Dysentery must now be regarded as an endemic infection in large cities. In all parts of Great Britain notifications of the disease have increased greatly in recent years, and in view of the mild nature of the symptoms it may be assumed that the notifications represent but a proportion of the actual incidence. It is no longer true to say that the maximal incidence is always in the summer months. Notifications have been excessive throughout the year, and, in some years the peak has occurred in the first quarter. A large proportion of the patients are children under five years of age.. It is not sufficiently well known that the presence of blood or mucus is not a necessary feature of the illness, and in many cases a few loose stools may comprise the whole complaint. As a result, many infections are missed and so increase the spread of the disease. Some convalescents may become carriers for long periods of time and act as a source of infection.
Dysentery is seldom an " individual " infection. When a case is diagnosed in a family it is usual to find some other members with the organism in their stools. Outbreaks in day nurseries and children's homes are commonplace— and here again the diagnosis of one case will often unmask a widespread epidemic of carriers.
Unlike typhoid fever, the infection remains almost entirely localized to the bowel and agglutinins do not appear in the blood to any great degree. Apart from toxic absorption due to bowel ulceration, the main danger in severe infections arises from exhaustion of the patient by loss of fluid and salt in watery stools. Such a degree of severity is fortunately unusual.
Diagnosis depends on accurate bacteriological examination. For this purpose a rectal swab outfit is used since by this means a suitable specimen can be secured quickly and easily. No time should be lost between obtaining the specimen and submitting it to the laboratory. Rectal swabbing and the use of selective media have added great precision to the diagnosis.
Dysentery is a notifiable disease. In Britain Flexner and Sonne types of Sh. dysenteries account for nearly all of the infections. The incubation period is two to five days.Prevention and Epidemiological Control.—The control of ward and institutional outbreaks often presents an overwhelming task. All further admissions should be stopped and a close search made for carriers and missed cases, both among patients and staff. The bacteriologist should be brought into consultation at once, for the addition to his routine work will be considerable and he should therefore be forewarned. Plans should also be prepared for the separation of those found to give positive results and arrangements made for the sterilization of food utensils, bed-pans, etc. Soiled napkins should be dropped direct into covered pails containing lysol. The nursing staff must be instructed regarding the method of transference of the infection and there must be great persistence in a campaign for repeated hand washing and a careful ritual of personal hygiene. The nurses should also be taught that the simplest case of diarrhoea may well be dysentery and that the occurrence of a loose or green stool should be reported at once.
The extent to which bacteriological freedom from infection prior to discharge is enforced must vary from case to case. When the patient is to return to a closed community—service personnel and children from nurseries—and when there is close association with food preparation it is desirable to obtain at least three negative bacteriological reports. When the patient is returning home, however, it is unnecessary to carry out protracted examinations, and the verage case may be regarded as free from infection by the eighth to tenth day of illness.
Curative Treatment.—The majority of cases/due to Sonne and Flexner infections, run a mild course of three or four days and call for little medicinal treatment. The administration of specific serum to cases of Shiga infection is of undoubted value. The dose is up to 100 ml. and the injection should be given intravenously after suitable precautions (p. 50).
SuJphonamides.—In most parts of Great Britain the endemic strains of shigella have now acquired resistance to sulphonamides, which are therefore no longer effective. In areas where this is not the case, sulphadiazine will prove as satisfactory as sulphaguanidine or succinylsulphathiazole.
Antibiotics.—Tetracyclines are effective in securing bacteriological clearance and do so in low dosage. This is undoubtedly important in dealing with food-handlers, etc. They should be used with caution in hospital wards, where the danger of superinfection of the bowel with resistant staphylococci is very real. It is doubtful if this complication will be encountered in general practice. The period of treatment should not exceed five days.
General Management.—The patient must be confined to bed and kept warm from the first symptom of the disease. When the attack is severe the bed-pan should be employed in order to avoid contamination of lavatory seats, etc. When the call to stool is incessant, the bed-pan may be dispensed with and the motions received into tow, which, when soiled, is collected and burnt.
In severe cases it will be necessary to correct the electrolyte disturbance by intravenous infusions. Apart from this, however, there is no need for special dietetic restrictions.
Carriers.—Persistent symptomless carriers are sometimes unmasked in the investigation of an outbreak. The strain isolated should be tested for sensitivity against a wide range of antibiotics effective against gram-negative organisms and an appropriate substance chosen.
Wednesday, July 30, 2008
LARYNGEAL DIPHTHERIA TREATMENT
On the slightest suspicion that a child is suffering from a diphtheritic laryngitis, the practitioner should immediately inject 8,000 units of antitoxin and 250 mg. of erythromycin estolate intramuscularly and arrange for the prompt removal of the patient to hospital. The steam kettle and the administration of 0-6 to 1-2 ml. (10 to 20 min.) of camphorated tincture of opium may be useful as temporary measures but, if rapid cure is not established, admission to hospital is essential for correct diagnosis and, when necessary, tracheostomy or intubation. Laryngo-Tracheo-Bronchitis.—The widespread practice of diphtheria immunization has resulted in the virtual disappearance of diphtheritic laryngitis ; and yet " croup " is still commonly encountered. The commonest form is that associated with a general inflammation of the respiratory tract. Although the condition is primarily a virus infection, secondary bacterial invaders are responsible for much of the subsequent damage. All ages may be affected, but because of the relatively small laryngeal opening in children, obstruction to respiration is usually confined to those under five years of age. In many cases Staph. pyogenes can be grown in pure culture from throat swabs. The organism has proved to be penicillin resistant in such a high proportion of cases that penicillin should never be the antibiotic of first choice. Since other bacteria may be involved, treatment should be started with a tetracycline while the results of sensitivity tests are awaited ; after more precise information is available, the suitable antibiotic can be chosen. Even after tracheostomy such cases often pursue a stormy course and require constant expert supervision.
DIPHTHERIA TREATMENT
Diphtheria is now a rare infection in Great Britain. The major credit for this state of affairs must be given to prophylactic inoculation of children with toxoids. It would seem possible, however, that with the passage of time public awareness of the disease diminishes so that immunization is not undertaken until entry to school in a considerable proportion of the child population. Local epidemics—often associated with mortality—have now occurred in a number of places so that there is real need to bear in mind the possibility of its reappearance.
Diphtheria is almost entirely a toxic disease. Although some slight tissue invasion takes place in severe infections, for the most part the organisms remain localized to the site of inoculation from which the toxin diffuses by lymphatics and blood stream to all parts of the body. The ability of the host to neutralize toxin thus constitutes an almost complete defence ; for, shorn of its toxic action, the diphtheria bacillus is a weak pathogen.
C. diphtheria is divisible by cultural methods into three main types—grains, intermedius and mitis. Broadly speaking, the first two are associated with a more severe form of the disease. Bacteriological typing is not of immediate importance to the clinician, who must estimate the initial dose of antitoxin before such information is available. The subsequent progress of the case, however, should be governed to some extent by the results of typing; gravis and intermedius infections should be supervised more strictly since complications are more frequent. Further, almost all gravis and intermedius strains are virulent, so that a carrier of these types may be regarded as harbouring pathogenic organisms. Mitis strains are frequently non-virulent, and a virulence test is essential before the final assessment of a carrier can be made. The importance of typing in epidemiological work will be obvious.
Cases and carriers constitute the main sources of infection. Usually the bacteria are carried in the throat or nose, the latter site being rather more common, so that in a search for a source of infection nasal cultures should never be omitted. Cutaneous diphtheria, often simulating a chronic sore, may be an unsuspected source of infection. Although in most instances infection is spread by droplet infection, contaminated milk, ice-cream and food have initiated local outbreaks.
The importance of the early diagnosis of diphtheria cannot be too strongly emphasized. Careful examination of the fauces should be a routine procedure in every febrile patient. Apart from the presence of " false membrane ", marked faucial and palatal oedema, accompanied by an acute gross enlargement of the cervical glands, should, in a child, always be treated as diphtheria until proved otherwise.
Diphtheria is a notifiable disease. It has an incubation period of two to five days.Prevention and Epidemiological Control.—Schick Test.—Susceptibility to diphtheria can be ascertained by the application of the Schick test—an intradermal injection into the left forearm of 0-2 ml. of diluted diphtheria toxin. Individuals showing an area of erythema from i to 4 cm. in diameter around the site of injection four to seven days after the application of the test are said to be Schick positive, an indication of susceptibility to the disease. When applying the primary Schick test to a large community, the highest proportion of positive results will be obtained when the reactions are read on the seventh day. No local reaction appears in those who are immune (Schick negative reactors). A precisely similar injection is made into the skin of the right forearm, but with toxin which has been previously inactivated by heat.
This control test discriminates between local reactions arising from sensitization to the protein present in the test fluid and the true positive Schick reaction. Reliable Schick and control test material can be obtained commercially.
Active Immunization.—Every child should be actively immunized against diphtheria during the first year of life. A preliminary Schick test is unnecessary.
Four vaccines1 are available : purified toxoid aluminium phosphate (PTAP), alum-precipitated toxoid (APT), formol toxoid (FT) and toxoid antitoxin floccules (TAF). For children under 5 years two intramuscular injections each of 0-5 ml. of one of the alum-toxoids with an interval of four weeks between injections will produce effective immunity. In older children or adults it is better to start with a small dose (0-2 ml.) and observe the degree of local reaction. If this is severe two further injections of 0-2 ml. with a four-week interval are advised. FT is not recommended since it is a weaker antigen and reactions are common in older children and adults. TAF is a good antigen and remarkably free from local reaction. It has the disadvantage that it contains horse-serum and may, therefore, have a sensitizing effect. Three injections of i-o ml. are required.
The first injection has no permanent immunizing effect. It is the subsequent doses which evoke a high level of antitoxin in the blood and confer immunity. The duration of this immunity is variable, but a child who has received the two immunizing doses may later have its immunity " boosted " by a further single injection. Such a " booster " injection is essential before the child enters school at the age of 5 years.
Combined vaccines are now commonly used. For example, diphtheria-tetanus adsorbed vaccine is a good antigen and remarkably free from local reactions in children. Diphtheria, tetanus and pertussis vaccines are best prepared without alum and in this form are good antigens, but should not be given before the age of three months in order to obtain a satisfactory response to the diphtheria and tetanus antigens. As it is so convenient to obtain this comprehensive immunizing effect with single injections, the method is recommended as a means of obtaining immunity during the first year of life. A quadruple vaccine, containing diphtheria, tetanus pertussis and killed poliovirus antigens, is now available but is not yet recommended for general use since it has been associated with somewhat severe side-effects.
General Measures.—For the control of an outbreak the first steps are the isolation of the patient. Contacts must be carefully examined for evidence of a missed infection. Particular attention should be paid to any person suffering from chronic nasal or aural discharge, or obviously unhealthy tonsils—or a suspicious cutaneous lesion—and the appropriate swabs taken for bacteriological examination.
The normal carrier rate in the general population is exceedingly low so that when a case of clinical diphtheria occurs it is important to try to identify the carrier from whom the infection was conveyed. After a preliminary warning to the bacteriologist when large numbers are involved, swabs should be taken from the nose and, throat and from any suspicious lesion of all contacts. Since the typing of C. diphtheria isolated from either the primary case or the contacts will take three to four days this time may be usefully occupied in eliciting precise1 The term " vaccine " was formerly confined to the description of materials which contained bacteria or viruses. It is now used to describe all antigenic substances designed to secure active immunity.
details regarding the immunization status of those involved. Contacts who have already received a full course in childhood can now be effectively " boosted " by a single injection of 0-2 ml. of an appropriate vaccine (PTAP). Persons who have never been immunized should be given active-passive immunization. To accomplish this 500 units of diphtheria antitoxin is injected into one arm at the same time as 0-5 ml. of PTAP is injected into the other arm. A note should be taken to ensure that these persons are given a further injection of 0-5 ml. of PTAP four weeks later to complete the active immunization course.
Any carriers disclosed by the bacteriological examination must be isolated in hospital and treated appropriately (p. 13). It is nowadays essential to ensure that the carrier state has been effectively eradicated before the individual is released from isolation.
Curative Treatment.—A history of immunization must never lead the practitioner to ignore the possibility of diphtheria. Indeed, it must be appreciated that mild diphtheria—usually due to gravis organisms—occasionally occurs in the inoculated and that such infections are usually atypical and may be more suggestive of tonsillitis. Further, although it is undoubtedly true that the disease in the immunized is often mild, failure to make an early diagnosis may result in the administration of serum too late to prevent nervous complications.
Antitoxic Serum.—An intramuscular injection of at least 4,000 units of diphtheria antitoxic serum should immediately be administered to any patient suspected to be suffering from the disease. The importance of early administration of antitoxin cannot be exaggerated. The doctor who " wonders whether this might be diphtheria " is under an obligation to give serum at once. Swabs can then be taken. By the time full bacteriological investigations have been made, several days must elapse. These are the critical days : omission of antitoxin treatment at this stage may be fatal. There is considerable difference of opinion regarding the optimum dose of antitoxin in the treatment of diphtheria. Broadly speaking, mild attacks require from 4,000 to 8,000 units intramuscularly ; cases of moderate severity from 16,000 to 32,000 units intramuscularly ; severe or toxic attacks from 48,000 to 96,000 units divided between the intramuscular and intravenous routes. When the diphtheritic infection is limited to the larynx, 8,000 units of antitoxin are usually sufficient, and a similar dose is adequate in purely nasal diphtheria unless toxasmia is severe.
There is no satisfactory method of assessing the correct amount of antitoxin, so that it is better to err on the side of overdosage. There are good grounds for believing that a dose of 48,000 units is more than adequate for the most severe case of diphtheria and that it is never necessary to give more than 96,000 units.
The route of administration is very important. It is seldom appreciated that a considerable time elapses after intramuscular injection before " peak " levels are attained in the blood stream. All severe cases (i.e. where more than 32,000 units are to be given) must receive at least part of the dose intravenously. In other words, the intramuscular route is the second-best and should only be used in mild or moderate cases. Intramuscular serum should be given into the lateral aspect of the thigh. (Before giving serum the doctor must be conversant with the possible dangers which may result, and the measures to be taken for their prevention and treatment are discussed Other Specific Treatment.—The bacteriological examination of the throat swab will include search for other pathogens—particularly Str. pyogenes—by suitable culture. Erythromycin has a definite value in the treatment of diphtheria after serum has been given. In the first place it is of value in dealing with the superadded infection so often present; and secondly it hastens the disappearance of C. diphtheria from the throat and reduces the risk of development of the carrier state. The dose must be large (in the range of 10 to la-mg. per kg. body weight) in order to ensure an adequate local concentration.
General Measures.—With the exception of the mildest attack, a case of diphtheria should not be treated at home unless adequate nursing attention is available day and night. From the moment that diphtheria is suspected, the patient must be confined to bed in a strictly recumbent position. Owing to the risk of cardiovascular complications, any attempt to sit up, reach over to a chair or bedside table, etc., must be prohibited. Indeed, in the most toxic forms the patient should not even feed himself. The period of recumbency varies from 14 davs in mild attacks to eight weeks or longer in severe cases, according to the condition of the cardiovascular system and the occurrence of paralysis. The need for strict recumbency is not dictated because of cardiac damage, but because the peripheral circulation is also severely affected.
After the addition of a second and a third pillow at intervals of two clear days, the patient is permitted to sit up, and may leave his bed seven to ten days later. The rate of progress will vary according to the severity of the attack and the response of the cardiovascular system to increased exertion. This is assessed by a study of the pulse rate: a rising pulse rate means that convalescence is being unduly hurried. Care should be taken to curtail activity when the patient begins to walk. Ocular paresis is a possible development and reading should be restricted; the print must be large and the page well illuminated.Complications.—The mitigation of serious toxic damage to the heart and vessels by the earlv application of the measures detailed above is the fundamental principle in the treatment of diphtheria. Once well-marked signs of cardiovascular weakness appear, the situation is grave and treatment other than skilful nursing is of little avail. The foot of the bed should be raised. Vomiting due to cardiac failure necessitates the replacement of oral feeding by the administration of intravenous infusions. The mouth may be moistened with sips of water or pieces of cracked ice. Epigastric pain, restlessness and anxiety are best relieved by repeated hypodermic injections of morphine : 2 mg. for a child of two years, 4 mg. at five years, and 5 mg. for a child of 10 years. The various vasomotor or cardiac stimulants have no place in the treatment of circulatory failure in diphtheria. Drugs of the digitalis group are definitely contraindicated. The administration of alcohol has nothing to commend it. Apart from involvement of the pharyngeal and respiratory muscles, noanxiety need be felt regarding the outcome of the post-diphtheritic palsies, since they tend to recover spontaneously within a few weeks. In palatal paresis the fluid part of the diet should be replaced by semi-solids. In pharyngeal paralysis the foot of the bed should be raised 18 in. and the patient nursed in the prone position. Saliva and mucus should be aspirated at frequent intervals from the pharynx and food administered by nasal tube. On the slightest indication of weakness of the intercostal muscles or diaphragm constant supervision is essential. The degree of respiratory dysfunction must be carefully assessed and the necessary preparations made for instituting mechanical assistance. Late generalized muscular weakness improves with massage, hot and cold douching, graduated exercise, fresh air and good food.
Convalescence.—It is necessary to obtain three consecutive negative cultures from both throat and nose at an interval of one week before the patient is released from isolation. Even after a mild attack the patient should not resume school or work for at least a fortnight after isolation is stopped. The convalescent period may require to be prolonged to six months or even longer following severe toxic diphtheria. Strenuous exercise must be forbidden.
CARRIERS
The first essential in dealing with a persistent convalescent—or contact— carrier of morphological diphtheria bacilli is to make sure that the organisms are virulent. Carriers of non-virulent bacilli are not dangerous to the community and need not be segregated.
If the organism isolated is virulent, tests to disclose its antibiotic sensitivity should be requested. Erythromycin is usually particularly effective against C. diphtheria and, while awaiting the laboratory results, its administration may be started. The estolate is a suitable preparation and a daily dosage in the range of 10 to 15 mg. per kg. body weight should be used. This will ensure a high local concentration. Erythromycin should be continued for 10 days and during this time the carrier must be strictly isolated in order to prevent re-infection.
While treatment is proceeding the time can be used to make a detailed clinical and radiological examination of the mouth and upper respiratory tract since, in persistent carriers, it is common to find some local abnormality which serves to prolong the carrier state. At the end of the course of treatment it is advised that six negative cultures from the nose and throat should be obtained over a period of at least 14 days. This period should not be shortened for it is often found that negative swabs may give place to positives at the end of the series. Should erythromycin fail the question of further chemotherapy may be considered in light of the known sensitivity of the organism. However, when the examination of the nose and throat has disclosed some abnormality which j should be corrected surgically it will usually be preferable to adopt this course for, in such circumstances, cure may prove exceedingly difficult with chemo-; therapy alone. The effective clearing of carriers is now all the more important because of the very low carrier rate in the community.
Diphtheria is almost entirely a toxic disease. Although some slight tissue invasion takes place in severe infections, for the most part the organisms remain localized to the site of inoculation from which the toxin diffuses by lymphatics and blood stream to all parts of the body. The ability of the host to neutralize toxin thus constitutes an almost complete defence ; for, shorn of its toxic action, the diphtheria bacillus is a weak pathogen.
C. diphtheria is divisible by cultural methods into three main types—grains, intermedius and mitis. Broadly speaking, the first two are associated with a more severe form of the disease. Bacteriological typing is not of immediate importance to the clinician, who must estimate the initial dose of antitoxin before such information is available. The subsequent progress of the case, however, should be governed to some extent by the results of typing; gravis and intermedius infections should be supervised more strictly since complications are more frequent. Further, almost all gravis and intermedius strains are virulent, so that a carrier of these types may be regarded as harbouring pathogenic organisms. Mitis strains are frequently non-virulent, and a virulence test is essential before the final assessment of a carrier can be made. The importance of typing in epidemiological work will be obvious.
Cases and carriers constitute the main sources of infection. Usually the bacteria are carried in the throat or nose, the latter site being rather more common, so that in a search for a source of infection nasal cultures should never be omitted. Cutaneous diphtheria, often simulating a chronic sore, may be an unsuspected source of infection. Although in most instances infection is spread by droplet infection, contaminated milk, ice-cream and food have initiated local outbreaks.
The importance of the early diagnosis of diphtheria cannot be too strongly emphasized. Careful examination of the fauces should be a routine procedure in every febrile patient. Apart from the presence of " false membrane ", marked faucial and palatal oedema, accompanied by an acute gross enlargement of the cervical glands, should, in a child, always be treated as diphtheria until proved otherwise.
Diphtheria is a notifiable disease. It has an incubation period of two to five days.Prevention and Epidemiological Control.—Schick Test.—Susceptibility to diphtheria can be ascertained by the application of the Schick test—an intradermal injection into the left forearm of 0-2 ml. of diluted diphtheria toxin. Individuals showing an area of erythema from i to 4 cm. in diameter around the site of injection four to seven days after the application of the test are said to be Schick positive, an indication of susceptibility to the disease. When applying the primary Schick test to a large community, the highest proportion of positive results will be obtained when the reactions are read on the seventh day. No local reaction appears in those who are immune (Schick negative reactors). A precisely similar injection is made into the skin of the right forearm, but with toxin which has been previously inactivated by heat.
This control test discriminates between local reactions arising from sensitization to the protein present in the test fluid and the true positive Schick reaction. Reliable Schick and control test material can be obtained commercially.
Active Immunization.—Every child should be actively immunized against diphtheria during the first year of life. A preliminary Schick test is unnecessary.
Four vaccines1 are available : purified toxoid aluminium phosphate (PTAP), alum-precipitated toxoid (APT), formol toxoid (FT) and toxoid antitoxin floccules (TAF). For children under 5 years two intramuscular injections each of 0-5 ml. of one of the alum-toxoids with an interval of four weeks between injections will produce effective immunity. In older children or adults it is better to start with a small dose (0-2 ml.) and observe the degree of local reaction. If this is severe two further injections of 0-2 ml. with a four-week interval are advised. FT is not recommended since it is a weaker antigen and reactions are common in older children and adults. TAF is a good antigen and remarkably free from local reaction. It has the disadvantage that it contains horse-serum and may, therefore, have a sensitizing effect. Three injections of i-o ml. are required.
The first injection has no permanent immunizing effect. It is the subsequent doses which evoke a high level of antitoxin in the blood and confer immunity. The duration of this immunity is variable, but a child who has received the two immunizing doses may later have its immunity " boosted " by a further single injection. Such a " booster " injection is essential before the child enters school at the age of 5 years.
Combined vaccines are now commonly used. For example, diphtheria-tetanus adsorbed vaccine is a good antigen and remarkably free from local reactions in children. Diphtheria, tetanus and pertussis vaccines are best prepared without alum and in this form are good antigens, but should not be given before the age of three months in order to obtain a satisfactory response to the diphtheria and tetanus antigens. As it is so convenient to obtain this comprehensive immunizing effect with single injections, the method is recommended as a means of obtaining immunity during the first year of life. A quadruple vaccine, containing diphtheria, tetanus pertussis and killed poliovirus antigens, is now available but is not yet recommended for general use since it has been associated with somewhat severe side-effects.
General Measures.—For the control of an outbreak the first steps are the isolation of the patient. Contacts must be carefully examined for evidence of a missed infection. Particular attention should be paid to any person suffering from chronic nasal or aural discharge, or obviously unhealthy tonsils—or a suspicious cutaneous lesion—and the appropriate swabs taken for bacteriological examination.
The normal carrier rate in the general population is exceedingly low so that when a case of clinical diphtheria occurs it is important to try to identify the carrier from whom the infection was conveyed. After a preliminary warning to the bacteriologist when large numbers are involved, swabs should be taken from the nose and, throat and from any suspicious lesion of all contacts. Since the typing of C. diphtheria isolated from either the primary case or the contacts will take three to four days this time may be usefully occupied in eliciting precise1 The term " vaccine " was formerly confined to the description of materials which contained bacteria or viruses. It is now used to describe all antigenic substances designed to secure active immunity.
details regarding the immunization status of those involved. Contacts who have already received a full course in childhood can now be effectively " boosted " by a single injection of 0-2 ml. of an appropriate vaccine (PTAP). Persons who have never been immunized should be given active-passive immunization. To accomplish this 500 units of diphtheria antitoxin is injected into one arm at the same time as 0-5 ml. of PTAP is injected into the other arm. A note should be taken to ensure that these persons are given a further injection of 0-5 ml. of PTAP four weeks later to complete the active immunization course.
Any carriers disclosed by the bacteriological examination must be isolated in hospital and treated appropriately (p. 13). It is nowadays essential to ensure that the carrier state has been effectively eradicated before the individual is released from isolation.
Curative Treatment.—A history of immunization must never lead the practitioner to ignore the possibility of diphtheria. Indeed, it must be appreciated that mild diphtheria—usually due to gravis organisms—occasionally occurs in the inoculated and that such infections are usually atypical and may be more suggestive of tonsillitis. Further, although it is undoubtedly true that the disease in the immunized is often mild, failure to make an early diagnosis may result in the administration of serum too late to prevent nervous complications.
Antitoxic Serum.—An intramuscular injection of at least 4,000 units of diphtheria antitoxic serum should immediately be administered to any patient suspected to be suffering from the disease. The importance of early administration of antitoxin cannot be exaggerated. The doctor who " wonders whether this might be diphtheria " is under an obligation to give serum at once. Swabs can then be taken. By the time full bacteriological investigations have been made, several days must elapse. These are the critical days : omission of antitoxin treatment at this stage may be fatal. There is considerable difference of opinion regarding the optimum dose of antitoxin in the treatment of diphtheria. Broadly speaking, mild attacks require from 4,000 to 8,000 units intramuscularly ; cases of moderate severity from 16,000 to 32,000 units intramuscularly ; severe or toxic attacks from 48,000 to 96,000 units divided between the intramuscular and intravenous routes. When the diphtheritic infection is limited to the larynx, 8,000 units of antitoxin are usually sufficient, and a similar dose is adequate in purely nasal diphtheria unless toxasmia is severe.
There is no satisfactory method of assessing the correct amount of antitoxin, so that it is better to err on the side of overdosage. There are good grounds for believing that a dose of 48,000 units is more than adequate for the most severe case of diphtheria and that it is never necessary to give more than 96,000 units.
The route of administration is very important. It is seldom appreciated that a considerable time elapses after intramuscular injection before " peak " levels are attained in the blood stream. All severe cases (i.e. where more than 32,000 units are to be given) must receive at least part of the dose intravenously. In other words, the intramuscular route is the second-best and should only be used in mild or moderate cases. Intramuscular serum should be given into the lateral aspect of the thigh. (Before giving serum the doctor must be conversant with the possible dangers which may result, and the measures to be taken for their prevention and treatment are discussed Other Specific Treatment.—The bacteriological examination of the throat swab will include search for other pathogens—particularly Str. pyogenes—by suitable culture. Erythromycin has a definite value in the treatment of diphtheria after serum has been given. In the first place it is of value in dealing with the superadded infection so often present; and secondly it hastens the disappearance of C. diphtheria from the throat and reduces the risk of development of the carrier state. The dose must be large (in the range of 10 to la-mg. per kg. body weight) in order to ensure an adequate local concentration.
General Measures.—With the exception of the mildest attack, a case of diphtheria should not be treated at home unless adequate nursing attention is available day and night. From the moment that diphtheria is suspected, the patient must be confined to bed in a strictly recumbent position. Owing to the risk of cardiovascular complications, any attempt to sit up, reach over to a chair or bedside table, etc., must be prohibited. Indeed, in the most toxic forms the patient should not even feed himself. The period of recumbency varies from 14 davs in mild attacks to eight weeks or longer in severe cases, according to the condition of the cardiovascular system and the occurrence of paralysis. The need for strict recumbency is not dictated because of cardiac damage, but because the peripheral circulation is also severely affected.
After the addition of a second and a third pillow at intervals of two clear days, the patient is permitted to sit up, and may leave his bed seven to ten days later. The rate of progress will vary according to the severity of the attack and the response of the cardiovascular system to increased exertion. This is assessed by a study of the pulse rate: a rising pulse rate means that convalescence is being unduly hurried. Care should be taken to curtail activity when the patient begins to walk. Ocular paresis is a possible development and reading should be restricted; the print must be large and the page well illuminated.Complications.—The mitigation of serious toxic damage to the heart and vessels by the earlv application of the measures detailed above is the fundamental principle in the treatment of diphtheria. Once well-marked signs of cardiovascular weakness appear, the situation is grave and treatment other than skilful nursing is of little avail. The foot of the bed should be raised. Vomiting due to cardiac failure necessitates the replacement of oral feeding by the administration of intravenous infusions. The mouth may be moistened with sips of water or pieces of cracked ice. Epigastric pain, restlessness and anxiety are best relieved by repeated hypodermic injections of morphine : 2 mg. for a child of two years, 4 mg. at five years, and 5 mg. for a child of 10 years. The various vasomotor or cardiac stimulants have no place in the treatment of circulatory failure in diphtheria. Drugs of the digitalis group are definitely contraindicated. The administration of alcohol has nothing to commend it. Apart from involvement of the pharyngeal and respiratory muscles, noanxiety need be felt regarding the outcome of the post-diphtheritic palsies, since they tend to recover spontaneously within a few weeks. In palatal paresis the fluid part of the diet should be replaced by semi-solids. In pharyngeal paralysis the foot of the bed should be raised 18 in. and the patient nursed in the prone position. Saliva and mucus should be aspirated at frequent intervals from the pharynx and food administered by nasal tube. On the slightest indication of weakness of the intercostal muscles or diaphragm constant supervision is essential. The degree of respiratory dysfunction must be carefully assessed and the necessary preparations made for instituting mechanical assistance. Late generalized muscular weakness improves with massage, hot and cold douching, graduated exercise, fresh air and good food.
Convalescence.—It is necessary to obtain three consecutive negative cultures from both throat and nose at an interval of one week before the patient is released from isolation. Even after a mild attack the patient should not resume school or work for at least a fortnight after isolation is stopped. The convalescent period may require to be prolonged to six months or even longer following severe toxic diphtheria. Strenuous exercise must be forbidden.
CARRIERS
The first essential in dealing with a persistent convalescent—or contact— carrier of morphological diphtheria bacilli is to make sure that the organisms are virulent. Carriers of non-virulent bacilli are not dangerous to the community and need not be segregated.
If the organism isolated is virulent, tests to disclose its antibiotic sensitivity should be requested. Erythromycin is usually particularly effective against C. diphtheria and, while awaiting the laboratory results, its administration may be started. The estolate is a suitable preparation and a daily dosage in the range of 10 to 15 mg. per kg. body weight should be used. This will ensure a high local concentration. Erythromycin should be continued for 10 days and during this time the carrier must be strictly isolated in order to prevent re-infection.
While treatment is proceeding the time can be used to make a detailed clinical and radiological examination of the mouth and upper respiratory tract since, in persistent carriers, it is common to find some local abnormality which serves to prolong the carrier state. At the end of the course of treatment it is advised that six negative cultures from the nose and throat should be obtained over a period of at least 14 days. This period should not be shortened for it is often found that negative swabs may give place to positives at the end of the series. Should erythromycin fail the question of further chemotherapy may be considered in light of the known sensitivity of the organism. However, when the examination of the nose and throat has disclosed some abnormality which j should be corrected surgically it will usually be preferable to adopt this course for, in such circumstances, cure may prove exceedingly difficult with chemo-; therapy alone. The effective clearing of carriers is now all the more important because of the very low carrier rate in the community.
CHICKENPOX (Varicella) TREATMENT
A viral disease of high infectivity, chickenpox is probably spread by droplet infection and by conveyance of material from the skin lesions either on the hands or clothes of a third person, or possibly by air. The incubation period is usually from thirteen to sixteen days. It is rarely less than 11 days or more than 20 days. The disease is probably infective for at least 24 hours before the appearance of the rash. The duration of infectivity is uncertain, but for practical purposes may be regarded as persisting until the last crust has separated from the skin.
Chickenpox is not a notifiable disease, but should smallpox be prevalent in a particular area, chickenpox cases may have to be reported to the local Public Health Authority.
Preventive Treatment.—There is no method of preventing chickenpox. Indeed attempts to avoid infection in childhood should not be made since in the adult chickenpox is almost always a more severe illness. It should be remembered that the viruses of chickenpox and herpes zoster are probably identical and that herpes zoster often produces chickenpox in susceptible contacts.
Curative Treatment.—General Management.—The treatment of chicken-pox is on general lines, no specific remedy being available. Even in mild attacks the patient should be confined to bed during the efflorescence of the eruption. When the rash is profuse it is wise to insist on rest in bed until the lesions have crusted. If there is a tendency to scratch the pocks, the hands may be wrapped in lint or gauze, or the arms lightly splinted. If itching is intense, the application of either calamine lotion or 2^ per cent. phenol in petroleum jelly or olive oil will give relief, or the skin may be dusted freely with a good sterilized talcum powder or with a powder consisting of equal parts of boric acid, zinc oxide and starch.Complications.—In children complications are rare. If severe secondary infection of the skin lesions occurs bacteriological examination should always be carried out and the appropriate antibiotic prescribed. The most severe forms of chickenpox are seen in the adult and are often a sequel to radiotherapy or to treatment with steroids. A primary chickenpox pneumonia is a common complication in such cases. When the patient is already receiving steroids the dose should be temporarily increased and indeed in any patient who develops chickenpox pneumonia the treatment should be a combination of tetracycline andprednisolone
Chickenpox is not a notifiable disease, but should smallpox be prevalent in a particular area, chickenpox cases may have to be reported to the local Public Health Authority.
Preventive Treatment.—There is no method of preventing chickenpox. Indeed attempts to avoid infection in childhood should not be made since in the adult chickenpox is almost always a more severe illness. It should be remembered that the viruses of chickenpox and herpes zoster are probably identical and that herpes zoster often produces chickenpox in susceptible contacts.
Curative Treatment.—General Management.—The treatment of chicken-pox is on general lines, no specific remedy being available. Even in mild attacks the patient should be confined to bed during the efflorescence of the eruption. When the rash is profuse it is wise to insist on rest in bed until the lesions have crusted. If there is a tendency to scratch the pocks, the hands may be wrapped in lint or gauze, or the arms lightly splinted. If itching is intense, the application of either calamine lotion or 2^ per cent. phenol in petroleum jelly or olive oil will give relief, or the skin may be dusted freely with a good sterilized talcum powder or with a powder consisting of equal parts of boric acid, zinc oxide and starch.Complications.—In children complications are rare. If severe secondary infection of the skin lesions occurs bacteriological examination should always be carried out and the appropriate antibiotic prescribed. The most severe forms of chickenpox are seen in the adult and are often a sequel to radiotherapy or to treatment with steroids. A primary chickenpox pneumonia is a common complication in such cases. When the patient is already receiving steroids the dose should be temporarily increased and indeed in any patient who develops chickenpox pneumonia the treatment should be a combination of tetracycline andprednisolone
ANTHRAX TREATMENT
Anthrax is an infection which is classed as an occupational risk, and in man is more or less confined to workers with animals or in wool, hair or hides. The importance of artificial fertilizers containing bone-meal must be borne in mind for this may explain the infection of individuals with no obvious occupational or other contact. The disease is seen principally in animal husbandmen and infection usually enters through minute wounds or abrasions on the exposed skin, giving rise after an incubation period of about 24 to 36 hours to a cutaneous lesion, the " malignant pustule ".
Anthrax is not a notifiable disease, but information regarding cases occurring in factories and workshops must be forwarded to the Chief Inspector of Factories at the Home Office.
Preventive Treatment.—Although there is a considerable animal reservoir of infection in this country the disease is so well diagnosed by veterinarians that human anthrax from indigenous sources is very uncommon. By law, carcasses of infected animals must be either burned or deeply buried in lime and the area of ground fenced for some years. Thus, in the British Isles most cases arise from imported material—hides or bones being principally involved. As a result of legislation regarding the proper ventilation of factories, human cases of gastro-intestinal or respiratory anthrax—invariably fatal in the past— are never seen in Britain. Factory legislation also ensures that protective clothing is worn and that workers are made familiar—by means of posters and individual cards—with the clinical appearances of the malignant pustule.
So far as the individual is concerned, great care must be taken in handling infected material. Workers with skin lesions should be excluded. Nurses or attendants must take all necessary precautions when handling infective discharges from the " pustule " or the respiratory and intestinal tracts. Contaminated dressings should be promptly burnt and discharges disinfected. Bedclothes, mattresses and bed linen must be subjected to steam disinfection.
Curative Treatment.—Penicillin alone proves adequate for practically all cases. Anti-anthrax serum (supplies of which are available in each hospital region) is not highly refined so that its administration is almost always followed by a serum reaction. It should not be used.
Large doses of benzylpenicillin are given, 0-5 to ro mega units four-hourly during the initial stages of treatment. The patient's temperature is not a reliable guide to the severity of the infection for it will often be normal. The best criterion is the amount of cedema. Further, in infections of the face and neck oedema has an additional significance as it may extend into the larynx and produce partial obstruction of the air way. As clinical improvement becomes obvious the dose of penicillin may be reduced but treatment should continue for 10 days.
Dressings are used because they reduce contamination of the bed linen. Instructions should be given for burning the scab when it separates. In the most severe cases there may be considerable sloughing so that skin grafting may be required.
Anthrax is not a notifiable disease, but information regarding cases occurring in factories and workshops must be forwarded to the Chief Inspector of Factories at the Home Office.
Preventive Treatment.—Although there is a considerable animal reservoir of infection in this country the disease is so well diagnosed by veterinarians that human anthrax from indigenous sources is very uncommon. By law, carcasses of infected animals must be either burned or deeply buried in lime and the area of ground fenced for some years. Thus, in the British Isles most cases arise from imported material—hides or bones being principally involved. As a result of legislation regarding the proper ventilation of factories, human cases of gastro-intestinal or respiratory anthrax—invariably fatal in the past— are never seen in Britain. Factory legislation also ensures that protective clothing is worn and that workers are made familiar—by means of posters and individual cards—with the clinical appearances of the malignant pustule.
So far as the individual is concerned, great care must be taken in handling infected material. Workers with skin lesions should be excluded. Nurses or attendants must take all necessary precautions when handling infective discharges from the " pustule " or the respiratory and intestinal tracts. Contaminated dressings should be promptly burnt and discharges disinfected. Bedclothes, mattresses and bed linen must be subjected to steam disinfection.
Curative Treatment.—Penicillin alone proves adequate for practically all cases. Anti-anthrax serum (supplies of which are available in each hospital region) is not highly refined so that its administration is almost always followed by a serum reaction. It should not be used.
Large doses of benzylpenicillin are given, 0-5 to ro mega units four-hourly during the initial stages of treatment. The patient's temperature is not a reliable guide to the severity of the infection for it will often be normal. The best criterion is the amount of cedema. Further, in infections of the face and neck oedema has an additional significance as it may extend into the larynx and produce partial obstruction of the air way. As clinical improvement becomes obvious the dose of penicillin may be reduced but treatment should continue for 10 days.
Dressings are used because they reduce contamination of the bed linen. Instructions should be given for burning the scab when it separates. In the most severe cases there may be considerable sloughing so that skin grafting may be required.
GENERAL MANAGEMENT OF THE FEBRILE STATE
GENERAL MANAGEMENT OF THE FEBRILE STATE
Although pyrexia, arising from interference with the function of the heat regulating centre, is usually a cardinal sign of an infection, in some of the most toxic cases the temperature may not rise above normal. Wasting, due to increased catabolism; dry hot skin, acceleration of the pulse and respiration; coated tongue, anorexia, vomiting and constipation or diarrhoea; headache, restlessness, insomnia and delirium; quantitative and qualitative changes in the urine; all these manifestations are a result of the reactions of the tissues of the host to the effects of the pathogen or its products.
In the general management of the febrile patient the essential needs are (a) rest; (b) efficient nursing ; (c) a suitable diet with adequate intake of water ; and {d) relief of symptoms.
Rest.—Confinement to bed is essential as long as the temperature remains elevated, and should be continued for a varying, but not prolonged, period in convalescence. Strict bed rest should never be regarded as an end in itself. When there is no obvious contraindication, early activity should be encouraged. The young patient is better to be up and properly dressed than to be continually in and out of bed without adequate clothing. In the elderly the real risks of a long period in bed far outweigh the potential risks of allowing a fair degree of freedom.
A single bed and firm mattress are preferable for nursing purposes. Careful bed-making contributes greatly to the patient's comfort. A length of plastic across the bed covered by a taut drawsheet will prevent extensive soiling and save linen. The bed should be made twice daily—oftener if the patient is perspiring profusely. An adequate supply of pillows will make for comfort. Bedclothes should be light and not tucked in tightly : a cage at the foot is often desirable. Quietness in the sickroom and its environment is essential; traffic in and out should be cut down to a minimum.
Ideally the sickroom should be bright and adequately ventilated and heated. Proximity to a bathroom, which should if possible be reserved for the patient's use, is advantageous. The temperature should be kept around 13° C. (55° F.) except in the case of infants or the aged, when it may be raised to between 15° to 18° C. (60° and 65° F.). Even when the room temperature is low the patient can be kept warm by hot-water bottles—and this is particularly appreciated by the elderly.
Nursing.—Practically all of the common infectious diseases, provided the illness is not unusually severe or complicated, are best treated at home. The mother will as a rule prove the best nurse. With modern therapy the period of heavy infectivity is comparatively short, so that the risk of spread of infection is slight. The mother should be given instructions in simple home nursing and, in particular, emphasis should be placed on the following points.
An overall should be worn when attending to the patient and should be hung conveniently near the door. A bowl of chloroxylenol or even plain water, with soap and towels, should also be adjacent to the door and the mother should be instructed to use this frequently for hand-washing. The practitioner should be careful to practise what he teaches. A simple temperature chart should be constructed ; the thermometer should be placed in the groin or the axilla and left in position for two minutes. All treatment ordered should be entered on the chart and precise instructions given regarding administration.The patient's skin should be kept clean by sponging with soap and warm water daily, especial care being paid to areas liable to soiling. These should be freely dusted with talcum powder. The body should be washed and dried limb by limb. The windows, of course, must be kept closed during the bathing process. The refreshing and soothing effect of a "blanket bath " of this nature is of inestimable value in any febrile condition. The seriously ill patient must have his position changed every two or three hours ; areas subject to pressure should be massaged with spirit and dried with talcum powder twice daily.
Food should be given at the usual meal times, but the individual patient's likes and dislikes must be noted. Any remaining scraps of food should be removed from the sickroom and burnt. Cold water, plain or with various flavourings, must be given freely. In young children the mouth should be gently cleansed after each meal by inserting the index finger enveloped in cotton-wool soaked in warm water or warm solution of bicarbonate of soda containing 2 g. (30 gr.) to 600 ml. In older children the teeth should be brushed and the mouth rinsed with warm water or mild antiseptic solution. The lips may be smeared with petroleum jelly.
Nasal discharge must be promptly removed preferably on paper handkerchiefs, and the nostrils gently cleaned with a cotton-wool swab soaked in' warm saline or bicarbonate solution. Older children should be encouraged to clear the nose by gentle blowing. Petroleum jelly applied to the nostrils and upper lips prevents crusting and excoriation.
The eyes may require regular cleansing, and saline swabbing is usually best. The very toxic or comatose patient often lies for long periods with the eyelids partially separated so that the cornea dries, and may become ulcerated. This can be prevented by instilling a drop of castor oil into the conjunctival sac.
All excreta should be removed from the sickroom and consigned to the closet as quickly as possible. Care must be taken to avoid contamination of water-closet seats. Specimens required for the physician's inspection should be placed in covered fly-proof receptacles. Bed-linen, towels, etc., which may have been soiled with excreta should be left soaking in weak lysol solution overnight before being thoroughly washed with soap and water. Swabs used for wiping away discharges from the mouth, nose, ears, eyes and other'organs must be burnt.
Flies must be excluded from the sickroom and, in summer, spraying with dicophane or some similar material is an important measure.
Diet.—The characteristic change in the metabolism of the fevered person is the greatly increased destruction of the nitrogen-containing tissues of the body. Instead of endeavouring to make good this loss by an increased nitrogen intake, it is a better policy to supply an abundance of " protein sparers " in the form of carbohydrates. Fevered patients strongly dislike fatty foods. On theoretical grounds a high caloric intake is indicated, but in practice, owing to loss of appetite and actual distaste for food, this is impossible to attain during the height of the fever.
When the febrile period does not exceed four or five days (and, it may be noted, this is now usual with specific therapy), the diet should be restricted to fluids and " feeding up " is to be deprecated. One and a half to three pints of milk daily usually form the basis of the diet. Not more than 150 to 180 ml. (5 to 6 fl. oz.) should be given at a feed. Glucose is a most valuable and easily assimilated food, which should be given freely in the form of sweetened lemon or orange juice drinks. From 150 to 300 g. (5 to 10 oz.) of glucose can readily be administered in the 24 hours. Jellies, clear soups, eggs and custards are useful additions to the diet, and varying flavouring agents can add spice to an otherwise monotonous round. Because of their low nutritive value, high content of extractives and relative cost, the various commercial beef-juice preparations have little to commend them.
The free intake of water favours the elimination of waste-products. Hence the patient should be encouraged to drink cold or hot water freely between feeds. Including glucose lemonade, the water intake should amount to at least 2 to 3 litres in the 24 hours. The best indication of an adequate fluid intake is the excretion of i -5 to 2 litres of urine daily. Alcohol should not be administered as a routine.
Relief of Symptoms.—Pyrexia.—A raised body temperature is in itself not harmful. The presence of fever is a natural reaction to infection and it should be assumed that the restoration of a normal temperature by means of antipyretic drugs is never desirable.
When the temperature exceeds 39-5° C. (103° F.), the skin of the whole body should be sponged with warm (37° C., 98° F.), tepid (27° C., 80° F.), or even cold water. Quite apart from any effect in reducing temperature, the application of tepid or cold water to the skin exerts an important reflex tonic effect on the nervous, respiratory and circulatory systems, and is very refreshing. This is particularly important at night, and a tepid sponge-down will often soothe a restless patient and be followed by a period of sound sleep.
Headache and Malaise.—A combination of 0-6 g. (10 gr.) of acetylsalicylic acid and 15 mg. (1/4 gr.) of codeine administered at intervals of six hours usually gives relief. Should headache persist, phenacetin, caffeine and phenazone, 0.2 g. (3 gr) of each dihydrocodeine (10-30 mg.), may be prescribed in place of the above ; the dose to be repeated every two hours for three or four doses. The severe headache which occurs in meningitis will require more potent drugs. When headache is severe, a quiet environment and the exclusion of bright light add to the comfort of the patient.
Imomnia and Delirium.—Restlessness and inability to sleep are characteristic symptoms in febrile cases and should always be taken seriously. Nursing technique should first be reviewed and everything done to make the patient comfortable. Where sleeplessness is due to worry or anxiety, some whisky diluted with hot water followed by i g. (15 gr.) of chloral hydrate is frequently successful. The relief of headache may cure the insomnia. If pain is keeping the patient awake, i ml. (15 min.) of tincture of opium may be added to the chloral mixture ; relief may only be obtained by the hypodermic injection of 10 to 15 mg. ( 1/6 to ¼ gr.) of morphine.
Paraldehyde, 8 ml., is another excellent and safe hypnotic; unfortunately it has a most unpleasant taste and odour. It may be administered by mouth well diluted with whisky or brandy and water, or by the rectum in double the oral dose. Cyclobarbitone, in a dose of 0.1 to 0.2 g. (1 ½ to 3 gr.), and butobarbitone, 0.1 g. (1 1/2 gr.), are valuable for their general sedative as well as their hypnotic effect and although the thoughtless use of tranquillizers is to be deprecated, promazine (50 mg.) and perphenazine (2, mg.) are valuable in the control of delirium especially in the elderly.
Mild confusion can usually be controlled by chloral and tincture of opium, but active delirium calls for the hypodermic injection of 15 mg. ( ¼ gr.) of morphine with, in cases of maniacal excitement, the addition of 0-6 mg. ( 1/100 gr.) of hyoscine hydrobromide ; the injection may be repeated after an interval of one hour Nausea and Vomiting.—Common initial symptoms in many febrile conditions, nausea and vomiting are seldom sufficiently severe or persistent to cause anxiety once specific therapy has been started. (The occurrence of vomiting can have great importance when the intention is to give specific treatment by mouth for, of course, much of the oral dose may be lost. Its presence should, therefore, always be elicited and the nurse attendant specifically instructed to report the matter.)
When vomiting is persistent arid severe, the electrolyte disturbance may require to be rectified by intravenous infusions. This demands the closest co-operation between biochemist and clinician and is in general beyond the scope of domiciliary practice .
Constipation.—Constipation is present during the course of many infectious fevers. It is seldom a matter of much importance though it may cause the patient great concern. During a severe illness it is usually better to empty the bowel by an enema than by the administration of purgatives.
In convalescence from a severe fever a patient may become excessively anxious about constipation. He should be reassured that his normal bowel habit will be regained. One of the anthracene purgatives may be given temporarily such as a teaspoonful of the elixir of cascara or two Senokot tablets at night.
Disinfection.—Although the aim of disinfectants is to destroy the micro-organisms released from the patient in his various discharges and excretions, it must be realized that as generally used they are not very effective. Many spores resist their action, viruses vary considerably in their susceptibility to them and the physical properties of the excretions themselves usually impair their lethal effect. Nevertheless, in the management of infectious diseases in the home, disinfectants have a limited place in reducing the contamination of objects surrounding the patient. As a rule the aim is to eliminate the vegetative forms of bacteria, and spores do not constitute a serious problem.
The most useful disinfectants are : Chloroxylenol (B.P.C.) a phenol-related substance which makes a pleasant disinfectant for hand-washing and damp-dusting and which is particularly effective against gram-positive but not against most gram-negative organisms; lysol and its allied preparations which are valuable general-purpose disinfectants for bed linen, etc., but which must not be brought into contact with the skin; hypochlorites which are useful in dealing with dishes and glassware, but to be effective must be mixed with a detergent; and chlorhexidine or hexachlorophane which have gained a wide popularity and are often contained in soaps, handcreams and dusting powders. They are specially effective against gram-positive organisms and, since Staph. aureus can be so dangerous in nurseries, they are of value in the care of the newborn. To be of greatest benefit they must be used repeatedly. The most important point to realize is that no disinfectant can be regarded as serving all purposes and that none is a sterilizing agent. Sunlight, fresh air and soap and water are equally important.
The Attendant.—The attendant must be instructed in the importance of observing some simple rules. The hands will become grossly contaminated by bed-manipulations, cleansing of discharges, etc., and the importance of washing the hands after any attention to the patient must be emphasized. An overall or gown must be put on as soon as the sickroom is entered and removed before leaving. The fact that the air and dust of the room is charged with infection should be explained to the attendant. Damp-dusting, wet-mopping of floor surrounds and the avoidance of " brush and pan" should be insisted on. Vacuum cleaners are an asset—but when they are used, it must be remembered that the contents of the bag are heavily infected and that it should therefore be emptied with as little disturbance of the dust as possible.
The attendant must in this way be " inoculated " with the concept that the patient is the centre of a series of concentric circles of infection : this is most dense at the inner circle, and the constant endeavour must be to prevent spread outwards. The air and dust of the room form the important means whereby the outer circles become contaminated, so that all steps to reduce dust and the careless circulation of air which disturbs dust will tend to limit spread. These measures are not only of importance in preventing the infection of others; the patient himself, especially if nursed alongside other patients, may acquire. secondary complications from the implantation (particularly in the respiratory tract) of organisms acquired from infected dust.
The use of a mask by the attendant is as a rule undesirable. If the attendant has a cold and the patient is under the age of a year, a mask is worth while, for at this period of life a very ill infant may have its chances of recovery reduced by the acquisition of secondary infection. An effective paper mask is now available which can be destroyed after use. It should only be used once and should not be touched by the hands when being worn. The wearing of a mask is often thought to infer a special efficiency in preventing infection, but it is worth' emphasizing that among careless or untrained attendants the''mask may constitute more of a danger than a safeguard.
The Patient.—All discharges emanating from the patient must be assumed to be infective. Attention should be particularly directed to :
Coughing and sneezing should be guarded by the use of paper handkerchiefs. Sputum as well as nasal, aural or ocular discharges should be carefully collected in paper handkerchiefs and placed in paper bags to be burnt.
Vomitus should, if possible, be collected in a basin and immediately disposed of. The basin should be disinfected by wiping with weak lysol and washing in hot soapy water. If the linen is soiled, it should be steeped in disinfectant and ' then washed. Children who are ill often vomit unexpectedly, and the bed-linen may be saved by the use of towels, old sheets and pieces of plastic sheeting at the top of the bed or cot. Faeces and faeces-soiled bed linen must be promptly disinfected.
Strict asepsis is of course essential in attending to wounds. Steps should be taken to avoid soiling of pillows and bed linen with discharge, for as this dries it may be shaken off to form infected dust. All fluids removed for testing (blood, cerebrospinal fluid) must be handled carefully and sent to the laboratory as speedily as possible.Articles closely associated with the Patient.—The most important of these are the bedclothes, linen, towels, etc. All of them become heavily contaminated and, if the bed is made vigorously, organisms will be liberated into the air of the room. The enclosing of the blankets in linen sheets will tend to limit the amount of fluff disseminated when beds are made. The attendant should be instructed to avoid vigorous movements of bedclothes, mattresses, etc. Feeding utensils are best kept separately for the patient. After each meal the dishes should be washed and scalded by pouring a kettleful of boiling water over them. Toys and comic papers are a possible source of transfer of infection in children. Books and papers should be burnt, and most toys can be adequately disinfected with soap and water at the end of the illness.Final Domestic Cleansing.—A thorough domestic cleansing is all that is required for those infections which can be treated in the home. The process of laundering will effectively purify all bed linen, clothing, etc. Bulky articles such as mattresses and carpets can be exposed to fresh air, and the vacuum cleaner will be effective for cleaning. Sprays and gases have no place in the ritual except in the case of smallpox when the responsibility will rest with the Medical Officer of Health.
Although pyrexia, arising from interference with the function of the heat regulating centre, is usually a cardinal sign of an infection, in some of the most toxic cases the temperature may not rise above normal. Wasting, due to increased catabolism; dry hot skin, acceleration of the pulse and respiration; coated tongue, anorexia, vomiting and constipation or diarrhoea; headache, restlessness, insomnia and delirium; quantitative and qualitative changes in the urine; all these manifestations are a result of the reactions of the tissues of the host to the effects of the pathogen or its products.
In the general management of the febrile patient the essential needs are (a) rest; (b) efficient nursing ; (c) a suitable diet with adequate intake of water ; and {d) relief of symptoms.
Rest.—Confinement to bed is essential as long as the temperature remains elevated, and should be continued for a varying, but not prolonged, period in convalescence. Strict bed rest should never be regarded as an end in itself. When there is no obvious contraindication, early activity should be encouraged. The young patient is better to be up and properly dressed than to be continually in and out of bed without adequate clothing. In the elderly the real risks of a long period in bed far outweigh the potential risks of allowing a fair degree of freedom.
A single bed and firm mattress are preferable for nursing purposes. Careful bed-making contributes greatly to the patient's comfort. A length of plastic across the bed covered by a taut drawsheet will prevent extensive soiling and save linen. The bed should be made twice daily—oftener if the patient is perspiring profusely. An adequate supply of pillows will make for comfort. Bedclothes should be light and not tucked in tightly : a cage at the foot is often desirable. Quietness in the sickroom and its environment is essential; traffic in and out should be cut down to a minimum.
Ideally the sickroom should be bright and adequately ventilated and heated. Proximity to a bathroom, which should if possible be reserved for the patient's use, is advantageous. The temperature should be kept around 13° C. (55° F.) except in the case of infants or the aged, when it may be raised to between 15° to 18° C. (60° and 65° F.). Even when the room temperature is low the patient can be kept warm by hot-water bottles—and this is particularly appreciated by the elderly.
Nursing.—Practically all of the common infectious diseases, provided the illness is not unusually severe or complicated, are best treated at home. The mother will as a rule prove the best nurse. With modern therapy the period of heavy infectivity is comparatively short, so that the risk of spread of infection is slight. The mother should be given instructions in simple home nursing and, in particular, emphasis should be placed on the following points.
An overall should be worn when attending to the patient and should be hung conveniently near the door. A bowl of chloroxylenol or even plain water, with soap and towels, should also be adjacent to the door and the mother should be instructed to use this frequently for hand-washing. The practitioner should be careful to practise what he teaches. A simple temperature chart should be constructed ; the thermometer should be placed in the groin or the axilla and left in position for two minutes. All treatment ordered should be entered on the chart and precise instructions given regarding administration.The patient's skin should be kept clean by sponging with soap and warm water daily, especial care being paid to areas liable to soiling. These should be freely dusted with talcum powder. The body should be washed and dried limb by limb. The windows, of course, must be kept closed during the bathing process. The refreshing and soothing effect of a "blanket bath " of this nature is of inestimable value in any febrile condition. The seriously ill patient must have his position changed every two or three hours ; areas subject to pressure should be massaged with spirit and dried with talcum powder twice daily.
Food should be given at the usual meal times, but the individual patient's likes and dislikes must be noted. Any remaining scraps of food should be removed from the sickroom and burnt. Cold water, plain or with various flavourings, must be given freely. In young children the mouth should be gently cleansed after each meal by inserting the index finger enveloped in cotton-wool soaked in warm water or warm solution of bicarbonate of soda containing 2 g. (30 gr.) to 600 ml. In older children the teeth should be brushed and the mouth rinsed with warm water or mild antiseptic solution. The lips may be smeared with petroleum jelly.
Nasal discharge must be promptly removed preferably on paper handkerchiefs, and the nostrils gently cleaned with a cotton-wool swab soaked in' warm saline or bicarbonate solution. Older children should be encouraged to clear the nose by gentle blowing. Petroleum jelly applied to the nostrils and upper lips prevents crusting and excoriation.
The eyes may require regular cleansing, and saline swabbing is usually best. The very toxic or comatose patient often lies for long periods with the eyelids partially separated so that the cornea dries, and may become ulcerated. This can be prevented by instilling a drop of castor oil into the conjunctival sac.
All excreta should be removed from the sickroom and consigned to the closet as quickly as possible. Care must be taken to avoid contamination of water-closet seats. Specimens required for the physician's inspection should be placed in covered fly-proof receptacles. Bed-linen, towels, etc., which may have been soiled with excreta should be left soaking in weak lysol solution overnight before being thoroughly washed with soap and water. Swabs used for wiping away discharges from the mouth, nose, ears, eyes and other'organs must be burnt.
Flies must be excluded from the sickroom and, in summer, spraying with dicophane or some similar material is an important measure.
Diet.—The characteristic change in the metabolism of the fevered person is the greatly increased destruction of the nitrogen-containing tissues of the body. Instead of endeavouring to make good this loss by an increased nitrogen intake, it is a better policy to supply an abundance of " protein sparers " in the form of carbohydrates. Fevered patients strongly dislike fatty foods. On theoretical grounds a high caloric intake is indicated, but in practice, owing to loss of appetite and actual distaste for food, this is impossible to attain during the height of the fever.
When the febrile period does not exceed four or five days (and, it may be noted, this is now usual with specific therapy), the diet should be restricted to fluids and " feeding up " is to be deprecated. One and a half to three pints of milk daily usually form the basis of the diet. Not more than 150 to 180 ml. (5 to 6 fl. oz.) should be given at a feed. Glucose is a most valuable and easily assimilated food, which should be given freely in the form of sweetened lemon or orange juice drinks. From 150 to 300 g. (5 to 10 oz.) of glucose can readily be administered in the 24 hours. Jellies, clear soups, eggs and custards are useful additions to the diet, and varying flavouring agents can add spice to an otherwise monotonous round. Because of their low nutritive value, high content of extractives and relative cost, the various commercial beef-juice preparations have little to commend them.
The free intake of water favours the elimination of waste-products. Hence the patient should be encouraged to drink cold or hot water freely between feeds. Including glucose lemonade, the water intake should amount to at least 2 to 3 litres in the 24 hours. The best indication of an adequate fluid intake is the excretion of i -5 to 2 litres of urine daily. Alcohol should not be administered as a routine.
Relief of Symptoms.—Pyrexia.—A raised body temperature is in itself not harmful. The presence of fever is a natural reaction to infection and it should be assumed that the restoration of a normal temperature by means of antipyretic drugs is never desirable.
When the temperature exceeds 39-5° C. (103° F.), the skin of the whole body should be sponged with warm (37° C., 98° F.), tepid (27° C., 80° F.), or even cold water. Quite apart from any effect in reducing temperature, the application of tepid or cold water to the skin exerts an important reflex tonic effect on the nervous, respiratory and circulatory systems, and is very refreshing. This is particularly important at night, and a tepid sponge-down will often soothe a restless patient and be followed by a period of sound sleep.
Headache and Malaise.—A combination of 0-6 g. (10 gr.) of acetylsalicylic acid and 15 mg. (1/4 gr.) of codeine administered at intervals of six hours usually gives relief. Should headache persist, phenacetin, caffeine and phenazone, 0.2 g. (3 gr) of each dihydrocodeine (10-30 mg.), may be prescribed in place of the above ; the dose to be repeated every two hours for three or four doses. The severe headache which occurs in meningitis will require more potent drugs. When headache is severe, a quiet environment and the exclusion of bright light add to the comfort of the patient.
Imomnia and Delirium.—Restlessness and inability to sleep are characteristic symptoms in febrile cases and should always be taken seriously. Nursing technique should first be reviewed and everything done to make the patient comfortable. Where sleeplessness is due to worry or anxiety, some whisky diluted with hot water followed by i g. (15 gr.) of chloral hydrate is frequently successful. The relief of headache may cure the insomnia. If pain is keeping the patient awake, i ml. (15 min.) of tincture of opium may be added to the chloral mixture ; relief may only be obtained by the hypodermic injection of 10 to 15 mg. ( 1/6 to ¼ gr.) of morphine.
Paraldehyde, 8 ml., is another excellent and safe hypnotic; unfortunately it has a most unpleasant taste and odour. It may be administered by mouth well diluted with whisky or brandy and water, or by the rectum in double the oral dose. Cyclobarbitone, in a dose of 0.1 to 0.2 g. (1 ½ to 3 gr.), and butobarbitone, 0.1 g. (1 1/2 gr.), are valuable for their general sedative as well as their hypnotic effect and although the thoughtless use of tranquillizers is to be deprecated, promazine (50 mg.) and perphenazine (2, mg.) are valuable in the control of delirium especially in the elderly.
Mild confusion can usually be controlled by chloral and tincture of opium, but active delirium calls for the hypodermic injection of 15 mg. ( ¼ gr.) of morphine with, in cases of maniacal excitement, the addition of 0-6 mg. ( 1/100 gr.) of hyoscine hydrobromide ; the injection may be repeated after an interval of one hour Nausea and Vomiting.—Common initial symptoms in many febrile conditions, nausea and vomiting are seldom sufficiently severe or persistent to cause anxiety once specific therapy has been started. (The occurrence of vomiting can have great importance when the intention is to give specific treatment by mouth for, of course, much of the oral dose may be lost. Its presence should, therefore, always be elicited and the nurse attendant specifically instructed to report the matter.)
When vomiting is persistent arid severe, the electrolyte disturbance may require to be rectified by intravenous infusions. This demands the closest co-operation between biochemist and clinician and is in general beyond the scope of domiciliary practice .
Constipation.—Constipation is present during the course of many infectious fevers. It is seldom a matter of much importance though it may cause the patient great concern. During a severe illness it is usually better to empty the bowel by an enema than by the administration of purgatives.
In convalescence from a severe fever a patient may become excessively anxious about constipation. He should be reassured that his normal bowel habit will be regained. One of the anthracene purgatives may be given temporarily such as a teaspoonful of the elixir of cascara or two Senokot tablets at night.
Disinfection.—Although the aim of disinfectants is to destroy the micro-organisms released from the patient in his various discharges and excretions, it must be realized that as generally used they are not very effective. Many spores resist their action, viruses vary considerably in their susceptibility to them and the physical properties of the excretions themselves usually impair their lethal effect. Nevertheless, in the management of infectious diseases in the home, disinfectants have a limited place in reducing the contamination of objects surrounding the patient. As a rule the aim is to eliminate the vegetative forms of bacteria, and spores do not constitute a serious problem.
The most useful disinfectants are : Chloroxylenol (B.P.C.) a phenol-related substance which makes a pleasant disinfectant for hand-washing and damp-dusting and which is particularly effective against gram-positive but not against most gram-negative organisms; lysol and its allied preparations which are valuable general-purpose disinfectants for bed linen, etc., but which must not be brought into contact with the skin; hypochlorites which are useful in dealing with dishes and glassware, but to be effective must be mixed with a detergent; and chlorhexidine or hexachlorophane which have gained a wide popularity and are often contained in soaps, handcreams and dusting powders. They are specially effective against gram-positive organisms and, since Staph. aureus can be so dangerous in nurseries, they are of value in the care of the newborn. To be of greatest benefit they must be used repeatedly. The most important point to realize is that no disinfectant can be regarded as serving all purposes and that none is a sterilizing agent. Sunlight, fresh air and soap and water are equally important.
The Attendant.—The attendant must be instructed in the importance of observing some simple rules. The hands will become grossly contaminated by bed-manipulations, cleansing of discharges, etc., and the importance of washing the hands after any attention to the patient must be emphasized. An overall or gown must be put on as soon as the sickroom is entered and removed before leaving. The fact that the air and dust of the room is charged with infection should be explained to the attendant. Damp-dusting, wet-mopping of floor surrounds and the avoidance of " brush and pan" should be insisted on. Vacuum cleaners are an asset—but when they are used, it must be remembered that the contents of the bag are heavily infected and that it should therefore be emptied with as little disturbance of the dust as possible.
The attendant must in this way be " inoculated " with the concept that the patient is the centre of a series of concentric circles of infection : this is most dense at the inner circle, and the constant endeavour must be to prevent spread outwards. The air and dust of the room form the important means whereby the outer circles become contaminated, so that all steps to reduce dust and the careless circulation of air which disturbs dust will tend to limit spread. These measures are not only of importance in preventing the infection of others; the patient himself, especially if nursed alongside other patients, may acquire. secondary complications from the implantation (particularly in the respiratory tract) of organisms acquired from infected dust.
The use of a mask by the attendant is as a rule undesirable. If the attendant has a cold and the patient is under the age of a year, a mask is worth while, for at this period of life a very ill infant may have its chances of recovery reduced by the acquisition of secondary infection. An effective paper mask is now available which can be destroyed after use. It should only be used once and should not be touched by the hands when being worn. The wearing of a mask is often thought to infer a special efficiency in preventing infection, but it is worth' emphasizing that among careless or untrained attendants the''mask may constitute more of a danger than a safeguard.
The Patient.—All discharges emanating from the patient must be assumed to be infective. Attention should be particularly directed to :
Coughing and sneezing should be guarded by the use of paper handkerchiefs. Sputum as well as nasal, aural or ocular discharges should be carefully collected in paper handkerchiefs and placed in paper bags to be burnt.
Vomitus should, if possible, be collected in a basin and immediately disposed of. The basin should be disinfected by wiping with weak lysol and washing in hot soapy water. If the linen is soiled, it should be steeped in disinfectant and ' then washed. Children who are ill often vomit unexpectedly, and the bed-linen may be saved by the use of towels, old sheets and pieces of plastic sheeting at the top of the bed or cot. Faeces and faeces-soiled bed linen must be promptly disinfected.
Strict asepsis is of course essential in attending to wounds. Steps should be taken to avoid soiling of pillows and bed linen with discharge, for as this dries it may be shaken off to form infected dust. All fluids removed for testing (blood, cerebrospinal fluid) must be handled carefully and sent to the laboratory as speedily as possible.Articles closely associated with the Patient.—The most important of these are the bedclothes, linen, towels, etc. All of them become heavily contaminated and, if the bed is made vigorously, organisms will be liberated into the air of the room. The enclosing of the blankets in linen sheets will tend to limit the amount of fluff disseminated when beds are made. The attendant should be instructed to avoid vigorous movements of bedclothes, mattresses, etc. Feeding utensils are best kept separately for the patient. After each meal the dishes should be washed and scalded by pouring a kettleful of boiling water over them. Toys and comic papers are a possible source of transfer of infection in children. Books and papers should be burnt, and most toys can be adequately disinfected with soap and water at the end of the illness.Final Domestic Cleansing.—A thorough domestic cleansing is all that is required for those infections which can be treated in the home. The process of laundering will effectively purify all bed linen, clothing, etc. Bulky articles such as mattresses and carpets can be exposed to fresh air, and the vacuum cleaner will be effective for cleaning. Sprays and gases have no place in the ritual except in the case of smallpox when the responsibility will rest with the Medical Officer of Health.
INFECTIOUS DISEASES AND TREAMENT
WHEN DISEASE is the result of invasion of the human tissues by bacteria and other micro-organisms, the condition is called an infection. Those infections which are transmitted naturally from one person to another are broadly classed " infectious diseases ". For various reasons, including administrative expediency, a number of these diseases are regarded as the responsibility of special hospitals—the infectious diseases hospitals. Although the classification is arbitrary rather than strictly scientific, it accounts for the selection of diseases included in this chapter. It also explains, why venereal diseases, tuberculosis, parasitic infections and tropical diseases are dealt with elsewhere in this site.
The more we know about the natural history of infections, the more rational is our treatment likely to be ; and we shall be more skilful in protecting our patients against the hazards of complications. Stated briefly, the effects of bacterial invasion are determined principally by the virulence of the microorganism and the efficiency of the defense mechanism of the host. There is a very wide range of possibilities: infection may occur without perceptible illness; and at the other end of the scale the infection may overwhelm the body defenses and cause death in a few hours.
An acute infection may thus be regarded as a struggle between a susceptible host and a pathogenic organism. To achieve success, whether in prevention or treatment, it is necessary to realize that measures which enhance the recuperative capacity of the host are no less important than those which diminish the attacking power of the micro-organism. The febrile period is so short—following effective chemotherapy—that the value of general nursing management is easily overlooked ; but there is no doubt of its importance in severe infection with constitutional upset.
At the outset, it is worth while to draw attention to an important contrast between bacterial and viral infections. In almost all bacterial infections the organism remains mainly extracellular and can thus be reached with comparative ease by substances which are present in the blood stream. Although it is reasonable to assume that there is a temporary stage of virasmia in many of the virus diseases, the causative organism is capable of growth only inside the cell so that it rapidly becomes inaccessible to the usual methods of treatment. Such localization of the virus in body cells has often occurred by the time the infection becomes manifest, and up to the present no practicable method has been devised of modifying the effect after the cell has been invaded. The . specific treatment of nearly all virus diseases therefore still remains beyond our reach. Cellular damage by a virus may be followed by secondary bacterial infection. This complication may call for the use of specific therapy; and such treatment is often used preventively—in anticipation of bacterial invasion.
The more we know about the natural history of infections, the more rational is our treatment likely to be ; and we shall be more skilful in protecting our patients against the hazards of complications. Stated briefly, the effects of bacterial invasion are determined principally by the virulence of the microorganism and the efficiency of the defense mechanism of the host. There is a very wide range of possibilities: infection may occur without perceptible illness; and at the other end of the scale the infection may overwhelm the body defenses and cause death in a few hours.
An acute infection may thus be regarded as a struggle between a susceptible host and a pathogenic organism. To achieve success, whether in prevention or treatment, it is necessary to realize that measures which enhance the recuperative capacity of the host are no less important than those which diminish the attacking power of the micro-organism. The febrile period is so short—following effective chemotherapy—that the value of general nursing management is easily overlooked ; but there is no doubt of its importance in severe infection with constitutional upset.
At the outset, it is worth while to draw attention to an important contrast between bacterial and viral infections. In almost all bacterial infections the organism remains mainly extracellular and can thus be reached with comparative ease by substances which are present in the blood stream. Although it is reasonable to assume that there is a temporary stage of virasmia in many of the virus diseases, the causative organism is capable of growth only inside the cell so that it rapidly becomes inaccessible to the usual methods of treatment. Such localization of the virus in body cells has often occurred by the time the infection becomes manifest, and up to the present no practicable method has been devised of modifying the effect after the cell has been invaded. The . specific treatment of nearly all virus diseases therefore still remains beyond our reach. Cellular damage by a virus may be followed by secondary bacterial infection. This complication may call for the use of specific therapy; and such treatment is often used preventively—in anticipation of bacterial invasion.
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