, 156
Hemorrhages, and whooping cough, 156
H isto r ic a l introduction, 1
H istory of p a tien t, in v estig a tio n o f , 44
329
Home
bathroom, 247
b o t t le s , m ilk, d isin fe c tio n
o f , 253
care o f communicable d isease
in , 245
care o f p a tien t by member o f
household, 246
con d ition s in , 245
d is in fe c tio n , term inal, 254
d ish e s, contaminated in , 251
equipment needed, 247
is o la t io n in , 33
lin e n , contaminated in , 252
p h y sicia n 's gown in , 249
post mortem care, 253
room, p a t ie n t 's , 246
serving tray in , 251
taking
pulse in , 250
re sp ir a tio n in , 250
temp erature in , 250
uniform o f nurse in , 249
w aste, d isp osal o f , 248, 253
Home care
chickenpox, 84
d ip h th eria, 130
epidemic e n c e p h a litis, 188
e s s e n tia l p o in ts, 254
m alaria, 243
m easles, 74
meningococcus m eningitis, 166
mumps, 147
p o lio m y e litis , 180
sc a b ie s, 199
s c a r le t fe v e r , 111
se p tic sore throat, 136
smallpox, 93
teta n u s, 206
V inrent’ s angina, 140
whooping cough, 157
Horses, and a n ti-b a c te r ia l sera,
40
H osp itals
clean areas in , 47
contaminated areas in , 47
establishm ent o f f i r s t , 7
general
d is in fe c tio n , 58
grouping, 58
H ospitals - continued
general - continued
medical a sep tic technic in , 58
s t e r iliz a t io n , 58
handbooks fo r , e a r lie s t , 11
individual equipment, 47
medical a sep tic technic in , 47
modern, open wards o f , 59
nursing op p ortun ities, 257
porches fo r a ir in g , 52
ru les o f , 44
scrub stan ds, 47
sm all, establishm ent o f , 29
sm allpox. See also P e st houses
s p e c ia l, f o r communicable d iseases,
30
voluntary, for communicable d isea ses,
80
Host. See a lso defenses
d e fin itio n o f , 20
d efen sive powers, as factor in flu ­
encing in fe c tio n , 21
in s e c ts as intermediary, 23
p rotection by a n ti-b o d ies, 22
r e sista n c e o f , 23
Hot water bags, washing, 52
Hot water b o t tle s , f i l l i n g and
applying, 274
Houses, p e s t. See Pest houses
Hydrophobia. See Rabies
Hygiene
mental. See Mental care
personal, education o f public, 35
Ice cap
f i l l i n g and applying, 275
fo r pain ful glands, 42
washing, 52
Ice c o lla r , f i l l i n g and applying, 275
I lln e s s
among nu rses, 17
o f nurse, 17
Immsrn sera . See Sera, immune
Immune serum. See Sera, immune
Immunity
acquired, 25
a c t iv e , 25
by exposure, 25
by in je c tio n , 25
e s s e n tia l p o in ts, 27
produced from vaccin es, 38
330
Immunity - continued
b io lo g ic a l products used to
secure, 26
cold-blooded animals, 25
d e fin itio n o f, 24
in fa n t, 26
natural, 25
p assive, 25
e sse n tia l p o in ts, 27
from a n ti-to x in in je c tio n , 26
from immune sera , 40
from p lacen tal e x tr a c ts, 26
how conferred, 26
use of con valescen ts' serum,
26
r a c ia l, 25
smallpox, 23
types o f, 25
Immunization
activ e
diphtheria, 117
sc a r le t fev er, 104
when acquired, 35
d e fin itio n o f, 35
diphtheria, 121
epidemic e n c e p h a litis , 186
importance o f , 32
leprosy, 194
malaria, 239
m easles, 68
meningococcus m en in g itis, 163
mumps, 145
nurse, 16
passive
diphtheria, 118
sc a r le t fe v e r , 104
p o lio m y e litis, 174
prospective stu d en ts, Willard
Parker H osp ital, 16
p s it t a c o s is , 219
rab ies, 213
ru b ella , 78
sca rlet fe v e r , 106
tetanus, 204
whooping cough, 153
yellow fe v e r , 226
Impetigo, in Middle ages, 6
Incubation, period o f
chickenpox, 81
d e fin itio n o f , 23
diphtheria, 115
Incubation, period of - continued
epidemic en cep h a litis, 184
leprosy, 192
malaria, 235
m easles, 64
meningococcus m en in gitis, 161
mumps, 143
p o lio m y elitis, 171
p s itta c o s is , 218
rab ies, 209
ru b ella, 77
scab ies, 197
sc a r le t fever, 100
smallpox, 87
tetanus, 202
Vincent's angina, 138
whooping cough, 149
yellow fev er, 224
Incineration, See a lso S t e r iliz a t io n
magazines, 54
papers, 54
refu se, 54
to y s, 54
In fa n tile p a ra ly sis. See P o lio m y elitis
In fection , V incent's. See V incent's
angina
India, sacred book o f, 2
Indians, American, 9, 25
Ind ustrial nursing, and coramunicable
d iseases, 260
In fectio n , 20
and immune sera, 40
and importance offhand clea n sin g , 45
and leu cocytes, 22
b a cteria l, o f wounds, 9
cross
and medical a sep tic te ch n ic , 45
degree of precaution required to
prevent, 58
d efin itio n o f, 44
methods of prevention, 45
d efin itio n o f, 20
d roplet, 24
in v estig a tio n of source, 35
mechanical tra n sfer, 24
pin pricks, 17
prevention o f tra n sfer, 43
secondary, and smallpox v a ccin a tio n , 96
source o f, 20, 35
strep to ccic, 26
In fectio u s. See also Contagious
331
In fectio u s d ise a se , d e fin itio n
o f, 20
I n fe c tiv e agents, 20, 22, 23
I n f e c t iv it y , and prim itive man, 1
Influenza, leucocyte count in , 22
Inh alation , steam, and m easles, 67
I n je c tio n s. See a lso Inoculation
fo r a c tiv e immunity, 25
Inoculation . See a lso In jectio n
See a lso A ntitoxin sera
fo r a ctiv e immunity, 25
Pasteur, against ra b ies, 26
smallpox, o rig in , 2
types o f b io lo g ic a l products
used, 26
In s e c ts, 23, 24
Insurance companies, s t a t i s t i c s
a v a ila b le , 36
In tern a l!d efen ses, 24, 25
In te r io r , Department o f, 29
Introduction, h is t o r ic a l, 1
Intubation, 295
diphtheria, laryn geal, 128
d ir e c t method, 295
equipment, 296
in d ir e c t method, 295
equipment, 295
In v estig a tio n
chickenpox, 84
co n ta cts, 32
p a tie n t’ s h isto r y , 44
Irr ig a tin g cans, s t e r iliz a t io n o f,
53
I r r ig a tio n p a il, co lo n ic, s t e r i l i ­
zation o f, 53
I r r ig a tio n , th roat. See Throat
ir r ig a tio n
I s o la tio n . See a lso Quarantine
Ohickenpox, 82, 83
d e fin itio n o f, 32
dip h th eria, 120
ep d em ic e n c ep h a litis, 186
importance o f, 32
in epidemics, 35
in home, 33
lep ro sy , 193, 194
m alaria, 239, 240
m easles, 68
meningogoccus m en in gitis, 163
methods employed, 32
Iso la tio n - continued
mumps, 145
p o lio m y e litis , 174, 175
p s it t a c o s is , 219
ra b ies, 203 , 214
ru b ella , 78
sc a b ie s, 198
sc a r le t fever, 105, 106
se p tic sore th ro a t, 134
smallpox, 89, 90
tetan u s, 204, 205
Vincent’s angina, 139
whooping cough, 152, 153
yellow fev er, 226, 227
Itch , th e. See Scabies
Jars
cotton , s t e r iliz a t io n o f, 53
thermometer, s t e r iliz a t io n o f, 53
Jenner, Edward, 8
J u ices, g a s t r ic , a s in ternal defense,
25
Jews, and communicable d ise a se s, 3
Ju stin ian plague, 4
Kircher, A lthanasius, doctrine of
"contagium animatum", 7
Kitchen
contaminated s h e lf in , 55
ward, tech n ic, 55
Knives, s t e r iliz a t io n o f, 53
Koch, and tu bercle b a c illu s , 9
Labor, Department o f, Children’ s
Bureau, 29
Laboratory
f i r s t , f o r b a c te r io lo g ic a l
diagnosis of d ise a se , 12
in d iagn osis, 32
Laryngeal d ip hth eria. See Diphtheria,
laryngeal
L aryngitis
and chickenpox, 82
and m easles, 73
Laryngoscopy and su ctio n , 292
equipment, 292, 294
nurse’s a ssista n ce in , 293
preparation o f p a tien t, 293
reccarding, 294 /•
room fo r , 292
332
Laundry porter, 51
Lavage s e t s , s t e r iliz in g , 53
Law, and community h ea lth , 12
Law, Mosaic. See Mosaic law
Laws, s ta t e , variance o f, 30
League, N ational, o f Nursing
Education, i i i
L eg isla tio n , 29
Lepers. See Leprosy
Leprosy, 190
a n esth etic, 192
communicability, period o f, 193
com plications, 193, 194
con trol, methods o f, 193
course of d isea se, 192
d e fin itio n o f, 190
d ie t, 194
e sse n tia l p oin ts, 194
e tio lo g y , 191
f i r s t laws, 5
h isto ry , 190
hygiene, personal, 194
immunization, 194
in fe c tio n , sources o f, 191
incubation period, 192
is o la tio n , 193, 194
mental hygiene, 194
mixed, 193
nodular, 192
nursing care, 194
pathology, 191
prevalence, 191
prognosis, 193
quarantine, 193
recogn ition, 193
reporting, 193
sequelae, 193
s u s c e p tib ility , 191
transm ission, mode o f, 191
treatm ent, 193
types of d isea se, 190, 192
Lethal dose, minimum, 38
Leucocyte count, importance o f, 22
Leucocytes, 22, 25
Leucopenia, presence in certa in
d isea se s, 22
L ife insurance companies, and public
health con trol, 31
Lime, chloride o f, to d is in fe c t
excreta, 54
Linen
contaminated, in home, 252
d isp osal o f, 51
s o ile d , d isp osal o f, 56
L is te r , and a n tise p tic treatment of
wounds, 9
Lockers, for j a t ie n t s ’ clo th in g , 50
Lockjaw. See Tetanus
L o e ffle r , discovery of diphtheria
b a c illu s , 9
Los Angeles H ospital, epidemic a t , 18
London
great f ir e o f, 8
great plague o f, 7
Lotion, calamine and phenol, fo r skin
ir r it a tio n , 41
Lubricant, tube, 47
Lumbar puncture and adm inistration o f
immune serum, 289
care o f p a tien t, 291
equipment, 289
preparation o f p a tien t, 290
procedure, 290
recording, 291
Lymph nodes, as in ternal defense, 25
Lyssa. See Rabies
M ail, p a tie n ts ', outgoing, s t e r i l i z a ­
tio n o f, 54
Malaria, 231
com plications, 237
community p rotection , 243
communicability, period o f , 237
con trol, methods o f, 239
course of d isea se, 236
d e fin itio n o f, 231
d ie t, 242, 243
elim ination, 242
e s se n tia l p oin ts, 243
e tio lo g y , 233
fumigation, 34
h isto r y , 231
home ca re, 243
immunization, 239
in ancient Rome, 4
incubation period, 235
in fe c tio n , source o f, 235
is o la tio n , 239, 240
m edication, 242
m ortality, 237
333
Malaria - continued
n ation al committee on, 31
nursing care, 240
nursing in stru ctio n s, 243
pathology, 235
p a tie n t, comfort o f, 240
prevalence, 232
prognosis, 237
prophylaxis, 239
quarantine, 239
reco g n itio n , 239
rep ortin g, 239
source, in v estig a tio n o f, 239
s u s c e p t ib ilit y , 235
tra n sfer o f, 24
transm ission, mode o f, 235
treatm ent, 237
Mask, 50
and diphtheria, 50
and irresp o n sib le p a tien t, 50
and resp iratory tra ct d is­
charge , 50
c lo th , b o iled and washed, 52
m aterials f o r , 50
M a sto id itis, and sca rlet fever,
108
M attresses, a ir in g , 52
M easles, 61
and activ e immunity, 25
and broncho-pneumonia, 72
and cer v ica l a d e n itis , 72
and con valescen ts’ serum, 66
and diarrhea, 73
and la r y n g itis , 73
and o t i t i s media, 71
and parental serum, 67
and p lacen tal ex tra ct, 67
and steam in h alation , 67
com plications, 65, 71
communicability, period o f, 66
community p rotection , 74
confusion with Rubella, 79
co n tro l, methods o f, 68
convalescence, 65, 73
course of d isea se, 64
d e fin itio n o f, 61
d ie t, 71
d is in fe c tio n , 73
ears, care o f, 70
elim in ation , 71
environment in , 69
Measles - continued
eruption, period o f, 65
e s s e n tia l p o in ts, 74e tio lo g y , 61
eyes, care o f, 69
h isto r y , 61
home care, 74
immunization, 68
incubation period, 64
in fa n t immunity, 26
in fe c tio n , source o f, 62
in vasion , period o f, 64
is o la t io n , 68
leucocyte count in , 22
m o rta lity , 66
mouth, care o f, 70
nose, care o f , 70
nursing care, 68
pathology, 63
p a tie n t, comfort o f, 69
personal hygiene, 69
prevalence, 61
p rognosis, 66
prophylaxis, 66
quarantine, 68
reco g n itio n , 68
rep ortin g, 68
sequelae, 65
serum, dosage o f , 67
skin , care o f , 69
s u s c e p t ib ilit y , 63
synonyms, 61
transm ission, mode o f, 62
treatm ent, 67
M easles, German. See Rubella
Measures
d isease prevention, education of
p u b lic, 35
epidemic, 35
gen eral, fo r communicable disease
co n tro l, 35
Mechanical tr a n sfe r , 23
d e fin itio n o f , 24
Media, o t i t i s . See O titis media
Medical a sep tic technic
e s s e n t ia l p o in ts, 59
general h o sp ita l, 58
h o sp ita l, 47
334
Medical a se p sis, 43
aim o f, 43
Chapin method, 12
d efin itio n o f, 43
patient in , 43
terminology o f, 46
Medication. See a lso
Treatment
equipment, 272
method of g iv in g , 271
n asal, 272
oral adm inistration, 271
procedure, 273
recording, 273
recta l adm inistration, 271
subcutaneous, 272
vaginal ad m in istration , 271
Medicine
Chinese, b a sis o f , 3
preventative, f i r s t v ic to r y , 5
p rim itive, and r e lig io n , 1
Membrane, mucous. See Mucous
membrane
M eningitis, c a r rie rs as source
o f, 21
M eningitis, meningogoecic, and
polyvalent sera, 40
M eningo-eneephalitis, and
mumps, 144, 146
Meningococcus m en in g itis, 159
and b lin d ness, 162
and c o n ju n c tiv itis , 165
and deafness, 162
and d ip lo p ia , 165
and en d ocard itis, 162
and f a c ia l muscles, weakening
o f , 165
and impaired hearing, 165
and m yocarditis, chronic, 162
and polyvalent sera, 40
and serum sick n ess, 165
and strabimus, 165
and v isio n , blurred, 165
communicability, period o f , 162
com plications, 162, 165
con trol, methods o f, 163
convalescence, 162, 166
course of d ise a s e , 161
d e fin itio n , 159
d ie t, 165
d isin fe c tio n , 166
Meningococcus m en in gitis - continued
elim ination, 164
e s se n tia l p oin ts, 166
etio lo g y , 160
eyes, care o f, 164
h isto ry , 159
home care, 166
hygiene, personal, 164
immunization, 163
incubation period, 161
in fe c tio n , source o f 160
is o la tio n , 163
medication, 165
mouth, care o f , 164
nose, care o f, 164
nursing in stru ctio n s, 166
pathology, 160
p atien t, comfort o f , 163
prevalence, 159
prognosis, 163
quarantine, 163
recognition, 163
reporting, 163
sequelae, 162
skin, care o f, 164
s u s c e p tib ility , 160
transm ission, mode o f , 160
treatment, 163
types of the d ise a se , 162
Mercury, bichloride o f , as d is in ­
fecta n t, 53
Merphenyl, for s t e r iliz a t io n , 53
Metaphen, fo r s t e r iliz a t io n , 53
Microbes. See a ls o B a c i lli; B a c illu s;
Bacteria; Germs
as casual organ ism? proof o f , 9
Microbiology, p rin cip les o f , in
d aily nursing ca re, 14
Mi croorganisms
carriers o f, 14
cause of in fe c tio n , 8
presence on sk in , 21
Middle age3, 5, 7
Milk
in vestigation o f, fo r source of
in fec tio n , 35
pasteurization o f, 35
Mirrors, head, s t e r iliz a t io n o f , 53
Montagu, Lady Mary Wortley, 8
Mops, 52, 57
Morbidity r a tes, value to nurse, 35
335
Morning care, 269
M o r ib illi, See Measles
M ortality
diphtheria, 116
m alaria, 237
m easles, 66
meningococcus m eningitis, 163
p o lio m y e litis, 173
p s it t a c o s is , 219
ra b ie s, 211
sca r le t fe v e r , 103
se p tic sore th roat, 134
smallpox, 89
teta n u s, 203
whooping cough, 151
yellow fev e r, 225
Mosaic law, 3
and d isin fe c tio n , 4
and excreta, 4
and food, 4
and le p e r s, 4
and quarantine, 4
and segregation, 4
Mosquito
and m alaria, 231
and yellow fev er, 223
breeding p la ces, elim ination
o f, 227, 239
Mouth
as p ortal o f entry, 17
as p o rta l o f e x it , 23
care o f
in diphtheria
laryn geal, 127
pharyngeal, 124
in epidemic e n c ep h a litis, 187
in m easles, 70
in meningococcus m eningitis,
164
in s c a r le t fev er, 107
in s e p tic sore th roat, 135
in smallpox, 91
in teta n u s, 205
in V in cen t's angina, 139
in yellow fev er, 228
nurse’ s , care o f, 17
trench. See V incent's angina
Mouthwash cups, s t e r iliz a t io n of
52
Mumps, 142
and impairment o f hearing, 144
and m eningo-encephalitis, 144
Mumps - continued
and o o p h o ritis, 146
and o r c h it is , 144
b ila t e r a l, 145
u n ila te r a l, 145
and p a n c r e a titis, 144, 146
communicability, period o f, 144
. com plications, 144, 145
co n tro l, methods o f, 144
convalescence, 144, 146
course of d isea se, 143
d e fin itio n o f, 142
d ie t , 145
d is in fe c tio n , 146
e s s e n t ia l p o in ts, 147
e tio lo g y , 142
h isto r y , 142
home care, 147
hygiene, personal, 145
immunization, 145
incubation period, 23, 143
in fe c tio n , source o f, 142
is o la t io n , 145
nursing care, 145
pathology, 143
p a tie n t, comfort o f, 145
prevalence, 142
prognosis, 144
reco g n itio n , 144
rep ortin g, 144
sequelae, 144
s u s c e p t ib ilit y , 143
transm ission, mode o f, 143
treatm ent, 144
Mucous membrane, as body defense, 24
M yocarditis
and diphtheria, 116, 125
and meningococcus m en in gitis, 162
Nasal ca th eters, s te r iliz a t io n o f, 53
Nasal m edication, 272
N ational League of Nursing Education, i i i
survey, ill n e s s among nurses, 18
National Organization far Public Health
Nursing, 31
N ational Tuberculosis A ssociation , 31
Negro
and yellow fev er, 25
immunity o f , 25
N igh tin gale, Florence, 11
Nodes, lymph, as internal defense, 25
336
Nose, care o f , in diphtheria,
n a sa l, 121
N o tific a tio n . See a lso Reporting
l i s t of d isea se s fo r which re ­
quired, 31, 306
Nurse
and American Red Cross, 260
and community, 256
and h o s p ita ls , 257
and in d u stria l nursing, 260
and o f f i c i a l a g en cies, 258
and public health nursing,
258
and school nursing, 259
and voluntary a gen cies, 258
as example, 19
as teacher o f h e a lth , 19
care o f hands, 17
fo u rfo ld d u ties o f , 43, 245
h ea lth o f , safeguarding, 16
immunization o f, 16
importance o f , in community,
256
in home, 59
o f tomorrow, 260
op p ortun ities fo r , 256
personal care, 17
p hysical examination o f, 16
p rivate p r a ctic e, 260
p r o te ctiv e measures fo r , 16
uniform in home, 249
uniform o f , 17
Nurses
and p oliom yelitu s epidemic, 18
i l l n e s s among, 18
Nursing care
broneho-pneumonia, 72, 92
chickenpox, 83
diphtheria
laryn geal, 126
n a sa l, 121
pharyngeal, 123
epidemic e n c e p h a litis, 186
lep ro sy , 194
m alaria, 240
m easles, 68
mumps, 145
p o lio m y e litis, 175
p s it t a c o s is , 220
r a b ie s, 214
ru b ella , 78
Nursing care - continued
scab ies, 198
sca rlet fe v e r , 106
sep tic sore th ro a t, 134
smallpox, 90
tetanus, 205
whooping cough, 153
yellow fev er, 227
Nursing o p p o rtu n ities, 256, 257
Ocular p a r a ly sis . See P a r a ly sis,
ocular
O ophoritis, and mumps, 144, 146
Opsonins, as in tern a l defense, 25
Oral m edication, 271
Organisms
channels o f entrance, 21
micro. See Microorganisms
spore-forming, 52
vegetable form, 52
O titis media
and dip hth eria, 116, 122
and sc a r le t fe v e r , 108
and sep tic sore th ro a t, 133, 135
and whooping cough, 156
Otoscope, p rotection from contamin­
a tio n , 54
P a n c r e a titis, and mumps, 144, 146
Paper t is s u e s , d isp osal o f , 54
Paper tow els, use in signing docu­
ments, 58
Pai&ly&is, in f a n t ile . See P o lio m y elitis
P a r a sites, as in fe c tiv e agent, 20
Parental serum. See Serum, parental
Park, William H ., 12
Parrot fe v e r . See P s itta c o s is
Pasteur
and germ theory, 9
and vaccihes fo r anthrax and ra b ies, 9
innoculation again st r a b ies, 26
Pathology
chickenpox, 80
diphtheria, 115
epidemic e n c e p h a litis, 184
leprosy, 191
malaria, 235
m easles, 63
meningococcus m en in gitis, 160
mumps, 143
p o lio m y e litis, 170
337
Pathology - continued
p s itta c o s is , 218
ra b ies, 209
scab ies, 197
sca rlet fev er, 100
sep tic sore throat, 133
smallpox, 87
tetanus, 202
Vincent’ s angina, 138
whooping cough, 149
yellow fever, 224
P atient
airing clothing o f , 52
care of
a fte r a n ti-to x in , 285
a fte r immune serum, 285
by member of household, 246
extubation, 298
in home, 248
in resp irator, 176
in v estig a tio n of h isto r y , 44
is o la tio n in epidemic, 35
morning care. See Morning Care
room o f, a t home, 246
tran sfer o f, from ward to ward,
276
P a tien t u n it, d e fin itio n o f term,
46
Personal hygiene. See Hygiene,
personal
Personnel, general h o sp ita l,
immunization o f , 58
P e r tu ssis, 25, 26
P est houses. See a lso H ospitals
and comunicable d ise a se s, 10
and smallpox in U. S . , 10
P e stile n c e , 3, 6
Pharyngeal diphtheria. See
Diphtheria, pharyngeal
Phenol, with calamine lo t io n , 41
Physical examination, of nurse, 16
P illo w cases. See a lso Linen
P illo w s, contaminated, care o f , 56
Placental extract
and measles, 67
use to produce p assive immunity,
26
Plague, 4, 6, 34
P len ciz, von, 8
Pneumonia, broncho. See Broncho­
pneumonia
Fneumococcic pneumonia, and immune
sera, 40
P o in ts, e s s e n tia l. See E ssential
p oin ts
P o lio m y e litis, 168
bulbar typ e, care o f, 176
care o f p a tien t, in resp irator, 176
coramunicability, period o f, 173
com plications, 173, 179
convalescence, period o f , 173
course of d isea se, 171
d e fin itio n o f, 168
d ie t , 180
elim ination , 176
epidemic at Los Angeles H osp ital, 18
e s s e n t ia l p o in ts, 180
e tio lo g y , 169
gaseous d isin fectio n fo r, 30
h isto r y , 168
home care, 180
hygiene, personal, 176
immunization, 174
incubation period, 171
in fe c tio n , source o f, 170
is o la t io n , 174, 175
m ortality, 173
nursing care, 175
p a tie n t, comfort o f, 175
prevalence, 169
prognosis, 173
quarantine, 174
recogn ition, 174
reporting, 174
sequelae, 173
skin , care o f, 176
s u s c e p t ib ilit y , 170
synonyms, 168
th roat, care o f , 176
transm ission, mode o f, 170
treatment, 174
types o f the d isease, 172
Porches, fo r a irin g , 52, 56
Portal o f entry
as factor influencing in fe c tio n , 21
e f fe c t on incubation period, 23
P ortals o f entry, lis t e d , 21
P ortals of e x it , 23
Porter, ambulance, 267
Post mortem care in home, 253
Pox, sm all. See Smallpox
P r e c ip itin s, as internal defense, 25
338
P reface, i i
Preventable d ise a s e , men o f
genius who died from, 36
Preventative measures, need for
ce n tr a liz ed control o f, 30
Prevention, 28
cross in fe c tio n , 58
nurse as teach er, 19
P rotein r e a ctio n , 41
P r o tein s, s p l i t b a c te r ia l,
d e fin itio n o f , 22
Protozoa, as in fe c tiv e agent, 20
P s it t a c o s is , 217
communicability, period o f, 219
com plications, 219
co n tro l, methods o f , 219
convalescence, period o f, 219
course o f the d ise a se , 218
d e fin itio n o f , 217
d ie t , 220
e s s e n tia l p o in ts, 220
e tio lo g y , 218
h isto r y , 217
immunization, 219
incubation period, 218
in fe c tio n , sources o f , 218
is o la t io n , 219
m o rta lity , 219
nursing care, 220
pathology, 218
prevalence, 217
p rogn osis, 219
quarantine, 219
reco g n itio n , 219
rep o rtin g , 219
seq uelae, 219
s u s c e p t ib ilit y , 218
synonym, 217
tran sm ission, mode o f , 218
treatm ent, 219
P u b lic, education o f, 35
Public h ealth co n tr o l. See
co n tro l, public health
Public h ealth nursing, 258
Public Health S erv ice, U.S.
and supervision o f b io lo g ic
products, 40
and yellow fe v e r , 226
cooperation w ith sta te author­
i t i e s , 28
fu nction s o f , 28
Public Health S erv ice, U .S. - continued
part o f Federal S ecu rity Agency, 29
regu lation s o f, 31
s t a t i s t i c s a v a ila b le , 35
value of weekly rep o rts, 36
yearly report of Surgeon General, 29
Public opinion, and community h ealth , 12
Pulse taking, 51, 250
Quarantine. See also Iso la tio n
and Mosaic law, 4
chickenpox, 82
defined by U .S .P .H .S ., 34
d erivation of word, 6
d iphtheria, 121
epidemic e n c e p h a litis, 186
importance o f , 32
lep rosy, 193
m alaria, 239
m easles, 68
meningococcus m en in gitis, 163
i> 6M oa£elitis; '174
p s it t a c o s is , 219
r a b ies, 213
ru b ella , 78
sc a b ie s, 198
s c a r le t fev er, 106
s ep tic fibre th roat, 134
smallpox, 89
Vincent’ s angina, 139
whooping cough, 152
yellow fe v e r , 226
Rabbits, and a n tib a cteria l sera, 40
Rabies, 208
contracted from dogs, 20
convulsions in , 210
course of the d ise a s e , 210
d e fin itio n o f , 208
dumb, 210
e tio lo g y , 209
fu rio u s, 210
h isto r y , 208
in man, 211
ca u teriza tio n of wound, 212
communicability, period o f, 211
community p ro tectio n , 215
co n tro l, methods o f , 213
d ie t , 215
e s s e n tia l p o in ts, 215
immunization, 213
339
Rabies - continued
in man - continued
is o la tio n , 213, 214
m ortality, 211
nursing care, 214
p a tie n t, comfort o f , 214
prognosis, 211
quarantine, 213
recogn ition , 213
reporting, 213
stages o f the d ise a se , 211
treatment
a c tiv e , 213
prophylactic, 211
in the dog, 210
communicability, period o f,
210
types o f the d ise a s e , 210
incubation period, 209
in fe c tio n , sources o f , 209
innoculation a g a in st, 25
p a r a ly tic , 210
Pasteur innoculation, 26
pathology, 209
p o rta l of e x it , 23
prevalence, 209
s u s c e p tib ility , 209
synonyms, 208
transm ission, mode o f , 209
use o f vaccine, 39
v ir u s, how obtained, 38
R ates, morbidity, value to nurse,
35
Reaction
anaphylaxis, 41
p rotein , 41
serum, 40
serum sick n ess, 41, 42, 109
thermal, 41
to in fe c tiv e agents, 22
Recognition of d ise a se , importance
o f , 32
Records, c l i n i c a l . See C lin ic a l
records
R ectal tubes, s t e r iliz a t io n o f, 53
Red Cross, American, 31
and nurse, 260
Reed, Walter, 12
Refuse, d isposal o f , 57
Refuse can, 51
Regulations
ambulance. See Ambulance technic
and regu lations
h ealth , lo c a l, in is o la t io n , 33
v is it in g , 57
R eligion , p rim itive, and m edicine, 1
R eligious orders, nursing care by, 11
Renaissance, th e, and communicable
d isea ses, 7
Renovation, d e fin itio n o f, 46
Reporting. See a lso N o tific a tio n
d iseases for which u su ally re­
quired, 306
d iseases on which not required
everywhere, 307
R esistance. See also Body Defenses
o f h ost, e ffe c t on incubation
period, 23
to d isea se, 18, 20
Respirator, care of patient in ,
p o lio m y e litis, 176
Respiratory d is tr e s s , treatm ent, 41
Respiratory muscles, p a ra ly sis o f.
See P a r a ly sis, respiratory
muscles
Respiratory passages, upper, as
body defense, 24
Respiratory tract
as portal of entry, 21
as portal of e x it , 23
upper, d isp osal o f discharges, 54
R estrain t, mummy, 286
R ockefeller Foundation
estab lish ed 1901, 12
International Health D iv isio n , 12
Room, of p a tien t, at home, 246
Rooms, care o f, 56
Roseola. See Rubella
Rotheln. See Rubella
Roux, 9
Rubber goods, s t e r iliz a t io n o f , 53
Rubella, 76
confusion
with m easles, 79
with sca rlet fev er, 79
con trol, methods o f, 78
d e fin itio n o f, 76
d ie t , 78
d isin fe c tio n , 79
eruption, period o f, 77
340
Rubella - continued
e s s e n t ia l p o in ts , 79
h is to r y , 76
hygiene, personal, 78
immunization, 78
incubation p eriod , 77
in v a sio n , period o f , 77
is o la t io n , 78
prevalence, 76
p rogn osis, 78
quarantine, 78
reco g n itio n , 78
rep o rtin g , 78, 79
sk in , care o f , 78
s u s c e p t ib ilit y , 77
synonyms, 76
Rubeola, See Measles
S a liv a , as in te r n a l defense
Sanitary code, 29, 245
Sanitary engineering, and war, 9
S a n ita tio n
and war, 9
Egyptian, 3
S ca b ies, 196
and eczema, 197
communicability, period o f, 197
com plications, 197
c o n tro l, methods o f , 198
d e fin itio n o f, 196
d i e t , 198
e s s e n t ia l p o in ts, 199
e tio lo g y , 196
h is to r y , 196
home ca re, 199
incubation period, 197
in fe c tio n , sources o f , 196
is o la t io n , 198
nursing care, 198
pathology, 197
prevalence, 196
prognosis, 197
quarantine, 198
reco g n itio n , 198
rep o rtin g , 198
seq u elae, 197
s u s c e p t ib ilit y , 197
transm ission, mode o f, 196
treatm ent, 197
S ca r la tin a . See S carlet fever
S ca rlet f e v e r , 98
and a r t h r it is , 108
and cardiac involvement, 109
and c e r v ic a l a d e n itis , 108
and m a sto id itis, 108
and n e p h r itis , 109
and o t i t i s media, 108
and s e p tic com plications, 102
and serum sick n ess, 103, 109
and to x ic com plications, 103
com municability, period o f, 103
community p rotection , 111
com plications, 102, 108
confusion with ru b ella , 79
c o n tro l, methods o f , 105
con trol t e s t , 103
convalescence, 102| 109
course o f the d isea se, 100
d e fin itio n o f , 98
desquamation, period o f , 101
Dick t e s t , 103
d ie t , 107
d is in fe c tio n , 109
elim in a tio n , 107
eru p tion, period o f , 100
e s s e n t ia l p o in ts, 110
e tio lo g y , 99
fe v e r , reduction o f , 106
h is to r y , 98
home ca re, 111
hygiene, personal, 106
immunization
a c t iv e , 104, 106
o f nurse, 16
p a ssiv e , 104
incubation period, 23, 100
in fe c tio n , source o f, 99
in vasion , period o f , 100
is o la t io n , 105, 106
mild form, 102
m o rta lity , 103
nursing ca re, 106
pathology, 100
p a tie n t, comfort o f , 106
p revalen ce, 98
p rogn osis, 103
p rophylaxis, 103
quarantine, 106
reco g n itio n , 105
rep o rtin g , 105
341
S carlet fever - continued
sep tic form, 102
sequelae, 102
serum, adm inistration o f ,
109, Appendix A
skin, care o f, 106
surgical form, 102
s u s c e p tib ility , 99
synonyms, 98
th roat, care o f, 107
toxic form, 102
to x in , use o f , 26
transm ission, mode o f , 99
treatment, 105
types o f, 102
vaccine, use o f, 39
S carlet fever a n tito x in , u n it o f ,
d efin itio n o f, 40
Schick control t e s t , 263
Schick t e s t , 39, 116, 118, 263
School o f nursing, 259
Schools of nursing, curriculum
fo r , i i i
Schultz-Chariton t e s t , and ad­
m ission tech n ic , 263
Scrub stands, 47
Secretion s, vag in a l, as in ter n a l
defense, 25
Semmelweis, 9
S e n sitiv ity t e s t s , g iv in g , 285
S ep tic sore throat
communicability, period o f , 133
community p rotection , 136
com plications, 133, 135
con trol, method o f , 134
convalescence, 133, 135
course of d isea se, 133
d e fin itio n , 132
d ie t, 135
d isin fe c tio n , 135
e sse n tia l p o in ts, 136
e tio lo g y , 132
h isto r y , 132
hygiene, personal, 135
incubation, period o f , 133
in fe c tio n , source o f, 132
is o la tio n , 134
m ortality, 134
nursing care, 134
pathology, 133
S ep tic sore throat - continued
p a tie n t, comfort o f, 134
prevalence, 132
prognosis, 134
quarantine, 134
recogn ition, 134
reporting, 134
sequelae, 133
s u s c e p t ib ilit y , 133
synonyms, 132
transm ission, mode o f, 133
treatm ent, 134
Sera. See also InoculatiOnn
immune, 38
and pneumococeic pneumonia, 40
as prophylaxis measure, 40
d e fin itio n o f , 39
preparation o f, 39
u ses o f, 40
Serum
a n ti-b a c te r ia l, d e fin itio n o f , 39
a s s is tin g in administration o f ,
109, Appendix A
blood, as in tern al defense, 25
convalescents *
and measles
and strep tococcic in fe c tio n , 26
d e fin itio n o f, 39
immune
and admission tech n ic, 263
and lumbar puncture, 289
adm inistration o f, 284
parental, and m easles, 67
Serum rea ctio n s, 38, 40, 120, 206
Serum sick n ess, 41, 42, 103, 165
S h eets. See Linen
Signing documents, p a tien t, 58
S in u s it is , and nasal diphtheria, 122
Skin, as portal o f entry, 21
Skin in fe c tio n
and chickenpox, 82
and smallpox, 89, 91
Skin ir r it a tio n , treatment o f, 41
Skin t e s t , dose, 39
Sleeping sick n ess, African, referred
t o , 182
Smallpox, 6, 86
and ab scesses, 91
and broncho-pneumonia, 89
and c e l l u l i t i s , 91
342
Smallpox - continued
and c o n ju n c tiv itis , 89
and cowpox, 93
and gangrene, 91
and pest houses in the
U .S ., 10
and p sy ch o sis, 89
and septicem a, 89
and skin in fe c tio n s , 89, 91
communicability, period o f, 89
community p ro tectio n , 93
com plications, 89, 91
con flu en t, 88
confusion with chickenpox, 84
co n tr o l, methods o f, 89
- convalescence, 88, 92
course o f the d ise a se , 88
d e fin itio n o f , 86
d ie t , 91
d is c r e te , 88
d is in fe c tio n , 92
eruption, period o f, 88
e s s e n tia l p o in ts, 92
e tio lo g y , 87
hemorrhagic, 89
h isto r y , 86
hygiene, p erson al, 91
immunization of nurse, 16
incubation p eriod , 87
in fe c tio n , source o f, 87
innoculation a g a in st, 3, 25
in vasion , period o f, 88
is o la t io n , 89, 90
m o rta lity , 89
nursing care, 90
pathology, 87
p ortal o f e x i t , 23
prevalence, 87
prognosis, 89
quarantine, 89
reco g n itio n , 89
rep o rtin g , 89
sequelae, 89
s u s c e p t ib ilit y , 87
transm ission, mode o f, 87
treatm ent, 89
types o f the d ise a s e , 88
v a ccin a tio n , 93
and e n c e p h a litis , 96
auto, 96
com plications, 96
Smallpox - continued
vaccin ation - continued
eruption, 96
procedure, 95
vaccine used a gain st, 26
v a r io lo id , 88
Smith, Theubold, 12
S o cia l S ecu rity Board, and care of
ch ild ren , 15
Sodium bicarbonate, and skin
ir r it a t io n s , 4L
Sore throat, epidemic, 132
Sore throat, sep tic# See Septic
sore throat
Sore th roat, streptococcus, r e fe r ­
ence t o , 132
Source of in fe c tio n . See In fectio n ,
source o f
Specimens, c o lle c tio n o f , 280
S piroch etes, as in fe c tiv e agent, 20
Spore-forming organisms, 52
Stand, bed side, items on, 47
Stands, scrub, 47
S t a t i s t i c s , m o rta lity , value to
nurse, 35
Steam in h a la tio n , 67
S t e r ile , d e fin itio n o f term, 46
S t e r iliz a t io n . See a lso Airing;
B o ilin g , D isin fectio n ; Fumiga­
tio n ; Scrubbing; Washing
bedpans, 53
books, 54
bowls, so lu tio n , 53
brushes, hopper, 53
cans, ir r ig a tio n , 53
ca th eter, n a sa l, 53
c lin ic a l records, 58
colon ic ir r ig a tio n p a il, 53
cotton ja r s, 53
c u b ic le s, 56
d e fin itio n o f , 33
d ish es, 53, 55
droppers, m edicine, 53
ear specula, 53
fla s h lig h t s , 54
fu rn ish in gs, 56
gavage s e t s , 53
g la s s e s , m edicine, 53
head m irrors, 54
instrum ents, 53
k n ives, 53
343
S te r iliz a tio n - continued
lavage s e ts , 53
m ail, p a tie n ts ’ , outgoing, 54
methods o f, 52
ipops, 57
nursing b o ttle s , 53
otoscopes, 54
oxygen tank gauge, 54
papers, 54
p itch ers, m etal, 53
r e c ta l tubes, 53
rubber goods, 53
silverw are, 53
sputum cup, 53
stethoscopes, 52
suction aparatus, 54
thermometers, c l i n i c a l , 55
to y s, non-washable, 54
tra y s, 55
u rin a ls, 53
S te r iliz e r
bedpan, 53
dish, 53
u te n s il, 53
S to o ls, formed, d is in fe c tio n o f ,
55
S trep tococci, p ortal of e x i t , 23
Streptococcus, hemolytac, 99
Suction, and larygoscopy. See
Laryngoscopy and suction
Sunshine. See also Airing
as d isin fe c ta n t, 33
fo r d isin fe c tio n and s t e r i l i z a ­
tio n , 52
S u p erstitio n s, and d ise a s e , 3
Supervision, o f b io lo g ic products,
40
Surgical a s e p sis, p a tien t in , 44
Technic - continued
p orter, ward, 56
ward kitchen, 55
Temperature taking, 51, 250
Terminal d isin fe c tio n . See
D isin fection
Terminology, medical a s e p s is , 46
T ests
Dick, 103, 263
Dick co n tro l, 263
diphtheria, fo r v iru len ce, 288
Schick, 116, 263
Schick control, 263
Schultz-Charlton, 263
s e n s it iv it y , 285
preparation fo r, 884
Wassermann, 263
Tetanus, 200
communicability, period o f , 203
community protection , 207
com plications, 206
con trol, methods o f, 204
convalescence, 203, 206
d efin itio n o f, 200
d ie t, 206
elim in ation , 205
e sse n tia l p oin ts, 206
e tio lo g y , 201
h isto r y , 200
home care, 206
hygiene, personal, 205
immunization, 204
incubation, period o f , 202
in fe c tio n , source o f , 201
is o la tio n , 204, 205
m ortality, 203
nursing care, 205
pathology, 202
p a tie n t, comfort o f, 205
Table, admission. See Admission
prevalence, 200
Table
prognosis, 203
Tables, hedside, fo r tr a y s, 55
prophylaxis in , 40
recogn ition , 204
Technic
admission, 263
reporting, 204
ambulance. See Ambulance technic
serum reaction , 40, 806
and regu lation s
s u s c e p tib ility , 202
synonyms, 200
discard, 148
transm ission, mode o f , 201
gown, 48
treatment, 203
in home, 59
medical a s e p tic . See a lso Medical
vaccine, use o f, 39
a sep tic technic
Thermometer, c lin ic a l, d isin fe c tio n
o f, 63
in h o sp ita l, 58
344
Throat, cu ltu r e s o f. See 6 u ltu res of nose and throat
Throat ir r ig a tio n , 282
Towel, paper, use to prevent
contamination, 54
T ox in -a n tito x in , 26
d ip h th eria, 39, 117
Toxins
and d ia g n o stic t e s t s , 39
b a c te r ia l, 22
Toxoids
dip h th eria, 26, 39, 117
staphylococcic in fe c tio n , 39
teta n u s, 39
Toys, for ch ild ren , 15
Tracheotomy, in diphtheria,
la ry n g ea l, 129
Tracheotomy tube, changing o f,
299
Transfer, b io lo g ic a l. See Bio­
lo g ic a l tra n sfer
Transmission of d isea se, 23
Transportation r eg u la tio n s, and
yellow fe v e r , 226
Trays, handing o f , 55
Trench mouth. See V incent's
angina
Trudeau, 12
Tubercle b a c illu s , discovery o f,
9
T u b ercu lo sis
la te n t c a se , as source of in ­
fe c tio n , 21
pulmonary, and whooping cough,
156
Typhoid fe v e r
c a r r ie r s as source o f, 21
immunization of nurse a g a in st, 16
v a ccin e, use o f, 26, 39
Typhus fe v e r , tra n sfer o f , 24
Uniform, n u r se 's, 17, 249
U n it, d e fin itio n o f term, 46
United S ta te s Public Health Ser­
v ic e . See Public Health
S erv ice, U.S.
U rine, c o lle c t io n of specimens,
280
Vaccina.
See Cowpox
V accination. See a lso Inoculation
auto, 96
d e fin itio n o f, 93
of nurse, 91
smallpox, 93
and e n c e p h a litis , 96
com p lication s, 96
eruption, 96
f i r s t in United S ta te s, 10
h isto r y , 93
procedure, 95
recording o f , 96
Vaccine v ir u s, 93
smallpox, 26, 94
Vaccines, 38
and Pasteur, 9
and war, 9
anthrax, 9
autogenous, 38
b a c te r ia l, d e fin itio n o f, 38
d e fin itio n o f , 38
p e r tu ss is, 26
preparation o f , 38
ra b ies, 9
stock, 38
typhoid, 26
uses o f, 39
Valuables, care o f , 50
V a ricella . See Chickenpox
V ariola. See Smallpox
V arioloid. See Smallpox
Vincent’ s angina, 137
communicability, period o f, 139
community p ro tectio n , 141
com plications, 138
co n tro l, methods o f , 139
course o f d ise a s e , 138
d e fin itio n o f , 137
d ie t , 140
d is in fe c tio n , 140
e s s e n t ia l p o in ts , 140
e tio lo g y , 137
h is to r y , 137
home care, 140
incubation p eriod , 138
in fe c tio n , source o f, 138
iso la ti© n , 139
pathology, 138
p a tie n t, comfort o f, 139
prevalence, 137
345
Vincent’ s angina - continued
prognosis, 139
quarantine, 139
recogn ition , 139
reporting, 139
sequelae, 138
s u s c e p t ib ilit y , 138
synonyms, 137
transm ission, mode o f , 138
treatm ent, 139
Vincent’ s in fe c tio n . See Vin­
cen t’ s angina
Virulence
d e fin itio n o f , 21
e ffe c t on incubation period, 23
of diptheria organisms, cu ltu res
for determining, 288
V irus, cowpox, 38
V is ito r ’s gown, 57
von Economo’s e n c e p h a litis. See
Epidemic en cep h a litis
War
and antigera, 9
and sanitary engineering, 9
and vaccin es, 9
C iv il, and d ise a se s, 10
Crimean, 9
European of 1939, 9
Revolutionary, and d ise a se , 10
value of s c ie n t if ic nursing in ,
9
World, and con trol of communicable
d isea se, 9
Ward kitchen, tech n ic, 55
Ward porter, te ch n ic , 56
Wards, cu b icled , v i s i t o r s , 57
Wards, open
f a c i l i t i e s o f , 59
grouping, 58
screen s, 58
Wassermann t e s t , 263
Waste, d isp osal o f , in home, 248,
253
Water, running, in general h o sp ita l,
58
Water supply
control o f, 35
in v estig a tio n o f , fo r source of
in fe c tio n , 35
supervision o f , by TJ»S*P.H.S., 28
Waterhouse, Benjamin, and smallpox
vaccin ation , 10
Wells and W ells, and air-borne
organisms, 43
White House conference, and care of
child ren, 15
Windows, c u b ic le , 57
Whooping cough, 148
and b ron ch iectasis, 156
end broncho-pneumonia, 155
and convu lsion s, 156
and hemorrhages, 156
and hernia, 156
and marasmus, 156
and o t i t i s media, 156
and pulmonary tu b e rcu lo sis, 156
communicability, period o f, 151
community p ro tectio n , 158
com plications, 151, 155
con trol, method o f , 152
convalescence, 149, 156
course o f d ise a se , 149
d e fin itio n o f, 148
d ie t, 154, 157
elim ination, 154
e sse n tia l p o in ts, 157
etio lo g y , 148
h isto ry , 148
home care, 157
hygiene, personal, 154
immunization, 153
incubation period, 149
in fe c tio n , source o f, 149
is o la tio n , 152, 153
m ortality, 151
nursing care, 153
p atieh t, comfort o f , 153
prevalence, 148
prognosis, 151
prophylaxis, 152
psychological elem ents, 155
quarantine, 152
recogn ition, 152
reporting, 152
sequelae, 151, 155
s u s c e p tib ility , 149
synonyms, 148
transm ission, mode o f, 149
treatment, 152
346
X-ray room, taking p atien t to ,
278
Yellow fe v er , 221
and mosquito, 223
and Negro, 25
and U .S .P .H .S ,, 226
communicability, period o f , 225
community p rotection , 229
com plications, 225
co n tro l, method o f , 225
convalescence, 225, 229
course of d ise a se , 224
d e fin itio n , 221
d ie t , 228
e s se n tia l p o in ts, 229
e tio lo g y , 223
fumigation, 34
h isto r y , 221
hygiene, personal, 228
immunity, 226
incubation period, 224
in fe c tio n , period o f, 223
is o la tio n , 226, 227
m o rta lity , 225
nursing care, 227
pathology, 224
p a tie n t, comfort o f, 228
prevalence, 222
prognosis, 225
quarantine, 226
reco g n itio n , 225
rep ortin g, 225
sequelae, 225
tra n sfer o f, 24
transm ission, mode o f , 223
. transportation r e g u la tio n s, 226
treatm ent, 225
-
o
-
M a u r i c e
3 8 0
L e n a r s k y , M .D .
R I V E R S I D E
N E W
Y O R K ,
MONUMENT
D R IV E
N . Y.
2 * 1 4 8 9
Ju ly 20 , 1940
To Whom I t May Concern:
I have examined the m anuscript, "Communicable
D ise a se Nursing" by Theresa I . Lynch, and I fin d the
m edical in form ation to be accurate*
JP^ry tr u ly your;
1m
iu rice Lenars
A sso c ia te V is it in g Physifeian
W illard Parker H o sp ita l
New York, N.Y.
NEW YORK UN IVERSITY
S C H O O L O F EDUCATION
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