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  • Professor, Neurology UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA

Petroleum 1 ounce Oil Juniper 1 dram Oil of Terebinth 1 ounce Oil Amber 4 ounces Linseed Oil 12 ounces Mix prandin 2mg low cost diabetes definition ada 2014. Smartweed 10 drams Alcohol 6 ounces Water 2 ounces Camphor 22-1/2 grains Oil of Hemlock 30 drops Oil of Sassafras 30 drops Extract the smartweed with the alcohol and water and to prandin 2mg discount diabetes mellitus definition the liquid obtained add the camphor and oils generic prandin 2mg fast delivery blood sugar quotes. Our busy life quality 2mg prandin blood sugar 88, our manner of dress, with all its attending demands are causing havoc with the health of women who are under its terrible strain. The number of women undergoing operations in our public and private hospitals from day to day bears witness to the ravages of the strenuous social life and mute testimony of the neglect of the laws of nature. Good health is the fruition of eternal vigilance and a blessing that money cannot buy. The conduct and health of our women represents the life of our nation; individually, in a measure at least, health governs the happiness of the home. Steele says: "All a woman has to do in this world is contained within the duties of a daughter, a sister, a wife, and a mother. Before puberty the girl should be taught to lead a life that will make her strong and healthy to prepare her for the coming strain upon her system. Do not offer prizes for high marks and otherwise add to the pressure of the present school system. A cheerful mind, plenty of fresh air and sunshine is more important at this period than school work. It is so called from its resemblance to a basin, is stronger and, more massively constructed than either the skull or chest cavity; it is a bony ring, interposed between the lower end of the spine, which it supports, and the lower extremities, upon which it rests. It is composed of four bones, the two innominated, (nameless), which bound it on either side and in front, and the Sacrum and Coccyx, which complete it behind. The cavity of the pelvis contains the bladder, the rectum, and some of the generative organs peculiar to each sex and some windings of the small intestine; they are partially covered by the peritoneum (lining membrane of the abdominal cavity). They join at each extremity, forming the anterior and posterior commissures (uniting together). Between the posterior commissure (union) and the margin of the bowel is a space of about an inch in extent, the Perineum. It is important to remember this part, for it is often torn in labor, to a greater or less extent. At their convergence at the clitoris each lip (labium) divides into two folds and these surround the glans (clitoris) forming its covering (prepuce) above and the bridle (frenum) below. They contain a network of vessels and numerous large mucous crypts (small sacs or follicles) which secrete a quantity of (fatty) matter. The clitoris is surmounted by a small tubercle (a small nodule) of spongy erectile tissue, the "glans clitoris," Two cavernous bodies of erectile tissue enclosed in dense fibrous tissue compose the body of the organ. The Hymen is a thin fold of mucous membrane of half moon in shape (semi-lunar) and is spread across the lower opening of the vagina. The Glands of Bartholin are small oblong bodies, two in number, situated on each side of the commencement of the vagina above the deep fascia band like tissue. Each gland has a single duct and by this duct opens the inner surface of the adjacent labia minoris just external to the hymen. They are made up of mucous glands and a colorless tenacious fluid is secreted by them, which lubricates the vagina. It is four to six inches in length, the anterior wall being from one to two inches shorter than the posterior. It lies in the cavity of the pelvis in front of the rectum, behind the bladder and follows first the line of axis of the cavity of the pelvis, and afterwards the axis of the outlet. The vagina consists of an internal mucous lining (membrane) continuous above with the mucous membrane lining the womb and below with the covering of the labia majora. The next covering (inward) is a muscular coat consisting of two layers-an external longitudinal and an internal circular. The lower end of the vagina is surrounded by a band of striped muscular fibers comprising the sphincter muscle of the vagina (sphincter vagina). The womb is the organ of pregnancy, and receives the fruitful egg (ovum), supports it during its development and expels it at the time of labor (parturition). Its upper broad extremity is called the fundus-base of the organ, and the lower, constricted, narrowed portion is called the Cervix (neck or constricted portion). Its anterior surface is covered on its upper three-quarters by the peritoneum, while the lower fourth is connected with the bladder. The womb is held up (suspended) in the pelvis by ligaments; two anterior, womb and bladder (utero-vesical), two posterior, womb-sacral (utero-sacral), two lateral broad ligaments, and two round ligaments. The womb sacral (utero-sacral) which holds the womb well up in the hollow of the sacrum and the round ligaments which keep the womb well forward enter most actively into the support of the womb. The round ligaments are strong muscular fibrous cords and serve to hold the womb forward. When pregnancy exists they increase in size with the womb, and keep the fundus forward in its excursion upwards into the abdominal cavity, and after confinement, become smaller with the womb, guiding the womb back again to its regular position. The broad ligaments are little more than reflection of the peritoneum serving to support the vessels that nourish, as they go to and from the womb. This cavity of the womb is small by comparison with the size of the organ and it communicates with the Fallopian tubes by two minute openings at each side of the body, and with the vagina below, through the mouth or opening of the womb. The external coat of the womb is called servos, derived from the peritoneum; the middle or muscular coat, which forms the chief substance of the womb, consists of bundles of unstripped muscular fibers intermixed, with loose connective tissue, blood vessels, lymphatics and nerves; the internal or mucous coat is continuous through the fringed extremity of the fallopian tubes, with the peritoneum, and through the mouth of the womb (os uteri) with the mucous membrane of the vagina. This mucous membrane is lined in the body of the womb by epithelium arrayed in columns (Columnar Epithelium) which loses its ciliated (eye-lash) movement character during pregnancy. In the lower half of the Cervix, the epithelium (this kind of cell lines all canals having communication with the external air) is of the stratified (arranged in layers) variety.

This factor is classified as one of the most important adherence mechanisms in the colonisation of the host surface purchase prandin 1 mg overnight delivery blood sugar test kit. Candida krusei is more hydrophobic compared to purchase prandin 1 mg on line blood sugar tester monitor other medically important Candida sp buy 2mg prandin overnight delivery diabetes organization. Candida krusei was reported to prandin 2 mg low price diabetes symptoms urinary tract infection possess the same hydrophobicity level with Candida glabrata and Candida tropicalis but is more hydrophobic compared to Candida albicans and Candida parapsilosis. The enzymes include aspartyl proteinase, phospholipases, lipases, phosphomonoesterase and hexosaminidase (Williams et al. Among these enzymes, aspartyl proteinase has attracted most interest and is widely considered to be central in the development of candidal infection. This enzyme has the ability to attack host and also contributes as a defence system of yeast. Examples of candidal species possessing this enzyme are Candida albicans and Candida krusei (Samaranayake, 1994). Another important hydrolytic enzyme is phospholipase which is identified as an enzyme that attacks the host tissue. This enzyme activity has been observed in many fungal pathogens including Candida sp. Phospholipase A and C can be found in Candida albicans; however, there is no evidence that shows the activity of phospholipase B and D in candidal species (Samaranayake, 1994). Phospholipase A can attack cell membranes and can be easily found on the cell surface especially at the sites of bud formation. Hence, the enzyme activity can be enhanced when the hyphae are in direct contact with the host tissue (Williams et al. This pathogenic yeast has been detected as an oral commensal and represented between 10% to 15% of yeasts isolated from the oral cavity of human. Since the 1960s, Candida krusei has emerged as a pathogen associated with the development of oral candidosis (Samaranayake, 1994). The strain is recognised as the causative agent of thrush which infects the mucosal layer including tongue, lips, gums or palate. The association of this numerous generic and variable species of microorganisms and the lesion formed in the oral cavity is called ?thrush fungus (Odds, 1988). Candida krusei has been discovered since 1839 by Langenbeck and was firstly isolated from the buccal epithelial layer in a typhus patient. However, it was unclassified as pathogenic to human until 75 years later when Castellani found that the strain was actually a commensal in warm-blooded animals (Castellani, 1912; Samaranayake and Samaranayake, 1994). In general, the yeast morphology of Candida krusei comprises of asexual and sexual species. The sexual form was renamed as Issatchenkia orientalis whereas the asexual form had remained as Candida krusei (Odds and Merson-Davies, 1989). The appearance of this cell is shared with Candida kefyr or also known as Candida pseudotropicalis (Samaranayake, 1997). The ultra structure of Candida krusei comprised of a six-layered cell wall with a few intra-cytoplasmic organelles including small vesicles, lipid droplets, ribosomes and glycogen-like particles (Joshi et al. The multilayered cell wall of Candida krusei comprise of an outer irregular coat of flocculent material, an electron dense zone, a granular layer, less granular layer, a thin layer of dense granules and another sparsely granular layer outside the trilaminar cell membrane (Samaranayake and Samaranayake, 1994). Chlamydiospores is a thick-walled spherical cell with approximately 10 ?m in diameter (Melville and Russells, 1975). In many causes however, Candida krusei is usually found in only two basic morphological forms which are the yeast and pseudohyphae forms. Pseudohyphae are important in the adherence of cells to the surfaces of the host (Soll, 1992; Dede and Okungbowa, 2009). Both characteristics may however appear simultaneously thus making it difficult to differentiate between these two basic characteristics. A characteristic that gives advantage to Candida krusei is that it can grow in vitamin-free media, which is a major contrasting feature from the other clinically important Candida sp. It is also reported that from a wide panel of carbohydrates component Candida krusei can only ferment glucose (Barnett et al. It has been shown that when saliva is supplemented with glucose, a number of short-chain 18 carboxylic acids such as acetate, pyruvate, succinate, propionate, lactate and formate will be formed. Another feature that adds to the advantage of Candida krusei is that it can produce acetoin which can be utilised when the growth environment is exhausted of carbon sources (Lategan et al. First is by undergoing mitotic recombination and second is by carrying out phenotypic switching. A direct consequence of mitotic recombination is the lost of heterozygosity throughout the entire genome. Phenotypic switching, on the other hand is a phenomenon that occurs as a result of changes in the growth environment. A severely suppressed growth condition may lead to high frequency switching in candidal cells. This adaptation is associated with the alteration of gene expression which eventually may lead to alteration of adhesiveness, susceptibility and the resistance of candidal cells to phagocytosis and polymorphonucleur leukocyte. This mechanism of action does not involves deletion of any candidal genome thus, the heterozygosity of the entire genomic are well maintained (Martin and Marsh, 2009). Phenotypic switching is identified as one of the important virulent factors in Candida albicans (Anderson et al. The significance of the switching strategy is in a way similar to the human immunity 19 function whereby it is aimed to counter threats in the host? Until now, there is no report that highlights the ability of Candida krusei to undergo phenotypic switching. However, scientist has suggested that phenotypic switching mechanism enhances the survivability of Candida sp. Phenotypic switching may influence the normal physiological growth of candidal species such as Candida albicans (Vargas et al, 2004).

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Effective immunocompromised patients or those being methods of cleaning and drying have been proven cared for under isolation or transmission-based to order 0.5 mg prandin overnight delivery managing diabetes zorgtraject limit cross infection in all healthcare settings generic prandin 2mg line diabetes symptoms in young children, precautions order prandin 1mg without prescription managing diabetes and shift work. For spillages of blood and other body fluids best prandin 2mg diabetes signs and causes, nosocomial infections, some organisms survive in the see universal precautions. Periodic cleaning of other sites close to patient areas such as ward kitchens and staff areas is also Routine cleaning important. Floors, toilets, and any equipment or furniture that is frequently handled by staff or patients should Equipment and surfaces that are hard to clean due be cleaned daily with a general detergent, hot clean to their poor condition can be a source of water, clean cloths, and/or mops. Maintenance and contaminated sites should be cleaned immediately; repairs are therefore essential. General detergents should be dispensed from their containers for use each day and kept covered to prevent contamination and to keep the solution fresh. Routine disinfection is not required and is more costly than using a general detergent. Periodic cleaning Periodic cleaning using the above-mentioned materials, is recommended for ceilings, walls, curtains, blinds, windows, shelves, cupboards, containers, and any other areas not cleaned daily. However, cleaning of some of these items is necessary and provides an aesthetically Page 16 Module 1 Disinfection methods Chemical disinfection are metal instruments including specula and There are many different chemicals that can be used sigmoidoscopes. Their effects on microorganisms method, which use wet heat at temperatures of vary. A chemical disinfectant must be able to withstand powerful water jets and is a compound or mixture capable of destroying alkaline detergents, for example reusable anaesthetic microorganisms. It should be noted that some disinfectant products are designated for specific use, for example, skin disinfectants, environmental disinfectants, or instrument disinfectants. A careful assessment should be made to ensure that the appropriate disinfectant is used. Moist heat disinfection and pasteurization these two methods kill most bacteria and viruses. A typical cycle in an appropriate disinfector is at 73 C for a period of not less than 10 minutes. Moist heat disinfection by boiling is also a common and effective method, which will kill Page 17 susceptible microorganisms. A typical process is exposure to soft water boiling at 100 C for 5 minutes or more. Suitable items for this process Page 17 Sterilization methods Autoclaving, or steam under pressure, is one of guidance protocols should be followed. Frequent testing and monitoring of ature combinations decontamination devices is essential to ensure that are: 121 C for 15 the devices are able to fulfil their purpose and are Autoclave. Hot air oven: recommended time/temperature combinations for this are 160 C for 2 hours. Chemical indicator tape is used to identify 170 C for 1 hour and 180 C for 30 minutes. Biological indicators are However, it can be used when items may be required to show this. Instructions combinations vary from 20?60 C over periods specifying the dilution of liquid disinfectants to of 2?24 hours. This method is useful for the proper concentration should be followed unwrapped delicate items that are heat sensitive, closely. Note that wet items may produce over such as fibre-optic endoscopes and reusable dilution when added to solutions. There are many hazards should be made up each time they are required for associated with use of ethylene oxide including its use. It is also important There are many additional factors to consider when not to overload autoclaves. Risk technical personnel, provides convenience and assessments must be carried out and manufacturers simplifies quality control efforts. Where required, the disinfection of potentially As mentioned earlier, medical items are generally infected linen should be carried out using a classified as: combination of high temperatures and appropriate. Autoclaving of surgical linen, such processes; or, as drapes, is essential in order to make them sterile. General concerns and points related to Unfortunately, in some healthcare settings, material decontamination: and financial resources are limited and thus items intended for single use must be reused, and thus. Boiling or that such practices will most probably not make filtration of water may be required. Decontamination water should be used if available, especially for the procedures themselves can also affect the integrity rinsing of items after disinfection has been carried and function of single use items, making them out. The items situations include: should then be stored in a clean area and dated so that if they are not used by a set time, they can be Disinfection of used gloves reprocessed for disinfection. Soak the infected gloves in out any method of decontamination is extremely a container for 10 minutes to decontaminate them, important. Health workers should be instructed and then remove them and wash them inside and in the minimal handling of contaminated items out with a cleaning solution. Chemical disinfection or autoclaving may also be suitable for some types of gloves. Page 19 Module 1 Page 19 Isolation or transmission-based precautions Reprocessing of needles and syringes All of the measures discussed this far (universal It is strongly recommended that needles and precautions, standard precautions and decontamin syringes be used only once. There are times, however, when the risk transmission through improperly processed needles of nosocomial infections is greatly increased, due and syringes.

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And thou generic 2mg prandin with amex blood sugar parameters for diabetics, O fairest Princesse vnder sky cheap prandin 2 mg on line diabetes mellitus made easy, In this faire mirrhour maist behold thy face buy prandin 1 mg free shipping blood sugar quotes, And thine owne realmes in lond of Faery purchase 0.5mg prandin otc blood glucose watch meter, And in this antique Image thy great auncestry. The which O pardon me thus to enfold In couert vele, and wrap in shadowes light, That feeble eyes your glory may behold, Which else could not endure those beames bright, But would be dazled with exceeding light. Guyon by Archimage abusd, the Redcrosse knight awaytes, Findes Mordant and Amauia slaine With pleasures poisoned baytes. Whom Princes late displeasure left in bands, For falsed letters and suborned wile, Soone as the Redcrosse knight he vnderstands, To beene departed out of Eden lands, To serue againe his soueraine Elfin Queene, His artes he moues, and out of caytiues hands Himselfe he frees by secret meanes vnseene; His shackles emptie left, him selfe escaped cleene. Him therefore now the obiect of his spight And deadly food he makes: him to offend By forged treason, or by open fight He seekes, of all his drift the aymed end: Thereto his subtile engins he does bend His practick wit, and his faire filed tong, With thousand other sleights: for well he kend, His credit now in doubtfull ballaunce hong; For hardly could be hurt, who was already stong. Still as he went, he craftie stales did lay With cunning traines him to entrap vnwares. And priuie spials plast in all his way, To weete what course he takes, and how he fares; To ketch him at a vantage in his snares. But now so wise and warie was the knight By triall of his former harmes and cares, That he descride, and shonned still his slight: the fish that once was caught, new bait will hardly bite. Vpon the way him fortuned to meet, Faire marching vnderneath a shady hill, A goodly knight, all armd in harnesse meete, That from his head no place appeared to his feete. His carriage was full comely and vpright, His countenaunce demure and temperate, But yet so sterne and terrible in sight, That cheard his friends, and did his foes amate: He was an Elfin borne of noble state, And mickle worship in his natiue land; Well could he tourney and in lists debate, And knighthood tooke of good Sir Huons hand, When with king Oberon he came to Faerie land. Him als accompanyd vpon the way A comely Palmer, clad in blacke attire, Of ripest yeares, and haires all hoarie gray, That with a staffe his feeble steps did stire, Least his long way his aged limbes should tire: And if by lookes one may the mind aread, He seemd to be a sage and sober sire, And euer with slow pace the knight did lead, Who taught his trampling steed with equall steps to tread. Such whenas Archimago them did view, He weened well to worke some vncouth wile, Eftsoones vntwisting his deceiptfull clew, He gan to weaue a web of wicked guile, And with faire countenance and flattring stile, To them approching, thus the knight bespake: Faire sonne of Mars, that seeke with warlike spoile. He stayd his steed for humble misers sake, And bad tell on the tenor of his plaint; Who feigning then in euery limbe to quake, Through inward feare, and seeming pale and faint With piteous mone his percing speach gan paint; Deare Lady how shall I declare thy cace, darkwing. Would God thy selfe now present were in place, To tell this ruefull tale; thy sight could win thee grace. Or rather would, O would it so had chaunst, That you, most noble Sir, had present beene, When that lewd ribauld with vile lust aduaunst Layd first his filthy hands on virgin cleene, To spoile her daintie corse so faire and sheene, As on the earth, great mother of vs all, With liuing eye more faire was neuer seene, Of chastitie and honour virginall: Witnesse ye heaue[n]s, whom she in vaine to helpe did call. How may it be, (said then the knight halfe wroth,) That knight should knighthood euer so haue shent? None but that saw (quoth he) would weene for troth, How shamefully that Maid he did torment. Her looser golden lockes he rudely rent, And drew her on the ground, and his sharpe sword, Against her snowy brest he fiercely bent, And threatned death with many a bloudie word; Toung hates to tell the rest, that eye to see abhord. Therewith amoued from his sober mood, And liues he yet (said he) that wrought this act, And doen the heauens afford him vitall food? He liues, (quoth he) and boasteth of the fact, Ne yet hath any knight his courage crackt. Where may that treachour then (said he) be found, Or by what meanes may I his footing tract? That shall I shew (said he) as sure, as hound the stricke[n] Deare doth chalenge by the bleeding wound. He staid not lenger talke, but with fierce ire And zealous hast away is quickly gone To seeke that knight, where him that craftie Squire Supposd to be. They do arriue anone, Where sate a gentle Lady all alone, With garments rent, and haire discheueled, Wringing her hands, and making piteous mone; Her swollen eyes were much disfigured, And her faire face with teares was fowly blubbered. The knight approching nigh thus to her said, Faire Ladie, through foule sorrow ill bedight, Great pittie is to see you thus dismaid, And marre the blossome of your beautie bright: For thy appease your griefe and heauie plight, And tell the cause of your conceiued paine. For if he liue, that hath you doen despight, He shall you doe due recompence againe, Or else his wrong with greater puissance maintaine. Which when she heard, as in despightfull wise, She wilfully her sorrow did augment, And offred hope of comfort did despise: Her golden lockes most cruelly she rent, And scratcht her face with ghastly dreriment, Ne would she speake, ne see, ne yet be seene, But hid her visage, and her head downe bent, Either for grieuous shame, or for great teene, As if her hart with sorrow had transfixed beene. Till her that Squire bespake, Madame my liefe, For Gods deare loue be not so wilfull bent, But doe vouchsafe now to receiue reliefe, the which good fortune doth to you present. For what bootes it to weepe and to wayment, When ill is chaunst, but doth the ill increase, And the weake mind with double woe torment? When she her Squire heard speake, she gan appease Her voluntarie paine, and feele some secret ease. Eftsoone she said, Ah gentle trustie Squire, What comfort can I wofull wretch conceaue, Or why should euer I henceforth desire, To see faire heauens face, and life not leaue, Sith that false Traytour did my honour reaue? False traytour certes (said the Faerie knight) I read the man, that euer would deceaue A gentle Ladie, or her wrong through might: Death were too little paine for such a foule despight. That short reuenge the man may ouertake, Where so he be, and soone vpon him light. Certes (saide she) I wote not how he hight, But vnder him a gray steede did he wield, Whose sides with dapled circles weren dight; Vpright he rode, and in his siluer shield He bore a bloudie Crosse, that quartred all the field. Now therefore Ladie, rise out of your paine, And see the saluing of your blotted name. Full loth she seemd thereto, but yet did faine; For she was inly glad her purpose so to gaine. Her purpose was not such, as she did faine, Ne yet her person such, as it was seene, But vnder simple shew and semblant plaine Lurckt false Duessa secretly vnseene, As a chast Virgin, that wronged beene: So had false Archimago her disguisd, To cloke her guile with sorrow and sad teene; And eke himselfe had craftily deuisd To be her Squire, and do her seruice well aguisd. For all he did, was to deceiue good knights, And draw them from pursuit of praise and fame, To slug in slouth and sensuall delights, And end their daies with irrenowmed shame. And now exceeding griefe him ouercame, To see the Redcrosse thus aduaunced hye; Therefore this craftie engine he did frame, Against his praise to stirre vp enmitye Of such, as vertues like mote vnto him allye. So now he Guyon guides an vncouth way Through woods & mountaines, till they came at last Into a pleasant dale, that lowly lay Betwixt two hils, whose high heads ouerplast, the valley did with coole shade ouercast, Through midst thereof a little riuer rold, By which there sate a knight with helme vnlast, Himselfe refreshing with the liquid cold, After his trauell long, and labours manifold. Loe yonder he, cryde Archimage alowd, That wrought the shamefull fact, which I did shew; And now he doth himselfe in secret shrowd, To flie the vengeance for his outrage dew; But vaine: for ye shall dearely do him rew, So God ye speed, and send you good successe; Which we farre off will here abide to vew.

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The papules become hollowed vesicles and a clear fluid fills them on the fifth or sixth day cheap prandin 2mg free shipping diabetic ulcer icd 10. They fill with pus about the eighth day order 2mg prandin mastercard diabetes definition ada, and their summits become globular buy cheap prandin 1mg on line diabetes test supplies, while the surrounding skin is red buy prandin 2 mg with visa what do diabetes medications do, swollen and painful. The general bodily symptoms again return and the temperature rises for about twenty-four hours. The pustules dry, forming crusts, while the swelling of the skin disappears and the temperature gradually falls. A scanty eruption of papules, often only on the face and hands, appears on the third or fourth day, with disappearance of constitutional symptoms. Disinfect and sterilize everything thoroughly that has been in contact with the patient. When the first (initial) fever subsides and the patient feels improved, give milk, eggs, chops, steak, or rare roast meat, bread or toast; vegetables, such as potato, spinach, celery, asparagus tips, cauliflower tops. When the second fever returns go back to the liquid diet again, and give regularly and as much as possible every two or three hours during the day, and every three or four hours during the night. Aconite may be used for the fever at first, in drop doses every hour for twenty-four hours. The constant application on the face and hands of lint soaked in cold water, to which antiseptics such as carbolic acid or bichloride may be added, is perhaps the most suitable treatment. It is very pleasant for the patient at least, and for the face it is well to make a mask of lint which can be covered with oiled silk. When the crusts begin to form, the chief point is to keep them thoroughly moist, which may be done with oil or glycerin; vaselin is particularly useful, and at this stage can be freely used upon the face. For the odor, which is sometimes so characteristic and disagreeable, the diluted carbolic acid solutions are probably the best. It should be done daily, using carbolic soap freely in order to get rid of the crusts and scabs. Then fumigate, at least three pounds of sulphur should be burned in the room for each 1,000 cubic feet of space. After scrubbing or fumigating, the room and its contents should be freely aired for several days, admitting sunlight if possible. Such pieces of clothing as will not be injured may be boiled or soaked in a one to one thousand formaldehyde solution (one ounce of twelve per cent solution in one gallon of water), or two per cent carbolic acid solution. Hands of the attendant should be washed in one to one thousand corrosive sublimate solution. It is well known that smallpox can be prevented or modified by vaccination; and a widespread epidemic of the disease can be attributed only to an equally widespread ignorance or willfulness concerning smallpox and its prevention by vaccination and re-vaccination. The rarity of smallpox in Michigan for several years led to a feeling of security and to neglect vaccination, resulting in an increased proportion of inhabitants not protected by recent vaccination. The proper preventive of such an epidemic is general vaccination and re-vaccination of all persons not recently thus protected. There is no better settled fact than that vaccination does protect against smallpox. But after a time the protection is weakened, therefore after a lapse of five years there should be re-vaccination. It is well established that those who have been properly vaccinated are far less likely to take smallpox if exposed to it, and that the very few who have been properly vaccinated and have smallpox have it in a much milder form and are much less disfigured by it than those who have not been thus vaccinated. The value of vaccination is illustrated by the following facts: On March the 13th, 1859, Dr. In the same families there were twenty-one children, who had never been vaccinated. The ten cases and the remaining members of the families, including the twenty-one children, were quarantined at home, and the children were all vaccinated and compelled to remain with the sick. Several other cases of smallpox occurred in the persons previously exposed, but not one of the twenty-one children referred to had the slightest touch of the disease. In Sweden, the average number of deaths in each year from smallpox per million inhabitants was: Before the introduction of vaccination (1774-1801), 1,973; During the period of optional vaccination (1802-1816), 479; And during the period of obligatory vaccination (1817-1877), 189. Vaccination was introduced in England near the beginning of the nineteenth century, and since 1853 compulsory vaccination has been attempted. In England the number of deaths in each year from smallpox per one million inhabitants was: At the close of the eighteenth century, 3,000. From that date till 1857, not even a single case of unmodified smallpox occurred, nor a single death from smallpox. Marson, physician of the London Smallpox Hospital, has never observed a single case of smallpox in the officers and employees of the hospital, who are re-vaccinated when they enter the service, and who are constantly exposed to the infection. The same immunity was shared by those, a much larger number, whom I had re-vaccinated and who at the same time were living in epidemic centers. It is believed that all persons except those mentioned in the following paragraph may, if the operation is properly performed, at the proper time, and with pure bovine virus, be vaccinated with perfect safety to themselves. Even those who have had smallpox should be vaccinated, for otherwise they may take the disease; and it seems to be proved that a larger proportion, of those who have smallpox a second time, die than of those who have the disease after vaccination. In all cases in which there is any doubt as to the propriety of vaccinating or postponing vaccination the judgment of a good physician should be taken. The restriction, as to vaccinating teething children makes it important that children should be vaccinated before the teething process has begun, because smallpox is very much more dangerous than vaccination. Children should be vaccinated before they are four months old; those who have never been vaccinated, should, except teething children, be vaccinated at once. Because the vaccination often loses its protective power after a time, those who have been vaccinated but once or twice should, in order to test and to increase the protective power of the former vaccination, be vaccinated again, and as often as the vaccination can be made to work.

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