initial commit of ebook 32250HEADmain

1 files changed, 9736 insertions, 0 deletions

diff --git a/32250-0.txt b/32250-0.txt
new file mode 100644
index 0000000..30816ee
--- /dev/null
+++ b/32250-0.txt
@@ -0,0 +1,9736 @@
+The Project Gutenberg eBook of American Red Cross Text-Book on Home Hygiene and Care of the Sick, by Jane A. Delano and Anne Hervey Strong and American Red Cross
+
+This eBook is for the use of anyone anywhere in the United States and
+most other parts of the world at no cost and with almost no restrictions
+whatsoever. You may copy it, give it away or re-use it under the terms
+of the Project Gutenberg License included with this eBook or online at
+www.gutenberg.org. If you are not located in the United States, you
+will have to check the laws of the country where you are located before
+using this eBook.
+
+Title: American Red Cross Text-Book on Home Hygiene and Care of the Sick
+
+Author: Jane A. Delano
+        Anne Hervey Strong
+        American Red Cross
+
+Release Date: May 4, 2010 [eBook #32250]
+[Most recently updated: April 20, 2021]
+
+Language: English
+
+Character set encoding: UTF-8
+
+Produced by: Heiko Evermann, Fox in the Stars, S.D., and the Online Distributed Proofreading Team
+
+*** START OF THE PROJECT GUTENBERG EBOOK AMERICAN RED CROSS TEXT-BOOK ***
+
+
+
+
+AMERICAN RED CROSS TEXT-BOOK
+
+ON
+
+HOME CARE OF THE SICK
+
+***
+
+DELANO
+
+
+
+
+  AMERICAN RED CROSS
+
+  TEXT-BOOK
+
+  ON
+
+  HOME HYGIENE
+
+  AND
+
+  CARE OF THE SICK
+
+  BY
+
+  JANE A. DELANO, R. N.
+
+  Chairman of the National Committee, Red Cross Nursing Service; Director,
+  Department of Nursing, American Red Cross; Late Superintendent
+  of the Nurse Corps, U. S. A.; of the Training Schools
+  for Nurses, Bellevue Hospital, New York City; and of the
+  Training School for Nurses, Hospital of the University
+  of Pennsylvania, Philadelphia
+
+  REVISED AND REWRITTEN
+
+  BY
+
+  ANNE HERVEY STRONG, R. N.
+
+  Professor of Public Health Nursing, Simmons College, Boston
+
+  _This is the Second Edition of the American Red Cross
+  Text-book in Elementary Hygiene and Home Care of
+  the Sick by Jane A. Delano and Isabel McIsaac._
+
+  PREPARED FOR AND ENDORSED BY
+
+  THE AMERICAN RED CROSS
+
+  PHILADELPHIA
+  P. BLAKISTON'S SON & CO.
+
+  1012 WALNUT STREET
+
+
+COPYRIGHT, 1918, BY AMERICAN RED CROSS
+
+THE MAPLE PRESS YORK PA
+
+
+
+
+PREFACE
+
+
+To the woman who wishes to protect her family from preventable diseases
+and is anxious to fit herself in the absence of a trained nurse to give
+intelligent care to those who are sick, this revision of the Red Cross
+text-book on Elementary Hygiene and Home Care of the Sick is
+particularly directed. It should appeal to men and to women who are
+interested in maintaining the health of their neighborhoods and
+communities and in affording effective coöperation to the public health
+authorities. To teachers wishing to impart protective health information
+to high school pupils, the book also should be useful as a class text as
+well as a guide.
+
+The war, which has caused the withdrawal from private practice of
+thousands of physicians and graduate nurses, makes it peculiarly
+important to the nation for every adult to have sound knowledge as to
+how to prevent contagion and epidemics, especially by precautionary
+attention to home and local sanitation. With nurses becoming more
+difficult to secure, the safety of the family demands that some member
+in each household know enough about elementary nursing to make a patient
+comfortable and to carry out accurately the instructions of the
+physician.
+
+The work of revision, based upon the latest knowledge of hygiene,
+sanitation and methods of home-nursing has been done by Miss Anne Hervey
+Strong, Professor of Public Health Nursing, Simmons College, under the
+personal direction of the author and the National Committee on Red Cross
+Nursing Service. The material has been painstakingly read by Dr. H. W.
+Rucker and Dr. Taliaferro Clarke of the United States Public Health
+Service, and Lieutenant Colonel Clarence H. Connor, Medical Corps,
+United States Army. Indebtedness to Dr. H. M. McCracken, President of
+Vassar College and Director of the Red Cross Junior Membership, for his
+valuable suggestion as to adapting the book for high school use as well
+as for the assistance rendered by his Department, also is gladly
+acknowledged.
+
+J. A. D.
+
+
+ACKNOWLEDGMENT
+
+I wish to express my gratitude to those who have so kindly helped in the
+work of preparing the present edition. Thanks are especially due to
+Professor Isabel Stewart, Miss Anna C. Jamme, Professor Curtis M.
+Hilliard, Professor Maurice Bigelow, Miss Katharine Lord, Miss Josephine
+Goldmark, and Miss Evelyn Walker.
+
+A. H. S.
+
+
+
+
+CONTENTS
+
+
+  PREFACE                                                            v
+
+  INTRODUCTION                                                      xi
+
+  CHAPTER I
+
+                                                                  PAGE
+
+  CAUSES AND PREVENTION OF SICKNESS                                  1
+
+     Communicable diseases, 1. Micro-organisms and bacteria,
+     1. Parasites, 3. Structure and development of parasites,
+     4. Bacteria, 4. Shape, 4. Size, 5. Motion, 5.
+     Multiplication, 5. Spores, 7. Distribution, 8. Protozoa,
+     8. Visible parasites, 8. Transmission of pathogenic
+     organisms, 9. Defenses of the body, 12. Immunity, 13.
+     Vaccination and inoculation, 15. Carriers, 17.
+     Non-communicable diseases, 20. Physical examinations, 22.
+
+  CHAPTER II
+
+  HEALTH AND THE HOME                                               27
+
+     Heredity, 27. Hygiene of environment and person, 28.
+     Ventilation, 29. Lighting, 32. Cleanliness of houses, 33.
+     Garbage, 37. Insects, 38. Sewage, 39. Personal
+     cleanliness, 41. Oral hygiene, 44. Treatment of teeth,
+     46. Clothing, 47. Food, 48. Elimination, 52. Rest and
+     fatigue, 53. Sleep, 55. Recreation, 55.
+
+  CHAPTER III
+
+  BABIES AND THEIR CARE                                             60
+
+     Growth and development, 64. Average size, 64. Muscular
+     development, 65. Development of special senses, of
+     speech, of teeth, 66. Normal excretions, 67. Clothing,
+     68. Sleep, 70. Fresh air, 72. Diet, 72. Intervals of
+     feeding, 73. Water, 75. Weaning, 75. Nursing bottles and
+     nipples, 75. Tables of diet, 78. Bathing, 78. Eyes, 80.
+     Mouth, 81. Nostrils, 81. Genital organs, 81. Development
+     of habits, 82. Exercise, 83. Play and toys, 85.
+
+  CHAPTER IV
+
+  INDICATIONS OF SICKNESS                                           88
+
+     Objective symptoms, 92. Temperature, 92. Pulse, 96.
+     Respiration, 99. General appearance, 100. Special senses,
+     101. Voice, tongue, throat, gums, 102. Cough, 103.
+     Appetite, 103. Excretions, 103. Loss of weight, 104.
+     Sleep, 104. Mental conditions, 104. Subjective symptoms,
+     105. Pain, 105. Records, 107. Tuberculosis, cancer and
+     mental illness, 107. Tuberculosis, 109. Cancer, 111.
+     Mental illness, 112.
+
+  CHAPTER V
+
+  EQUIPMENT AND CARE OF THE SICK ROOM                              117
+
+     Choice of a sick room, 118. Furnishing, 120. Ventilation,
+     123. Heating, 124. Lighting, 124. Cleaning, 126. The
+     attendant, 127.
+
+  CHAPTER VI
+
+  BEDS AND BEDMAKING                                               132
+
+     Bedsteads, 133. Mattresses, 135. Care of the mattress,
+     136. Pillows, 136. Protection of the mattress and
+     pillows, 137. Rubber sheets and pillow-cases, 138.
+     Sheets, 139. Draw sheets, 139. Pillow covers, 140.
+     Blankets, 140. Comforters and quilts, 141. Counterpanes,
+     141. Bedmaking, 141. To make an unoccupied bed, 143. To
+     change a patient's pillows, 146. Lifting a patient in
+     bed, 146. To turn a patient in bed, 147. To change sheets
+     while patient is in bed, 147. To move patient from one
+     bed to another, 150.
+
+  CHAPTER VII
+
+  BATHS AND BATHING                                                154
+
+     Cleansing baths, 154. Bed bath, 156. Care of the mouth
+     and teeth, 160. Care of the hair, 163. To wash the hair
+     of a bed patient, 164. Hot foot-baths, 165. Cool sponge
+     bath, 166.
+
+  CHAPTER VIII
+
+  APPLIANCES AND METHODS FOR THE SICK-ROOM                         169
+
+     Devices to give support, 172. Bedpans, 176. Daily routine
+     in the sick-room, 179. Time for visitors, 182.
+
+  CHAPTER IX
+
+  FEEDING THE SICK                                                 187
+
+     The digestive process, 188. Feeding the sick, 191. Liquid
+     diet, 192. Semi-solid diet, 192. Light or convalescent
+     diet, 193. Full diet, 193. Serving food for the sick,
+     195. To feed a helpless patient, 197.
+
+  CHAPTER X
+
+  MEDICINES AND OTHER REMEDIES                                     200
+
+     Action of drugs, 200. Amateur dosing, 202. Patent
+     remedies, 205. Administration of medicine, 206.
+     Suppositories, 209. Enemata, 210. Sprays and gargles,
+     213. Inhalation, 213. Inunction, 214. Household medicine
+     cupboard, 215.
+
+  CHAPTER XI
+
+  APPLICATION OF HEAT, COLD AND COUNTER-IRRITANTS                  220
+
+     Inflammation, 220. Hot applications, 225. Dry heat, 225.
+     Moist heat, 227. Stupes or hot fomentations, 229. Cold
+     applications, 231. Dry cold, 231. Moist cold, 232. Cold
+     compresses for the eyes, 232. Counter-irritants, 233.
+     Mustard paste, 233. Mustard leaves, 234.
+
+  CHAPTER XII
+
+  CARE OF PATIENTS WITH COMMUNICABLE DISEASES                      236
+
+     Incubation period, 238. Care of patients with colds or
+     other slight infections, 238. Care during more serious
+     infections, 242. Children's diseases, 246. Rules for
+     isolation and exclusion from school, 247. Disinfection,
+     248. Care of nose and throat discharges, 249. Care of
+     discharges from the bowels and bladder, 249. Bath water,
+     250. Care of the hands, 250. Care of utensils, 251. Care
+     of linen, 251. Disinfection of the person, 252.
+     Termination of quarantine, 252. Terminal disinfection,
+     253. Fumigation, 254.
+
+  CHAPTER XIII
+
+  COMMON AILMENTS AND EMERGENCIES                                  257
+
+     Conditions in which the nervous system is involved, 257.
+     Headache, 257. Sleeplessness, 258. Fainting, 259.
+     Convulsions, 260. Shock, 261. Stimulants, 263. Sunstroke
+     and heat exhaustion, 264. Conditions in which the
+     digestive tract is affected, 265. Nausea and vomiting,
+     265. Hiccough, 265. Diarrhœa, 266. Constipation, 266.
+     Colic, 266. Conditions in which the eyes or ears are
+     affected, 267. Styes, 267. Foreign bodies in the eye,
+     267. Disorders affecting the ears, 268. Conditions in
+     which the skin is affected, 269. Prickly heat, 269.
+     Insect bites and stings, 270. Ivy poisoning, 270. Other
+     emergencies, 270. Chills, 270. Croup, 271. Bleeding, 272.
+     Treatment of slight wounds, 272. Nose bleed, 274. Profuse
+     menstruation, 275. Other injuries, 275. Sprains, 275.
+     Bruises, 276. Burns and scalds, 277. Brush burn, 278.
+
+  CHAPTER XIV
+
+  SPECIAL POINTS IN THE CARE OF CHILDREN, CONVALESCENTS,
+  CHRONICS, AND THE AGED                                           280
+
+     Children, 281. Physical defects, 283. Eye-strain, 284.
+     Enlarged tonsils and adenoids, 284. Defective hearing,
+     285. Defective teeth, 286. Posture, 286. Predisposition
+     to nervousness, 292. Convalescent patients, 294. Chronic
+     patients, 299. Care of the aged, 303.
+
+  CHAPTER XV
+
+  QUESTIONS FOR REVIEW                                             312
+
+  APPENDIX                                                         319
+
+     Circulars of information issued by Division of Child
+     Hygiene, New York Department of Health.
+
+  GLOSSARY                                                         326
+
+  INDEX                                                            331
+
+
+
+
+INTRODUCTION
+
+
+Health and sickness, at all times momentous factors in the welfare of
+our nation, now as never before are matters of vital importance. To win
+its victories both in peace and in war, the nation needs all its
+citizens with all their powers, and it is a matter of more than passing
+interest that, as conservative estimates show, at least three persons
+out of every hundred living in the United States are constantly
+incapacitated by serious sickness. In 1910 these seriously sick persons
+numbered more than 3,000,000. Even more significant, perhaps, is the
+fact that at least half of our national sickness could be prevented if
+knowledge and resources that we now possess were fully utilized.
+
+The problem of sickness is by no means peculiar to our own day and
+generation. It has been a medical, a religious, and a social problem in
+every age. From the time of Job its meaning has baffled philosophers;
+from his day to ours thoughtful men have devoted their lives to
+searching for causes and cures. Yet before the middle of the last
+century little progress was made, either in scientific treatment or in
+prevention of disease.
+
+The invention of the microscope first made possible a real
+understanding of sickness. Through the microscope a new world was
+revealed,--a world of the infinitely small, swarming with tiny forms of
+animal and vegetable life. No one, however, appreciated the significance
+of these hitherto invisible plants and animals until the latter part of
+the 19th century, when the great French savant, Pasteur, proved that
+little vegetable forms, now called bacteria, cause putrefaction and
+fermentation, and also certain diseases of animals and man. Pasteur's
+discoveries were carried still further by other scientists, with the
+result that bacteriology has revolutionized medicine, agriculture, and
+many industries, and has made possible the brilliant achievements of
+modern sanitary science. For the first time in history the prevention of
+epidemics has become possible, and sickness is no longer regarded as a
+punishment for sin.
+
+Actual care of the sick, both in homes and in hospitals, has always been
+one of the responsibilities of women. The first general public hospital
+was built in Rome in the 4th century after Christ by Fabiola, a
+patrician lady. There she nursed the sick with her own hands, and from
+her day to ours extends an unbroken line of devoted women, handing down
+through the centuries their tradition of compassionate nursing service.
+It remained for Florence Nightingale, however, to give to the training
+its technical and scientific foundation, and thus to found the
+profession of nursing. As a result of her work, effectiveness was added
+to the spirit of service, that spirit which inspires the modern nurse no
+less than in an earlier day it inspired the Sisters of Charity who died
+nursing the wounded on the battlefields of Poland.
+
+But different generations have different needs, and to meet them the
+spirit of service must manifest itself in widely varying ways. The sick
+need care today no less than they did when St. Elizabeth bathed the feet
+of the lepers; but such limited service, however beautiful, is no longer
+enough. Today we serve best by preventing sickness. Cure of sickness and
+alleviation of suffering must never be neglected; not in cure, however,
+but in prevention lies the hope of modern sanitary science, of modern
+medicine, and of modern nursing.
+
+Nearly every woman at some time in her life is called upon to assist in
+caring for the sick. Indeed, approximately 90% of all sick persons in
+the United States are cared for at home, even in cities where hospital
+facilities are good. Moreover, every woman is largely responsible for
+maintaining her own health, and few escape responsibility at some time
+for maintaining the health of others. For such responsibility most women
+are poorly prepared. Every year in our own country thousands of persons,
+many of them babies and children, die merely because someone, in many
+cases a woman, is fatally ignorant of the laws governing sickness and
+health.
+
+Only prolonged and careful training, such as good hospital
+training-schools afford, can furnish the skill and judgment required in
+nursing persons who are seriously ill. Upon the trained nurse the modern
+practice of medicine makes great and ever-increasing demands: a nurse
+must perform complicated duties, meet critical situations, and carry out
+a wide variety of measures based on scientific principles which she must
+understand. Good will and sympathy are no longer enough; amateur
+nursing, even when performed with the best intentions, may involve grave
+dangers for those who are seriously ill.
+
+On the other hand, although it is true that a little knowledge is a
+dangerous thing, it is no less true that total ignorance may be more
+dangerous still. For instance, in cases of incipient, slight, or chronic
+illness, and in certain emergencies a little knowledge may be safer far
+than no knowledge at all; and no one, surely, should be ignorant of the
+principles of hygiene.
+
+The American Red Cross, recognizing the part that women can and should
+play in preventing sickness and in building up the health and vigor of
+the nation, has added to its larger patriotic services this elementary
+course of instruction in hygiene and home care of the sick. The lessons
+are not intended to take the place of a nurse's training, and procedures
+requiring technical skill are necessarily omitted. The object of the
+book is to supply a little knowledge of sickness, which though limited
+may yet be safe. The book is also designed to set forth some general
+laws of health; to make possible earlier recognition of symptoms; to
+teach greater care in guarding against communicable disease; and to
+describe some elementary methods of caring for the sick, which, however
+simple, are essential to comfort, and sometimes indeed to ultimate
+recovery.
+
+
+FOR FURTHER READING
+
+A History of Nursing--Dock and Nutting, Volume I.
+
+The Life of Florence Nightingale--Cook.
+
+The Life of Pasteur--Vallery-Radot.
+
+The House on Henry Street--Wald.
+
+Public Health Nursing--Gardner, Part I, Chapters I-III.
+
+Origin and Growth of the Healing Art--Berdoe.
+
+Medical History from the Earliest Times--Withington.
+
+Under the Red Cross Flag--Boardman.
+
+Report on National Vitality--Fisher, (Bulletin 30 of the Committee of
+One Hundred on National Health. Government Printing Office, Washington).
+
+
+
+
+CHAPTER I
+
+CAUSES AND PREVENTION OF SICKNESS
+
+
+Diseases of two kinds have long been recognized: first, those
+transmitted directly or indirectly from person to person, like smallpox,
+measles, and typhoid fever; and second, diseases like heart disease and
+apoplexy, which are not so transmitted. These two classes are popularly
+called "catching" and "not catching;" the former are the infectious or
+communicable diseases, and the latter the non-infectious or
+non-communicable. The term contagious, formerly applied to diseases
+supposed to be spread only by direct contact, is no longer an accurate
+or useful term.
+
+
+THE COMMUNICABLE DISEASES
+
+The invention of the microscope, as we have seen, revealed the existence
+of innumerable little plants and animals, so small that even many
+millions crowded together are invisible to the naked eye. These tiny
+living creatures are called micro-organisms or germs. The plant forms
+are called bacteria (singular, bacterium), and the animal forms
+protozoa (singular, protozoön). The common belief that all or even most
+bacteria are harmful is quite unfounded. As a matter of fact, while not
+less than 1500 different kinds of micro-organisms or germs are known,
+only about 75 varieties are known to produce disease.
+
+Most bacteria belong to the class of micro-organisms called saprophytes,
+which find their food in dead organic matter, both animal and vegetable,
+and cannot flourish in living tissues. These saprophytes act upon the
+tissues of dead animals and vegetables, and resolve them into simpler
+substances, which are then ready to serve as nourishment for plants
+higher in the vegetable kingdom. Thus the processes which we know as
+fermentation and putrefaction are due to the action of saprophytes.
+Higher plants in turn furnish food for men and animals, and so the food
+supply is used over and over in different forms, making what is known as
+the _food cycle_. If it were not for bacterial activities vegetation
+would be robbed of its supply of nourishment, and plant life would
+speedily end; destruction of plant life would deprive the animal kingdom
+of food and thus all life would become extinct. The saprophytes are
+consequently essential to the existence of both animals and vegetables.
+
+There are, however, other organisms called _parasites_, which can exist
+in living tissues of animals or vegetables. The organisms at whose
+expense the parasites live are called their _hosts_. Parasites not only
+contribute nothing to their hosts, but generally harm them by producing
+poisonous substances or depriving them of food. Some parasites are able
+to lead a saprophytic existence also, but as a rule they live at the
+expense of animal or plant life. Pathogenic, or disease-producing, germs
+belong to the group of parasites. The pathogenic germs which find
+favorable soil in the body produce poisons called toxins. These poisons
+or toxins interfere with the bodily functions, and thus cause what we
+know as communicable disease. Communicable diseases are caused by
+specific germs only: that is, a certain disease cannot develop unless
+its particular germs are present; the germs of typhoid for instance, can
+cause typhoid fever only, and not tuberculosis or other disease.
+
+A number of diseases are caused by micro-organisms that are now well
+known. Chief among these diseases are colds, septicæmia (blood
+poisoning), influenza, pneumonia, diphtheria, typhoid fever,
+tuberculosis, whooping cough, Asiatic cholera, bubonic plague,
+meningitis, tetanus ("lock jaw"), leprosy, gonorrhœa, syphilis,
+relapsing fever, typhus fever, glanders, and anthrax. Micro-organisms
+not yet identified probably cause the communicable diseases whose origin
+is not known with certainty. These include infantile paralysis,
+smallpox, scarlet fever, measles, mumps, chicken-pox, Rocky Mountain
+spotted fever, yellow fever, hydrophobia (rabies), foot-and-mouth
+disease. We can hardly doubt that the intensive laboratory research now
+in progress will reveal in the near future the specific germs of these
+diseases also.
+
+
+STRUCTURE AND DEVELOPMENT OF PARASITES
+
+The group of parasites consists of two general classes, the vegetable,
+and the animal. In the former class belong the bacteria, and in the
+latter the protozoa. The two classes are not sharply differentiated, but
+in general the vegetable parasites are less highly organized than the
+animal.
+
+
+BACTERIA
+
+SHAPE.--Bacteria are composed of single cells and are consequently
+called unicellular organisms. Under the microscope individual cells are
+seen to differ in size, shape, and structure. In shape bacteria show
+three different types; the rod-shaped (bacillus), the spherical
+(coccus), and the spiral (spirillum). The organisms causing typhoid
+fever for example are a variety of bacilli, those causing pneumonia are
+cocci, while those causing Asiatic cholera are spirilla.
+
+[Illustration: FIG. 1.--BACILLI OF VARIOUS FORMS. (_Williams._)]
+
+SIZE.--Bacteria vary greatly in size. Average rod-shaped bacteria are
+about 1/25000 of an inch long, but there are undoubtedly organisms so
+small that they cannot be seen, even by means of the strongest
+microscopes we now possess.
+
+[Illustration: STAPHYLOCOCCI. STREPTOCOCCI. DIPLOCOCCI. TETRADS.
+SARCINÆ. FIG. 2.--(_Williams._)]
+
+MOTION.--The power of motion in certain species of bacteria is due to
+hair-like appendages called flagella. These flagella by a lashing
+movement somewhat resembling the action of oars enable the organisms to
+move through fluids.
+
+MULTIPLICATION.--After bacteria have fully developed, each cell divides
+into two equal parts; the process of division is called fission. Each
+of these two parts rapidly grows into a full-sized organism. Then
+fission again takes place, so that four bacteria replace the original
+one. In each of the four, fission occurs again, and so the process of
+multiplication continues. As bacteria develop they group themselves in
+characteristic ways. Some, like the streptococci, arrange themselves in
+chains; the diplococci, in pairs; the tetrads, in groups of four; others
+in packets called sarcinæ, and still others, the staphylococci, form
+masses supposed to resemble bunches of grapes.
+
+[Illustration: FIG. 3.--SPIRILLA OF VARIOUS FORMS. (_Williams._)]
+
+[Illustration: FIG. 4.--BACTERIA SHOWING FLAGELLA. (_Williams._)]
+
+Under favorable conditions fission occurs rapidly; in some types a new
+generation may appear as often as every 15 minutes. Enormous
+multiplication would result if nothing occurred to check the process.
+But in nature such increase never continues unhindered, and bacteria,
+acting upon their food substances, produce acids and other materials
+injurious to themselves. Furthermore, lack of proper food, moisture, or
+favorable temperature, and competition with other organisms tend to
+prevent their unrestricted growth and multiplication.
+
+[Illustration: FIG. 5.--BACTERIA WITH SPORES. (_Williams._)]
+
+SPORES.--Most bacteria die if conditions become unfavorable to their
+growth, but some enter into a resting stage. This stage is characterized
+by the development of round or oval glistening bodies called spores,
+which are of dense structure and possess an extraordinary power to
+withstand heat, chemicals, and unfavorable surroundings. Except in rare
+instances a single cell produces but one spore. As soon as favorable
+conditions of temperature, moisture, and food supply are restored, the
+spore develops into the active form of the germ; it may, however, remain
+dormant for months or years. Spore formation, however, occurs in only a
+very few varieties of pathogenic bacteria.
+
+DISTRIBUTION.--Bacteria are very widely distributed in nature; they are
+in fact found practically everywhere on the surface of the earth. They
+are present in plants and water and food; on fabrics and furniture,
+walls and floors; and they are found in great numbers on the skin, hair,
+many mucous surfaces, and other tissues of the body.
+
+
+PROTOZOA
+
+The protozoa are the lowest group of the animal kingdom. Like bacteria
+they are composed of single cells so small as to be visible only under
+the microscope. They play an important part in causing certain diseases
+of man, especially in the tropics. Among the well-known human diseases
+of protozoan origin are malaria, amoebic dysentery, and
+sleeping-sickness. Protozoa also cause several wide-spread and serious
+plagues of domestic animals.
+
+
+VISIBLE PARASITES
+
+A few diseases are caused by parasites large enough to be seen with the
+naked eye. One of the most important is hookworm disease. This disease
+is caused by a tiny worm which penetrates the victim's skin and
+ultimately finds its way into the intestine. Other diseases also are
+caused by parasitic worms, such as tapeworms, pinworms, and trichinæ.
+The latter are acquired as a result of eating infected meat,
+particularly infected pork that has not been thoroughly cooked.
+
+
+TRANSMISSION OF PATHOGENIC ORGANISMS
+
+Pathogenic or disease producing organisms need for their development
+food, moisture, darkness, and warmth, conditions that exist within the
+human body. When one or more of these factors is unfavorable,
+development of germs is checked; if unfavorable conditions are extreme
+or long continued, the organisms begin to die. It is difficult to say at
+exactly what moment they will die if deprived of moisture or exposed to
+extremes of temperature or other unfavorable conditions, just as it
+would be impossible to state at exactly what moment a collection of
+house plants would all be dead if water were withheld, or if the room
+temperature were greatly reduced.
+
+Most pathogenic organisms, however, do not flourish long outside the
+body, and owe their continued existence to a fairly direct transfer
+from person to person. They gain access to the body through mucous
+surfaces such as the respiratory and digestive tracts, and through
+breaks in the skin, such as cuts, abrasions, and the bites of certain
+insects. They leave the body chiefly in the nasal and mouth discharges,
+as in coughing, sneezing, and spitting, in the urine and bowel
+discharges, and in pus or "matter."
+
+[Illustration: FIG. 6. (_L. H. Wilder._)]
+
+The problem of controlling communicable diseases, consequently, lies in
+preventing the bodily discharges of one person from travelling directly
+into the body of another. If a person is not expelling pathogenic germs,
+it is clear that he cannot pass diseases on to others. But both
+pathogenic and harmless germs follow the same routes from person to
+person, so that safety as well as decency lies in preventing so far as
+possible all exchanges of bodily discharges.
+
+There are five routes by which the bodily discharges most frequently
+travel from one person to another. Four of these routes of infection are
+called public, because in most cases efforts of individuals alone are
+not sufficient to control them. The public routes are water, milk, food,
+and insects. The fifth, or private route, includes all means by which
+fresh discharges of one person are passed to another, as when nose and
+mouth discharges are carried in coughing, sneezing, and kissing, or when
+bowel and bladder discharges are carried by the hands. These five routes
+in a given case differ greatly in relative importance, but the fifth, or
+direct route plays an immense part, although its importance in causing
+sickness has only lately been recognized. It cannot be too strongly
+emphasized that the chief agent in the spread of human diseases is man
+himself, and the human hand is the great carrier of disease germs both
+to and from the body. If unclean hands could be kept away from the
+orifices of the body, particularly the mouth, many diseases would soon
+cease to exist.
+
+
+Defenses of the Body
+
+In view of all the dangers from disease-producing germs it may seem
+surprising that the human race has not long ago succumbed to its
+invisible enemies. But the body has various defenses by means of which
+it may prevent invasion, or successfully combat its enemies in case they
+do gain access.
+
+The unbroken skin is usually impassable to bacteria. Virulent organisms
+are often found upon the skin of perfectly healthy persons, where they
+appear to be harmless unless an abrasion occurs which affords entrance
+into the deeper tissues. Most bacteria breathed in with the air cling to
+the moist surfaces of the air-passages and never reach the lungs.
+
+Mucous membranes lining the mouth and other cavities of the body would
+prove favorable sites for the growth of bacteria if the mucus secreted
+by them were not frequently removed. The mouth of a healthy person may
+contain bacteria of many kinds, but the saliva has a slight disinfectant
+power and serves as a constant wash to the membranes. The normal gastric
+(stomach) juice is decidedly unfavorable to the growth of bacteria,
+although it does not always kill them; they often pass through the
+stomach and are found in large numbers in the intestines. Other bodily
+secretions, such as the tears and perspiration, tend to discourage
+bacterial growth.
+
+Tissues of the body vary greatly in their power to resist invading
+germs, so that the route by which germs enter influences the severity of
+their effects. Typhoid bacilli and the spirilla of Asiatic cholera when
+taken with food or water produce far more serious disturbances than when
+injected under the skin; infections from pus germs through an abrasion
+of the skin may result in a slight local disturbance, while the same
+amount introduced into a deeper wound might cause a fatal infection.
+Certain germs nourish in certain tissues only; even tuberculosis, which
+attacks practically all tissues, has its favorite locations.
+
+IMMUNITY.--In addition to its mechanical defenses against disease, the
+body shows a varying degree of _immunity_, or the power possessed by
+living organisms to resist infections. Immunity or resistance is the
+opposite of susceptibility. It is exceedingly variable, being greater or
+less in different people and under different conditions, but the exact
+ways in which it is brought about are still in many cases far from
+clear.
+
+Immunity may be _natural_ or _acquired_. By natural immunity is meant
+an inherited characteristic by which all individuals of a species are
+immune to a certain disease. The natural immunity of certain species of
+animals to the diseases of other animals is well known. Man is immune to
+many diseases of lower animals, and they in turn are immune to many
+diseases of man. Cattle, for instance, are immune to typhoid and yellow
+fever, while man shows high resistance to rinderpest and Texas fever;
+both, however, are susceptible to tuberculosis, to which goats are
+immune. There are all gradations of immunity within the same species.
+Moreover, certain individuals have a personal immunity against diseases
+to which others of the same race or species are susceptible.
+
+Immunity may be _acquired_ in several ways. It is commonly known that
+one attack of certain communicable diseases renders the individual
+immune for a varying length of time, and sometimes for life. Among these
+diseases are smallpox, measles, whooping-cough, scarlet fever, infantile
+paralysis, typhoid fever, chicken-pox, and mumps; erysipelas and
+pneumonia on the other hand appear to diminish resistance and to leave a
+person more susceptible to later attacks.
+
+Again, in some cases immunity may be artificially acquired by
+introducing certain substances into the body to increase its
+resistance. Examples of this method include the use of antitoxin as a
+protection against diphtheria, of sera in pneumonia and other
+infections, and vaccination against smallpox and typhoid fever whereby a
+slight form of the disease is artificially induced. Laboratory research
+goes on constantly, and doubtless many more substances will eventually
+be discovered that will reduce human misery as vaccines and antitoxin
+have already reduced it.
+
+Vaccination and inoculation have saved thousands of lives. Smallpox,
+once more prevalent than measles, was the scourge of Europe until
+vaccination was introduced. During the 18th century it was estimated
+that 60,000,000 people died of it, and at the beginning of the 19th
+century one-fifth of all children born died of smallpox before they were
+10 years old. In countries where vaccination is not practised the
+disease is as serious as ever; in Russia during the five years from
+1893-97, 275,502 persons died of smallpox, while in Germany where
+vaccination is compulsory, only 8 people died of it during the year
+1897. Death rates from diphtheria and typhoid fever have been greatly
+reduced by the use of antitoxin and antityphoid vaccine. Thus in New
+York State in 1894, before antitoxin was generally used, 99 out of every
+100,000 of the population died of diphtheria, while only 20 out of
+100,000 died of it in 1914. In 1911 a United States Army Division of
+more than 12,000 men camped at San Antonio, Texas, for four months. All
+of these men were vaccinated against typhoid fever and only a single
+case occurred during the summer, although conditions of camp life always
+tend to spread the disease.
+
+While many and various factors tend to lower resistance rather than to
+increase it, the idea that these factors act equally in all kinds of
+infection is erroneous.
+
+      "The principal causes which diminish resistance to
+      infection are: wet and cold, fatigue, insufficient or
+      unsuitable food, vitiated atmosphere, insufficient sleep
+      and rest, worry, and excesses of all kinds. The mechanism
+      by which these varying conditions lower our immunity must
+      receive our attention, for they are of the greatest
+      importance in preventive medicine. It is a matter of common
+      observation that exposure to wet and cold or sudden changes
+      of temperature, overwork, worry, stale air, poor food,
+      etc., make us more liable to contract certain diseases. The
+      tuberculosis propaganda that has been spread broadcast with
+      such energy and good effect has taught the value of fresh
+      air and sunshine, good food, and rest in increasing our
+      resistance to this infection.
+
+      "There is, however, a wrong impression abroad that because
+      a lowering of the general vitality favors certain diseases,
+      such as tuberculosis, common colds, pneumonia, septic and
+      other infections, it plays a similar rôle in all
+      communicable diseases. Many infections, such as smallpox,
+      measles, yellow fever, tetanus, whooping-cough, typhoid
+      fever, cholera, plague, scarlet fever, and other diseases,
+      have no particular relation whatever to bodily vigor. These
+      diseases often strike down the young and vigorous in the
+      prime of life. The most robust will succumb quickly to
+      tuberculosis if he receives a sufficient dose of the
+      virulent micro-organisms. A good physical condition does
+      not always temper the virulence of the disease; on the
+      contrary, many infections run a particularly severe course
+      in strong and healthy subjects, and, contrariwise, may be
+      mild and benign in the feeble. Physical weakness,
+      therefore, is not necessarily synonymous with increased
+      susceptibility to all infections, although true for some of
+      them. In other words, 'general debility' lowers resistance
+      in a specific, rather than in a general, sense."--(Rosenau:
+      Preventive Medicine and Hygiene, pp. 403 and 404.)
+
+
+CARRIERS
+
+Well persons who carry in their bodies pathogenic germs but who
+themselves have no symptoms of disease are called carriers. Thus typhoid
+carriers have typhoid bacilli in the intestinal tract, while they
+themselves show no symptoms of typhoid fever; diphtheria carriers have
+bacilli of diphtheria in the throat or nose, but have themselves no
+symptoms of diphtheria, and so on. It has now been proved that many
+patients harbor bacteria for weeks, months, or even years following an
+infection, and are dangerous distributors of disease; also, some
+healthy individuals without a history of illness harbor living bacteria
+which may infect susceptible persons in the usual ways. Transmission by
+healthy carriers goes far to explain the occurrence of diseases among
+persons who have apparently not been exposed. This explanation has
+greatly clarified the whole problem of the spread of communicable
+diseases. Carriers, unfortunately, exist in large numbers, and render
+the ultimate control of disease exceedingly difficult. They can usually
+be identified by bacteriological tests. To some extent they can be
+supervised; food handlers at least should be legally obliged to submit
+to physical examinations, and should be licensed only when proved free
+from communicable disease.
+
+Diseases are also spread by persons suffering from them in a form so
+mild or so unusual that they pass unrecognized. These persons are known
+as "missed" cases. Carriers of disease and "missed" cases go freely
+about the community, handling food, using common drinking cups,
+travelling in crowded street cars, standing in crowded shops; in various
+ways coming into close contact with other people, coughing and sneezing
+and kissing their friends no less often than normal individuals. It is
+consequently clear that the bodily discharges of supposedly normal
+persons may be hardly less a menace than those of persons known to be
+infected.
+
+Diseases that depend for transmission upon milk, water, food, and
+insects may be controlled by public action, that is, by specific
+measures taken by a large group of people in order to protect the
+individual. Such action constitutes _public sanitation_. There is,
+however, a large group of diseases, chiefly sputum-borne, that cannot be
+controlled except by individual action. Such individual action
+constitutes a large part of _personal hygiene_.
+
+The whole problem of controlling infections sounds simple, depending as
+it does for the most part upon unpolluted water, milk, and food,
+extermination of certain insects, and cleanliness in personal behaviour.
+In practice the problem is not so easy. Public sanitation has performed
+miracles in the past, and will do much in the future; behaviour,
+however, will continue to be influenced by many factors, social and
+economic as well as personal. Ignorance of the laws of health is an
+obstacle to progress, but in modern conditions even the instructed may
+be unable to control their ways of living and working. Indeed, such
+control is at present limited to the privileged few. On the ignorant and
+the poor, those least able to bear it, society loads the heaviest burden
+of sickness. Only when ignorance and poverty are abolished, as one day
+they will be, can the final stage be reached in the fight for public
+health.
+
+
+THE NON-COMMUNICABLE DISEASES
+
+In this group is included a great variety of maladies. Of some the
+causes are known, while in the case of others, origin, prevention, and
+remedy are still obscure. Here belong defects in structure of the body,
+both hereditary and acquired; insanity and other nervous diseases; new
+growths, like tumors and cancer; disturbances of bodily processes, as
+malnutrition and gout; and the important class of degenerative diseases,
+like arteriosclerosis, in which tissues become hardened and fibrous and
+hence less able to perform their normal functions.
+
+The degenerative diseases are playing a menacing part in national
+health. The average length of life in the United States has shown a
+marked increase it is true, during the last 40 years. But this gain
+represents chiefly the saving of life through prevention of communicable
+diseases, especially among babies and children; among people who have
+passed the 30th year on the other hand, death rates are actually
+increasing. This increase is most marked after the age of 45, and is
+caused chiefly by the increase of cancer, and of degenerative diseases
+of the heart, blood vessels, and kidneys. Degeneration of tissues is
+normally a condition typical of old age, and in aged persons it may
+occur in any tissue. There is no elixir of youth, and for old age there
+is no cure. But the important facts in this connection are that
+degenerative changes now occur prematurely, and that among a vast number
+of people, in various classes of society and various occupations, the
+vital organs show a marked tendency to break down after the age of 45.
+
+This condition is not inevitable. Before the beginning of the present
+war, death rates at all ages were decreasing in England, Sweden, and
+other European countries. In America also degenerative diseases can be
+checked or prevented to a large extent, and it is highly important that
+their causes should be generally understood.
+
+The two groups following include some of the probable causes:
+
+1. Conditions of life which result in continued overwork, and mental
+overwork in particular; worry, excitement, insufficient recreation and
+exercise, and other kinds of nervous strain typical of modern life,
+especially in cities.
+
+2. Irritating substances in the body, including poisonous substances
+resulting from infectious diseases, and from syphilis in particular;
+poisons from chronic infections, alcohol, and industrial poisons such
+as lead and other metals; overeating and improper eating, especially of
+meat and other proteins, and rich or highly seasoned food; faulty
+digestion, constipation, and imperfect elimination through the
+kidneys.--(See Dr. A. E. Shipley, in bulletin of the N. Y. City Dept. of
+Health, Feb., 1915.)
+
+The importance of early recognition cannot be overemphasized. In many of
+these troubles the symptoms are not pronounced, and the victims have no
+knowledge of their condition until they happen to be examined for life
+insurance, or until the disease is far advanced. And even when they
+realize that trouble exists, as for example constipation or overwork,
+most people absolutely fail to realize how serious the consequences may
+be. The first step toward remedy is periodic complete physical
+examination by a competent physician, in order to learn in time how to
+prevent these degenerative diseases, if present, from growing worse. The
+custom of undergoing an annual physical examination is becoming more
+common, and "such a course, conservatively estimated, would add 5 years
+to the average life of persons between 45 and 50."--(Winslow.)
+
+      "Recently, we have been making examinations of the
+      employees of whole institutions, large banks and other
+      industrial concerns in New York City, and we find almost
+      the same conditions there. Out of 2000 such examinations
+      among young men and women of an average age of 33, just in
+      the early prime of life, men and women supposedly picked
+      because of their especial fitness for work, only 3.14% were
+      found free of impairment or of habits of living which are
+      obviously leading to impairment. Of the remaining persons,
+      96.69% were unaware of impairment; 5.38% of the total
+      number examined were affected with chronic heart trouble;
+      13.10% with arteriosclerosis; 25.81% with high or low blood
+      pressure; 35.65% with sugar, casts or albumen in the urine;
+      12.77% with combination of both heart and kidney disease;
+      22.22% with decayed teeth or infected gums; 16.03% with
+      faulty vision uncorrected.... The fact of greatest import,
+      however, was that impairment, sufficiently serious to
+      justify the examiner in referring the examinee to his
+      family physician for medical treatment, was found in 59% of
+      the total number of cases, while 37.86% were on the road to
+      impairment because of the use of "too much alcohol," or
+      "too much tobacco," constipation, eye-strain, overweight,
+      diseased mouths, errors of diet, and so forth....
+
+      "And what is the cause of this appalling increase, in the
+      United States, of these and other degenerative diseases? I
+      believe it can be shown to the satisfaction of any
+      reasonable person that the increase is largely due to the
+      neglect of individual hygiene in United States....
+
+      "If a man were suddenly afflicted with smallpox or typhoid
+      fever or any other acute malady, he would lose no time in
+      getting expert advice and applying every known means to
+      save his life. But his life may be threatened just as
+      seriously, though possibly not so imminently, by
+      arteriosclerosis, heart disease, or Bright's disease, and
+      he will do nothing to prevent the encroachment of these
+      diseases until it is too late, but will continue to eat as
+      he pleases, drink as he pleases, smoke as he pleases, or
+      overwork, and worry himself into a premature
+      grave."--("Conservation of Life at Middle Age," Prof.
+      Irving Fisher, Am. Journal of Public Health, July, 1915.)
+
+Periodic physical examinations are as necessary for children as for
+adults, in order to detect physical defects. These defects are known to
+have such an immense bearing upon health that routine examinations of
+all children have become an integral part of the work of enlightened
+public schools.
+
+Prevention of degenerative disease, then, as well as of the enormous
+numbers of preventable accidents and injuries, depends in large measure
+upon proper living conditions and proper personal habits. The infectious
+diseases, according to Dr. Hill, cost us annually at least 10 billion
+dollars in addition to the loss of life, and he adds: "The infectious
+diseases in general radiate from and are kept going by women."--(Hill--
+New Public Health, p. 30.) Women, it is true, can prevent many of the
+infections, but they can do still more, for hygienic habits to be
+effective must be acquired early, and mothers and teachers, because they
+have practically the entire control of children, have the power to
+prevent many cases of degenerative as well as of communicable disease.
+
+
+EXERCISES
+
+1. Distinguish between communicable and non-communicable disease.
+
+2. Describe the part played by micro-organisms in causing disease.
+
+3. Describe the structure of bacteria and their method of
+multiplication.
+
+4. In what ways are pathogenic germs transmitted from person to person?
+
+5. Upon what preventive measures does the control of communicable
+diseases depend?
+
+6. What is meant by immunity?
+
+7. Against what diseases may immunity be acquired artificially? How has
+the practice of immunizing affected death rates from communicable
+diseases?
+
+8. What factors tend to lower resistance? Do they act equally in the
+case of all diseases?
+
+9. Define a carrier, and explain the importance of carriers in the
+spread of disease.
+
+10. Name some of the characteristics and causes of degenerative
+diseases.
+
+11. Whom do the degenerative diseases most commonly affect?
+
+12. Describe methods that should be employed to prevent degenerative
+diseases.
+
+
+FOR FURTHER READING
+
+The New Public Health--Hill, Chapters I-IX.
+
+Health and Disease--Roger I. Lee, Chapters XV-XXIV.
+
+Principles of Sanitary Science and the Public Health--Sedgwick, Chapters
+I, II, III.
+
+Scientific Features of Modern Medicine--Frederic S. Lee, Chapters II,
+IV-VI.
+
+Disease and Its Causes--Councilman, Chapter I.
+
+Preventive Medicine and Hygiene--Rosenau.
+
+Publications of the Life Extension Institute--25 West 45th Street, New
+York City.
+
+
+
+
+CHAPTER II
+
+HEALTH AND THE HOME
+
+
+Of all the considerations that determine health, heredity is the one
+unalterable factor. Although certain characteristics are obviously
+hereditary,--complexion, height, and mental and physical traits in great
+variety,--yet in the past heredity has been little understood. In
+consequence it has served too often as a scape goat for faults and
+failings not beyond an individual's control. Our first clear
+understanding of the principles underlying heredity resulted from
+experiments made by Mendel, an Austrian monk, during the last century,
+and it is now possible to predict with a high degree of accuracy the
+inheritance of certain characteristics.
+
+Many diseases, formerly considered hereditary because their actual
+causes were unknown, are now known to be communicable. Thus, it is now
+understood that tuberculosis is not hereditary, although little children
+may be infected by tuberculous parents. No germ diseases are inherited
+in the strict sense of the word; but a baby may be infected with
+syphilis before birth if his father or his mother has the disease.
+
+It is true, however, that certain tissue weaknesses of the body seem to
+be hereditary, and in consequence one family is more susceptible to
+digestive disorders, another to diseases of the lungs, a third to
+deafness, and so on. Moreover, general low vitality may be inherited. It
+should be emphasized, however, that hereditary weakness does not
+inevitably lead to disease. Many persons have succeeded in preventing
+the development of active disease by guarding against strain in
+directions where they are weak by inheritance.
+
+Of all tissue weaknesses that may be inherited, defects of the nervous
+system are the most serious. Nervous disorders of every degree of
+severity, from slight nervous instability even to insanity, may result
+when these tissues are defective; but it is now a recognized fact that
+nervous disorders in many cases can be prevented from developing.
+Feeblemindedness, another condition due to defective tissue, is known to
+be inherited in the majority of cases, and in all cases it is incurable.
+
+
+HYGIENE OF ENVIRONMENT AND PERSON
+
+By environment is meant everything outside the body that affects it;
+taken in its complete meaning the word might include everything that is
+or ever was in the whole universe. It is possible to consider here a few
+only of the many environmental and personal factors affecting the health
+of individuals.
+
+The home constitutes the important part of environment for most persons,
+and for children in particular, since they spend the greater part of
+their time in or about it, and get there the foundation on which their
+health in later years depends. For persons employed away from home,
+industrial and occupational hygiene is hardly less important; but those
+subjects are too extensive to be considered here.
+
+Most people live where they must, and few have any part in planning the
+construction of their own houses. In choosing a house, however, one
+should remember that rooms where sunshine never enters are unfit for
+continued occupation. For children in particular fresh air and sunshine
+are essential, and it may be economy in the end to pay a comparatively
+high rent for an apartment having sunshine during at least a part of the
+day. Ignorance and carelessness, unfortunately, can spoil the best
+living conditions, and sometimes even in the country fresh air and
+sunshine are excluded from sleeping and living rooms.
+
+VENTILATION.--Ventilation has a direct bearing on health, although,
+contrary to former belief, the actual amount of oxygen in the air is not
+ordinarily the most important factor; even badly ventilated rooms
+contain more than enough oxygen to support life. The factors of prime
+importance in ventilation are temperature, humidity, air movement, and
+the number of persons in a given space since the greater the distance
+from one another the less is the probability that diseases will be
+spread.
+
+Room temperature should not be above 70° F. and, except for the aged or
+sick, it is better to be between 60° and 65°. Some moisture in the air
+is desirable; the amount needed is from 50% to 55% of the total moisture
+that the air can hold at a given temperature. We have no apparatus to
+decrease humidity in the air of houses, and in summer we are obliged to
+endure humidity, if excessive, no matter how uncomfortable we may be.
+But in winter the air in most houses is too dry, so that the mucous
+membranes of the nose and throat often become irritated and susceptible
+to infection. Most heating systems, particularly in small buildings,
+make no provision for supplying moisture. Keeping water in open dishes
+on or near radiators is often recommended, and would greatly improve the
+condition of the air, if people remembered to keep the dishes filled.
+
+The following is a simple but effective device to increase humidity:
+Roll an ordinary desk blotter into a cone about 8 inches in diameter at
+the base, and keep it constantly submerged for about one inch in a dish
+of water. The water rises to the top of the blotter and a large surface
+for evaporation is thus afforded.
+
+[Illustration: FIG. 7.]
+
+Stagnant air is harmful. Air should be in constant though not
+necessarily perceptible motion. Air about the body, if motionless, acts
+like a warm moist blanket, preventing the passage of heat from the body.
+
+The three factors, heating, humidity, and air motion, must be considered
+together. Every person requires each hour about 3000 cubic feet of air,
+and the problem of heating and ventilating is that of providing this
+amount in gentle motion, at a temperature of about 65° F., and of
+humidity from 50-55%. Higher temperatures and stagnant air cause
+disinclination to work, headache, nausea, restlessness, or sleepiness,
+and if continued are likely to result in loss of appetite, and anemia.
+The tuberculosis movement has clearly shown the benefits both for the
+sick and the well of living in the open air, and has caused great and
+beneficial changes within a generation. The more time spent in the open
+air the better; since however most persons who work must spend the
+greater part of the day indoors, ventilation is a matter of great
+importance.
+
+Although fresh air enthusiasts are still too few, yet some go to the
+extreme and think that because cool air in motion is good, the colder
+the air and more violent the motion the better. On the contrary,
+chilling the whole body or a part of the body lowers resistance.
+Draughts of air have no bad effects upon persons in good health,
+particularly those accustomed to changes in temperature. But draughts
+are likely to be injurious to aged or sick persons and babies, by
+diminishing their resistance to such infections as common colds and
+pneumonia. It should be remembered that draughts or cold alone cannot
+cause colds; the specific germs must be present.
+
+LIGHTING.--Amount and direction of light are physiologically important.
+Defects of the eyes, too prolonged use, and insufficient light are the
+commonest causes of eye strain. Most eye defects can be relieved by
+glasses. Children's eyes should be examined upon entering school, and as
+often afterward as the oculist advises. Prolonged use causes fatigue of
+the eyes, especially when the illumination is poor; within limits, the
+amount of light needed depends on the nature of the work. Light should
+come from the left side of right handed people; never from the front.
+Light reflected from snow, sand, glazed white paper of books, or other
+bright surfaces is fatiguing from its intensity, and from the unusual
+angle at which it enters the eyes. Too much light is harmful, and
+probably causes some of the effects, such as nausea and headache,
+commonly attributed to poor ventilation.
+
+Almost all blindness is preventable, and blindness due to industrial
+accidents and processes is no exception to this rule. Surely no
+individual precautions or legal measures are too great in order to guard
+against this saddest of all physical defects.
+
+CLEANLINESS OF HOUSES.--A clean, well-cared for house is desirable from
+every point of view, but certain kinds of cleanliness affect health more
+than others.
+
+The most scrupulous care should be exercised wherever food is stored or
+prepared. The kitchen is in reality a laboratory; in it either
+intelligently or ignorantly are formed chemical compounds which have a
+far-reaching effect upon family health. From the standpoint of health no
+other room in the house is so important. It should be bright, airy, and
+easy to clean. In cleaning kitchen tables and woodwork water should not
+be allowed to soak into cracks and dark corners, carrying with it
+particles of food for the nourishment of bacteria and insects. Linoleum,
+if used to cover the floor, should be well fitted at the edges to
+prevent water from running underneath. There should be neither cracks
+nor crevices in wall or floor, and no dark corners or out-of-the-way
+cupboards in which dust, food particles, and moisture can accumulate.
+Such conditions not only attract mice and roaches, but furnish favorable
+soil for the development of moulds and fungi which by their growth
+affect food deleteriously. Waging a constant warfare against the
+development of bacteria constitutes a large part of good housekeeping.
+
+All cooking utensils should be thoroughly washed, scalded, and dried
+before they are put away; the use of carelessly washed dishes is bad.
+Enameled or agate ware which has begun to chip should be discarded.
+Dish-cloths and towels should be washed and boiled after using, and if
+possible dried in the sun.
+
+Every place in which food is kept should have constant care. The
+refrigerator is particularly important. Its linings should be
+water-tight, and the drain freely open at all times; otherwise the
+surrounding wood will become foul and saturated with drainings. At least
+once a week it should be entirely emptied and cleaned in the following
+way: The racks should be thoroughly washed in hot soapsuds to which a
+small amount of washing soda has been added, rinsed in boiling water,
+dried and placed in the sun and air. All parts of the refrigerator
+should be washed in the same manner, especially grooves and projections
+where food or dirt may lodge. The drainpipe should be flushed, the whole
+interior rinsed again with plain hot water, thoroughly dried with a
+clean cloth, and left to air for at least an hour. The drainage pan
+should be washed and scalded frequently. Food showing the slightest
+evidence of spoiling should be removed from the refrigerator at once.
+
+Even more attention should be paid to the hands of the cook. They should
+be washed always before handling food, and always after visiting the
+toilet, using the handkerchief, or otherwise coming in contact with
+nose, mouth, or other bodily secretions. Theoretically coughing and
+sneezing ought not to occur in the neighborhood of food, especially of
+food to be eaten raw; and persons with coughs, colds, or other
+communicable disease, however slight, ought not to handle food. If this
+rule were observed in practice, more persons would go hungry, but fewer
+would be sick.
+
+Thorough cleaning of rooms involves soap, water, sunshine, air, and
+elbow grease, just as it did before germs were discovered. Cleaning
+means actually removing dirt and dust, not merely stirring it up to
+settle again; consequently dry sweeping and dusting are ineffectual.
+Vacuum cleaning, and sweeping and dusting with damp or "dustless" mops
+and dusters are good. Deodorants and disinfectants do not take the place
+of ordinary cleanliness.
+
+Dust does not carry living disease germs to an appreciable extent; the
+fact is now well established that diseases formerly thought to be
+transmitted by dust or even supposed to travel directly through the air,
+are carried on tiny particles of moisture and mucus expelled in coughing
+and sneezing. This mode of transmission is called droplet or spray
+infection; it is one of the most active agents in spreading certain
+kinds of communicable diseases.
+
+Nevertheless dust in motion is harmful; it irritates the lining
+membranes of the nose, throat, bronchial tubes, and lungs, even causing
+tiny wounds through which disease germs enter. Thus tuberculosis is
+especially prevalent among stone cutters, felt workers, and others
+engaged in dusty trades. Metallic dust is especially harmful, because it
+is harder and sharper than dust from organic substances like wool and
+cotton. Furthermore, presence of dust indicates a low standard of
+cleanliness. People who tolerate it generally tolerate uncleanliness in
+other forms, more serious though less apparent.
+
+Cleaning would not be so great a problem if most houses were not
+littered with such dust catchers as carpets, so-called ornaments, carved
+and upholstered furniture, banners, draperies, and a vast collection of
+articles that can only be classified as Christmas presents. In actual
+practice things that are difficult or expensive to clean seldom are
+cleaned; carpets for example are considered unhygienic, not because they
+cannot be cleaned, but because they are not. William Morris' advice to
+exclude from houses all articles not known to be useful or believed to
+be beautiful would, if followed, add years to the lives of housekeepers.
+
+GARBAGE, has little bearing on health, except in so far as it affords a
+breeding place for flies. If it contains disease germs it may be
+dangerous, but statistics show that garbage handlers, although they can
+hardly be called especially careful, are not more subject to sickness
+than other men of their class. Garbage disposal is chiefly a question of
+preventing a public nuisance; it is a matter of cleanliness and public
+decency.
+
+INSECTS.--Flies, cockroaches, and other scavenging insects may carry
+disease germs on their feet and thus infect food on which they walk.
+Typhoid, cholera, dysentery, and other diseases have been carried by
+flies. Flies are always a menace, and should not be tolerated; moreover,
+the thought of their coming to food directly from manure piles and privy
+vaults is disgusting. Houses should be thoroughly screened in the fly
+season, but it is better to destroy the nuisance at its source. The
+chief breeding places of flies are garbage cans and manure piles. If
+the garbage can is water tight, closely covered, frequently emptied, and
+thoroughly cleaned, flies will not develop in it; about ten days must
+elapse from the time when the egg is laid until the insect is ready to
+fly. Fly traps to fit on the garbage can are useful. Manure should be
+screened and removed frequently, or it can be treated chemically.
+Methods for treating it are given in "Preventive Medicine and
+Hygiene."--Rosenau, p. 255, and in Bulletin No. 118, of the U. S. Dept.
+of Agriculture, July 14, 1914.
+
+[Illustration: FIG. 8.--A FLY WITH GERMS (GREATLY MAGNIFIED) ON ITS
+LEGS. (_U. S. Dept. Agri._)]
+
+Other diseases carried by insects are malaria and yellow fever, each by
+a special species of mosquito; typhus fever, by lice; and bubonic
+plague, by rat fleas. Various diseases less common in this country are
+carried by other insects. Even when mosquitoes are not carrying disease
+germs their bites may be harmful since they are often rubbed, especially
+by children, until the skin is broken, and various infections may enter
+through the wounds. Insects of every kind, rats, mice, and vermin should
+be excluded from houses.
+
+SEWAGE.--Discharges from the bowels and bladder contain various germs,
+and constitute one of the most important routes by which germs of
+typhoid fever, cholera and certain other diseases travel from person to
+person. Keeping sewage out of the water supply is consequently of great
+importance. Where a system of sewage disposal exists, the responsibility
+of making the system adequate and thus safeguarding public health rests
+upon the community as a whole. Communities ordinarily get just as much,
+or just as little typhoid fever as they are willing to endure.
+
+[Illustration: FIG. 9.--HOW A WELL MAY BE POLLUTED. (_From "The Human
+Mechanism."_ Copyright by Theodore Hough and William T. Sedgwick. Ginn
+and Company, publishers. Used by permission.)]
+
+In places having no system of drainage privies must be used. They can be
+made harmless, as army camps prove, but they require scrupulous care.
+Fecal matter must be prevented from draining into wells and other water
+supplies, and must be screened from flies. The privy should be located
+at a distance from the well. The minimum distance that is safe depends
+in each case upon the nature of the soil and the direction of the
+natural drainage. Even when the privy is situated below the well on
+sloping ground, drainage may still occur from the privy to the well;
+however, a well-made, properly located pit privy is safe unless it is
+near a limestone formation. The dry earth system is satisfactory in
+places having an efficient public scavenger system; in this system pails
+or cans are used to receive the discharges, which are then covered with
+sand, ashes, earth or, preferably, chloride of lime. The buckets are
+frequently emptied and the contents buried at least one foot below the
+surface of the ground. The objection to this method for more extended
+use is that proper care of the cans is a disagreeable duty of which most
+households soon tire.
+
+PERSONAL CLEANLINESS.--The main functions of the skin are three: to
+protect underlying tissues, to excrete waste matter, and to regulate
+bodily heat by checking or allowing the evaporation of perspiration.
+After perspiration has evaporated solid matter is left upon the skin,
+and oily matter also is deposited on it by the glands that keep the
+skin lubricated. Removing these and other materials at least once a day
+is desirable to improve the bodily tone and sense of well-being. Real
+cleanliness is impossible without frequent use of warm water and soap.
+
+Cold baths are stimulating, though not very efficacious for cleansing
+purposes. They are valuable tonics if properly used, but delicate or
+elderly persons should use them only by a physician's advice. Chilly
+feelings or depression following should be the signal for any person to
+discontinue cold bathing or swimming in cold water.
+
+Warm baths are soothing in their effects, and are appropriate at bed
+time, particularly for persons inclined to sleeplessness. Very hot
+baths, especially if prolonged, may be harmful, and should not be taken
+often.
+
+There is no clear connection between general cleanliness and disease.
+Frequent bathing does not protect a person from any particular disease,
+except in so far as bathing necessarily includes washing the hands. If
+typhoid germs for example have actually been swallowed, a clean bodily
+exterior is of no avail in preventing typhoid fever or in diminishing
+its severity. The same is true of other diseases.
+
+But it is impossible to emphasize unduly the importance of clean hands.
+Hands are prime offenders in distributing fresh bodily secretions, and
+germs both innocent and harmful. All health authorities agree on this
+point.
+
+      "Perhaps 90% of all infections are taken into the body
+      through the mouth. They reach the mouth in water, food,
+      fingers, dust, and upon the innumerable objects that are
+      sometimes placed in the mouth. The fact that the great
+      majority of infections are taken by way of the mouth gives
+      scientific direction to personal hygiene. Sanitary habits
+      demand that the hands should be washed after defecation and
+      again before eating, and fingers should be kept away from
+      the mouth and nose, and that no unnecessary objects should
+      be mouthed. All food and drink should be clean or
+      thoroughly cooked. These simple precautions alone would
+      prevent many a case of infection."--(Rosenau: Preventive
+      Medicine and Hygiene, p. 366.)
+
+As Dr. Chapin says:
+
+      "Probably the chief vehicle for the conveyance of nasal and
+      oral secretion from one to another is the fingers. If one
+      takes the trouble to watch for a short time his neighbors,
+      or even himself, unless he has been particularly trained in
+      such matters, he will be surprised to note the number of
+      times that the fingers go to the mouth and the nose. Not
+      only is the saliva made use of for a great variety of
+      purposes, and numberless articles are for one reason or
+      another placed in the mouth, but for no reason whatever,
+      and all unconsciously, the fingers are with great frequency
+      raised to the lips or the nose. Who can doubt that if the
+      salivary glands secreted indigo the fingers would
+      continually be stained a deep blue, and who can doubt that
+      if the nasal and oral secretions contain the germs of
+      disease these germs will be almost as constantly found upon
+      the fingers? All successful commerce is reciprocal, and in
+      this universal trade in human saliva the fingers not only
+      bring foreign secretions to the mouth of their owner, but
+      there exchanging them for his own, distribute the latter to
+      everything that the hand touches. This happens not once,
+      but scores and hundreds of times during the day's round of
+      the individual. The cook spreads his saliva on the muffins
+      and rolls, the waitress infects the glasses and spoons, the
+      moistened fingers of the peddler arrange his fruit, the
+      thumb of the milkman is in his measure, the reader moistens
+      the pages of his book, the conductor his transfer tickets,
+      the "lady" the fingers of her glove. Every one is busily
+      engaged in this distribution of saliva, so that the end of
+      each day finds this secretion freely distributed on the
+      doors, window sills, furniture and playthings in the home,
+      the straps of trolley cars, the rails and counter and desks
+      of shops and public buildings, and indeed upon everything
+      that the hands of man touch. What avails it if the
+      pathogens do die quickly? A fresh supply is furnished each
+      day."--(Chapin: The Sources and Modes of Infection, p.
+      188.)
+
+ORAL HYGIENE.--Cleanliness and proper care of the mouth and teeth can
+hardly be over emphasized. Their bearing upon health is direct. Long ago
+it was recognized that persons with decayed or missing teeth frequently
+suffered from dyspepsia, a natural result of inability to masticate
+properly, but only within recent years has it been realized that decayed
+teeth give rise to many other diseased conditions. Bacteria are
+constantly present in the mouth. If the mucus of the mouth is not
+removed, it forms a sticky coat upon the surfaces of the teeth and gums.
+In this bacteria collect, and pus or matter may also be formed, which,
+if carried by the blood to other parts of the body, may cause digestive
+troubles, rheumatism, and diseases of heart and kidneys. (See Dr. T. B.
+Hartzell, Health News, Oct., 1915, "The Importance of Mouth Hygiene and
+How to Practise it.")
+
+To keep the mouth and teeth healthy they must have:
+
+1. Proper use.
+
+2. Proper care.
+
+3. Proper treatment.
+
+1. Teeth, like other parts of the body, need exercise. Foods that
+require a considerable amount of chewing should be included in the diet.
+Such food is needed by children as soon as their first teeth have come,
+but care must be exercised to see that the food is actually chewed
+before it is swallowed.
+
+2. A good brush should be provided. The stiffness of the bristles should
+be regulated according to the individual. The brush should be
+thoroughly rinsed after using, and discarded as soon as it is worn.
+Dental floss is generally needed to remove particles that have lodged
+between the teeth.
+
+Brushing the teeth by passing the bristles across them is not
+efficacious. They should be brushed not across but with the cracks, as a
+good housewife sweeps a floor.
+
+      "In the light of recent investigation conducted by some of
+      the leading students of mouth hygiene, the most effective
+      way to use the toothbrush is to place the bristles of the
+      brush firmly against the teeth, applying firm pressure, as
+      though trying to force the bristles between the teeth,
+      using a slight rotary or scrubbing motion.... After a
+      little practice the user of this method will be surprised
+      at the results obtained. Care should be used to go over all
+      the surfaces of the teeth in this manner."--(See Dr. W. G.
+      Ebersole. "The Importance of Mouth Hygiene and How to
+      Practice it," Health News, Oct., 1915.)
+
+After brushing the teeth, the mouth should be rinsed by forcing lukewarm
+water about the teeth, using all the force that can be brought to bear
+by the cheeks, lips, and tongue.
+
+3. TREATMENT.--The teeth, including the first teeth of children, should
+be inspected by a competent dentist at least twice a year. Periodic
+cleansing by a dentist, and early attention to small cavities, may
+prevent serious ill health and impairment of the body, as well as the
+acute suffering generally accompanying treatment of advanced dental
+defects.
+
+CLOTHING.--Clothing was originally used for purposes of ornament. Desire
+for protection from cold and dampness came later. The amount of clothing
+required varies greatly according to individual needs and habits, but it
+is increasingly recognized that light clothing is best, provided that
+the wearer is really protected from cold. Clothing should be porous in
+order to allow ventilation of the body, supported so far as possible
+from the shoulders, and clean and well aired. Dampness favors the growth
+of germs which may cause irritation of the skin.
+
+Clothing should not constrict the body or hamper its movements. Perhaps
+the worst health menace for which clothing is to blame comes from the
+high heeled shoes on which many women prefer to limp through life. From
+the health standpoint shoes are of great importance. Bad shoes are
+responsible for many cases of flat feet, whose muscles have degenerated
+through non-use, and for much so-called "rheumatism," which is merely
+the protest of abused muscles. Bad shoes also, by distorting the feet,
+prevent comfortable walking, which is the only out-of-door exercise
+readily available for the vast majority of people; and still worse, the
+resulting unnatural position of the body sometimes has serious
+consequences by bringing injurious strains on other muscles and organs.
+
+FOOD.--Two distinct problems are encountered here: the problem of
+nutrition, and the problem of preventing sickness. Nutrition, or proper
+feeding, is a subject beyond the scope of this book; it is nevertheless
+one of the most important, if not the most important, factor in
+maintaining health. Food preparation and care of children, the two most
+important functions of the home, are unfortunately relegated to the
+least intelligent and least interested members of most households in
+which servants are employed.
+
+Most American families eat too much protein food, such as meat and eggs.
+Excess of protein probably leads to degeneration of tissues, and plays a
+part in causing the degenerative diseases already mentioned. Habit is
+important here as in other ways of living, but cereals and vegetables
+should in large measure make up the diet of sedentary persons and indeed
+of everyone in warm weather.
+
+The amount of food required in 24 hours depends on many factors: age,
+height, weight, occupation, season, and habit. Underweight and
+overweight are both abnormal conditions; probably the latter is the more
+easily remedied. Both require the advice of a physician. Rapid reduction
+of weight involves certain dangers, especially for persons with weak
+hearts.
+
+Food may cause sickness either because it is in itself harmful, or
+because it carries disease germs. Meat from diseased animals should be
+destroyed before it reaches the market, but bacterial activities in food
+originally wholesome may form in it poisonous substances.
+
+The chief diseases known to be carried by food, water, or milk are
+typhoid fever, paratyphoid, dysentery and other diarrhœal diseases,
+scarlet fever, diphtheria, septic sore throat, and tuberculosis. The
+sole problem here is to keep human and animal excretions out of food,
+water, and milk. Since thorough cooking kills disease germs, danger
+arises chiefly from raw foods. All fruits and vegetables eaten raw
+should first be thoroughly washed.
+
+Water is essential to health. At least three pints should be taken
+daily, the amount varying somewhat according to diet, exercise,
+temperature, and so forth. Most persons drink too little water.
+
+Cities and towns should of course have public supplies of pure water.
+Contamination of water, when it occurs, is caused chiefly by sewage
+from cesspools, privies, and drains. All well or spring water must be
+constantly watched and Boards of Health are always ready to examine
+samples of water and to report whether it is safe to drink. At the
+present time a porcelain filter is the only satisfactory kind for a
+household, but many domestic filters are so badly cared for that in
+actual practice they are worse than none. Danger from a filter
+containing an accumulation of impurities is greater than the danger from
+most ordinary water supplies. Boiling water for ten minutes kills all
+pathogenic germs, but this method is inconvenient on a large scale and
+is not practical for continued family use.
+
+Every effort should be made to insure a regular supply of pure water in
+every house. It is not satisfactory to have two kinds, one for drinking
+and one for other purposes, since mistakes are sure to be made,
+especially by children. Some families who use only bottled or filtered
+water for drinking purposes habitually run the risk involved in using
+impure water from the tap for cleaning the teeth.
+
+Freezing destroys most germs, but ice is not necessarily free from
+bacterial life, and should be used in drinking water only when known to
+be free from impurities. Neither does freezing milk or cream
+necessarily kill germs that may be contained in it.
+
+Raw milk plays so important a part in the spread of disease that its
+fitness for human consumption is open to serious question. Certified
+milk, where obtainable, is safe but expensive. Boiled milk is safe, but
+changed in taste and to some extent in quality. If milk is heated to
+142°-145° F. and kept at that temperature for 30 minutes all disease
+germs in it are killed. This process, called pasteurization, renders
+milk safe. The objection is sometimes made that continued use of
+pasteurized milk for infants causes scurvy, but in New York City where
+over 90 per cent. of the milk is pasteurized no increase in scurvy has
+been noticed, while a large diminution in deaths of infants from
+diarrhœal diseases has resulted, as in all cities where pasteurization
+is required.
+
+The following is a simple method for pasteurizing a quart bottle of
+milk. If the directions are exactly followed the milk will be
+pasteurized at the end of the process; no thermometer need be used. To
+prevent the bottle from breaking, it is first warmed by placing it for a
+few minutes in a pail of warm water.
+
+      "From the results of the experiments it was concluded that
+      any housewife can pasteurize a one quart bottle of milk by:
+
+      1. Boiling 2½ quarts of water in a large agate saucepan; or
+      better
+
+      2. Boiling 2 quarts of water in a 10 pound tin lard pail,
+      placing the slightly warmed bottle from the ice chest in
+      it, covering with a cloth and setting in a warm place. At
+      the end of one hour the bottle of milk should be removed
+      and chilled promptly. The water must be boiled in the
+      container in which the pasteurization is to be
+      done."--(Ruth Vories, in "Health News," Sept., 1916.)
+
+ELIMINATION.--Careful attention should be paid to elimination through
+the bowels and kidneys. Constipation is responsible for many common
+ailments; among them are headache, disinclination to work, irritable
+temper, and lowered resistance. If long continued, constipation becomes
+serious both from congestion and displacement of pelvic organs, and from
+absorption over a considerable time of even small amounts of the
+poisonous substances resulting from decomposition of food in the large
+intestine. The bowels can best be regulated by diet, water, exercise,
+and habit. The habitual use of cathartic and laxative drugs is most
+unwise, because they tend to aggravate the trouble. Moreover the
+habitual and continued use of injections and "internal baths" is
+harmful, and would not be considered necessary if bran and coarse flour
+and vegetables were substituted for concentrated foods. Greed, laziness,
+and lack of intelligence lead most persons suffering with constipation
+to prefer pills to the restraints demanded by hygienic living. The habit
+of evacuating the bowels at a regular time, if established in early
+childhood and rigidly adhered to, will prevent constipation among most
+healthy people. Any person who thinks drugs necessary should consult a
+physician, and be prepared to follow the régime he advises over a
+considerable period of time and at the cost of some self-denial.
+
+For healthy people, voiding urine presents no difficulty if a sufficient
+amount of water is taken; but some persons reduce the amount of liquid
+taken in order to escape the inconvenience of urination. This practice
+is harmful, and may involve insufficient cleansing of the entire system.
+If frequent urination disturbs sleep, liquids may be withheld during the
+evening; but the total amount of water taken in 24 hours should not be
+diminished.
+
+REST AND FATIGUE.--A fatigued person is a poisoned person. Muscular
+exertion burns the fuel constituents of the body, as we recognize by the
+greater heat generated within us during muscular exertion. Waste
+products, resulting from this burning process, accumulate if not
+removed, and clog the body in somewhat the same way that ashes and
+cinders clog a furnace. The fatigued person remains fatigued,
+consequently, until the accumulations of waste matter are removed by the
+normal action of the lungs, skin, and kidneys.
+
+Fatigue is caused by both mental and physical work, and when excessive,
+affects the nervous system most disastrously. The body can and should
+respond to occasional extra drafts on strength and endurance; its
+flexibility and power of adjusting to varying conditions may even be
+stimulated thereby. But even slight fatigue, if continued and especially
+if associated with anxiety or worry, has caused many nervous and mental
+breakdowns.
+
+Work carried beyond the point of normal fatigue requires a
+proportionately longer time for recovery. For example, if the point of
+fatigue has been reached by a certain finger muscle after 15
+contractions, and if half an hour is required to rest it completely, one
+might suppose that one hour would rest it after 30 contractions. This is
+not so, however; after 30 contractions 2 hours are required, or 4 times
+as much rest for twice the amount of work, if continued beyond the point
+of fatigue. Laboratory experiments and experience alike show that this
+principle holds true in other forms of fatigue. Thus the output of
+factories has been shown in many instances to be greater, other things
+being equal, when operatives work 8 hours a day than when they work
+longer. Excessive hours in any kind of work are the poorest economy.
+
+Fatigue is increased in direct proportion not only to muscular exertion
+but also to the amount of speed, complexity, responsibility, monotony,
+noise, and confusion involved in an occupation. Ability to bear fatigue
+differs greatly with different people, as ability varies to bear other
+kinds of strain. Rest at night and on Sunday, and the annual vacation
+should be enough to keep a person in good condition. If not, there is
+probably something wrong with the worker's health, the nature of his
+work, or his adaptation to his particular kind of work. This statement
+is not only true of persons regularly employed, but of those living at
+home, including children in school, women in "society," and especially
+mothers of families.
+
+SLEEP.--A sufficient amount of sleep is essential to health, but
+individual requirements vary widely. Each person should know and regard
+his own need, and children and young people should be obliged to go to
+bed early. Ability to sleep is largely habit; good habits should be
+formed and continued. Sleep-producing drugs should never be taken,
+except by a doctor's prescription.
+
+RECREATION.--Owing to the speed, complexity, and worry of modern life
+among all classes, and to the monotony of work in industry, recreation
+has become a matter of vital importance for everyone. Some muscular
+activity, preferably in the open air, is needed by every healthy person.
+Recreation should be as unlike the regular occupation as possible: going
+to the theatre, for example, is not the best exercise for sedentary
+workers employed all day in artificially lighted offices. The element of
+pleasure is essential. Hoisting dumb-bells purely from conscientious
+motives is seldom beneficial, and is generally soon abandoned.
+
+The part played by habit in matters of health is often overlooked.
+Although the body adjusts itself to widely varying conditions and even
+to unfavorable ones, the importance of forming desirable habits cannot
+be overemphasized. Sudden or radical changes in living, however,
+particularly among people no longer young, may play havoc. New and
+violent systems of exercise, weight reduction, and food fads forced on
+families by enthusiastic discoverers involve considerable risk.
+
+Many elements enter into health; in no single one is found hygienic
+salvation. Temptation always exists to emphasize one element at the
+expense of others. For instance, people who insist upon overventilating
+rooms regardless of others' comfort may themselves be utterly careless
+in regard to necessary sleep, and more than one fastidiously clean
+person has disregarded the highly unclean condition of constipation. To
+maintain sound health only a rational program will suffice: properly
+balanced work and play, sleep and food and all other elements must be
+included in due proportion. And over-anxious health seekers might well
+remember that health is not so much an end in itself, as a means to a
+happy and productive life; even in concern over health, it is possible
+for him that saveth his life to lose it.
+
+
+EXERCISES
+
+1. Explain the difference between an hereditary disease and hereditary
+susceptibility to a disease. How may hereditary susceptibility to a
+disease be combatted?
+
+2. What are the essentials of good ventilation?
+
+3. What is the proper temperature for a living room? What are the
+effects of higher temperatures? Of lower temperatures?
+
+4. Describe methods for maintaining household cleanliness.
+
+5. Discuss the importance from the point of view of health, of dust; of
+insects; of garbage; of sewage.
+
+6. What principles should guide one in deciding whether a certain water
+supply is safe to use for drinking purposes? What are the dangers of
+impure water? How can impure water be rendered safe?
+
+7. What diseases may be carried by milk? How can milk be rendered safe?
+
+8. Explain the health aspects of personal cleanliness.
+
+9. What care should be given the teeth and mouth? Why?
+
+10. What bad results frequently follow constipation? How should
+constipation be remedied?
+
+11. Name seven factors that are important in causing fatigue. Why is it
+uneconomical to continue work, either physical or mental, beyond the
+point of fatigue?
+
+12. What facilities for recreation, especially in the open air, does
+your community provide for little children? For school children? For
+working boys and girls? For grown people?
+
+
+FOR FURTHER READING
+
+Health and Disease--Roger I. Lee, Introduction and Chapters I, III-V,
+VII-IX.
+
+How to Live--Fisher and Fisk, Chapters I, III-V.
+
+The Human Mechanism--Hough and Sedgwick, Chapters V, XXII-XXIX.
+
+Disease and Its Causes--Councilman, Chapters X, XII.
+
+Fatigue and Efficiency--Goldmark, Chapters II, III.
+
+Preventive Medicine and Hygiene--Rosenau.
+
+A Manual of Personal Hygiene--6th Edition, Edited by Walter L. Pyle.
+
+Four Epochs of a Woman's Life--Galbraith.
+
+Hygiene and Physical Culture for Women--Galbraith.
+
+The Home and Its Management--Kittredge.
+
+Exercise and Health--F. C. Smith, Supplement 24 to the Public Health
+Reports, Government Printing Office, Washington.
+
+The Sanitary Privy--Farmers' Bulletin 463, United States Department of
+Agriculture, Government Printing Office, Washington.
+
+Safe Disposal of Human Excreta at Unsewered Homes--Lumsden, Stiles and
+Freeman, Bulletin 68, Public Health Reports, Government Printing Office,
+Washington.
+
+The Disposal of Human Excreta and Sewage of the Country Home--New York
+State Department of Health, Albany.
+
+Milk and Its Relation to Public Health--Bulletin 56, Hygienic
+Laboratory, Government Printing Office, Washington.
+
+Milk and Its Relation to Health--New York State Department of Health,
+Albany.
+
+Other Publications of the United States Public Health Service and of the
+Departments of Health of the different states and cities.
+
+
+
+
+CHAPTER III
+
+BABIES AND THEIR CARE
+
+
+The principles of hygiene are fundamentally the same for young and old.
+The applications, however, differ at different ages. From the time when
+physical growth and development are complete until changes due to old
+age appear, an individual commonly has greater resistance than at other
+ages, and is able in consequence to endure unfavorable conditions of
+life with more success.
+
+Babies, on the other hand, are exceedingly sensitive to their
+environment. Surroundings that are even slightly unfavorable are likely
+to make babies sick. In order to remain healthy, they must have exactly
+the right kind of food, in the right quantities and at the right times;
+their sleep, exercise, and clothing must be carefully regulated; they
+must be protected from careless handling, from nervous strain, and above
+all, from the many kinds of infection to which they are peculiarly
+susceptible. The life of a baby fortunately can be controlled almost
+completely; when properly regulated it offers, therefore, an unequalled
+opportunity to see how hygienic principles work out in actual practice.
+
+The primitive mother's instinct to nourish and protect and succor her
+helpless child was the original form of nursing. Instinct alone,
+unfortunately, has never accomplished much in preserving health. The
+human race has now had an experience in the care of infants that extends
+over thousands of years. Yet today we are still, on the whole, less
+successful in keeping babies alive than we are in raising domestic
+animals; we still allow society to continue, like a modern Herod, in its
+ruthless career of slaughtering the innocents.
+
+About 14 babies out of every 100 born in the registration area[1] of the
+United States die before reaching the age of one year, while in some of
+our industrial cities as many as 25 out of every 100 born die before
+they are a year old. Most of these deaths are preventable. Thus, in a
+few American cities, the death rates have been so reduced that fewer
+than 10 babies out of every 100 die before completing the first year;
+while in Dunedin, New Zealand, as a result of the work of the Society
+for the Health of Women and Children, the infant death rate has been so
+reduced that in 1912 only about 4 out of every 100 babies died before
+they were a year old.
+
+While ignorant mothers, who may or may not be uneducated women, and
+contaminated milk, are as a matter of fact, chiefly responsible for our
+high infant death rates, yet as we have already seen, every factor in
+the environment has its effect upon a baby. This fact has led Sir Arthur
+Newsholme, an eminent English authority, to say:
+
+      "Infant Mortality is the most sensitive index we possess of
+      social welfare. If babies were well born and well cared
+      for, their mortality would be negligible. The infant death
+      rate measures the intelligence, health, and right living of
+      fathers and mothers, the standards of morals and sanitation
+      of communities and governments, the efficiency of
+      physicians, nurses, health officers, and educators."
+
+Care of the child should begin at the earliest possible moment: that is,
+nearly nine months before he is born. Care before birth, for want of a
+better name, is called prenatal care of the mother. Every woman who
+thinks that she is pregnant should put herself at once under the care of
+a competent physician, so that he can make the necessary examinations as
+early as possible. If she follows his advice in regard to hygiene and
+proper regulation of her life, she may be free from anxiety, and may
+justly expect that her delivery will be a safe and normal process.
+
+A demonstration of the value of prenatal care was recently made by the
+Boston District Nursing Association. During the year 1915 prenatal care
+was given to 751 expectant mothers in 5 wards of the city; each woman
+attended a pregnancy clinic, where she was under the care of an
+experienced obstetrician, and was visited at intervals by a nurse who
+kept careful watch of her general condition and gave necessary advice
+and encouragement. In consequence the death rate among the babies whose
+mothers had prenatal care was only half as great, through the whole
+first year of life, as the death rate of babies in the same wards whose
+mothers had not had prenatal care. Moreover, the rate of still-births
+was only half as great as the rate among the general population of
+Boston. If prenatal care can save so many lives, surely it ought to be
+available for every pregnant woman in the land, including even that
+generally neglected class of people who are neither very rich nor very
+poor.
+
+Each baby's birth should be recorded by the registrar of births, and
+parents should make sure that registration has been attended to in the
+city or town where they live. In some states birth registration is
+already obligatory, but in any case it is required by the child's own
+interest. For instance, in later life it may be necessary for him to
+prove the date and place of birth in order to establish, among other
+things, his right to vote and to inherit property, and to settle the
+question of his liability to military service. Moreover, complete and
+accurate birth registration is needed by every community because it is
+essential to such reforms as reducing infant mortality and abolishing
+child labor.
+
+
+GROWTH AND DEVELOPMENT
+
+Statements in regard to growth and development are based on observations
+of many children. It should be remembered that the following figures
+represent averages only, and that healthy children may vary from them
+considerably without giving cause for alarm.
+
+AVERAGE SIZE.--The average weight of a baby at birth is from 7 to 7½
+lbs. and the average length is about 20 inches, but it is not unusual
+for a child to weigh anywhere from 5 to 10 pounds at birth and to
+measure from 16 to 22 inches in length. During the first week of life a
+baby loses slightly in weight. After the first week a healthy baby
+should gain from 4 to 8 ounces a week until he is six months old; after
+that time the weekly gain is less. The weight at birth will usually
+double during the first five months, and treble during the first year.
+Consequently, a baby weighing 7 pounds at birth may be expected to weigh
+14 pounds when five months old, and 21 pounds when a year old. Weight is
+one of the most important indications of a baby's condition. He should
+be weighed every week during the first 6 months, once in two weeks
+during the second 6 months, and once a month throughout the 2nd year.
+
+MUSCULAR DEVELOPMENT.--A baby at birth is helpless, and during the first
+few months he has little muscular control. During the third month he
+ordinarily begins to lift his head, and he can usually hold it up
+without support by the time he is 3 months old; when 7 to 8 months old
+he sits erect and begins to play with toys. From this time a baby makes
+rapid progress; he attempts to stand on his feet, begins to creep, and
+by the time he is 14 months old he is usually able to stand alone, or
+even to walk a few steps. He is usually running about without difficulty
+when fifteen or sixteen months old.
+
+Babies should never be urged to walk or to bear their weight on their
+feet. If healthy they are generally eager to go about unaided, and like
+to investigate their surroundings without assistance. If walking is
+unusually delayed, a physician should be consulted.
+
+DEVELOPMENT OF SPECIAL SENSES.--A new-born baby is unable to
+distinguish objects, but the eyes are sensitive to light and need
+careful protection. Hearing, although undeveloped at birth, soon becomes
+acute; consequently the child should stay in a quiet room. When six or
+eight weeks old he notices objects, and at three months old he welcomes
+his mother when he is hungry. A month or two later he begins to
+distinguish between familiar and unfamiliar faces, and to show approval
+or disapproval.
+
+DEVELOPMENT OF SPEECH.--A baby six or seven months old begins
+consciously to utter sounds, and usually can say a few unconnected words
+by the time he is a year old. The average child, however, does not begin
+to form sentences of more than two or three words until he is about two
+years old.
+
+DEVELOPMENT OF TEETH.--The so-called milk teeth are twenty in number;
+they are followed by thirty-two permanent teeth. The two lower front
+teeth (central incisors) generally appear when a child is from five to
+nine months old, and in from one to three months later the four upper
+front teeth (upper incisors) appear. All the first or milk teeth should
+have come through by the time a child is two and a half years old, but
+wide variations occur both in the time and order of appearance and
+should occasion no uneasiness if the child seems well. Unusual
+conditions of any sort should be referred to the physician; it is a
+great mistake to attribute all illness at this time to teething.
+
+The first of the permanent teeth appear when a child is about six years
+old. Mothers sometimes mistake the first permanent molars for temporary
+teeth, a mistake that frequently leads to neglect and even extraction of
+highly important teeth. All but the last four molars, sometimes called
+wisdom teeth, should be through by the time a child is fifteen. The
+wisdom teeth may not appear before the 20th or even the 25th year.
+
+NORMAL EXCRETIONS.--A new-born baby should have one or two bowel
+movements during the first twenty-four hours; the first bowel movements
+are sticky and almost black in color. After the baby begins to nurse,
+three to four movements a day are not unusual, and throughout infancy
+and childhood as well as adult life there should be one or two
+evacuations of the bowels daily. The character of the stools is more
+important than the number. While the baby is taking milk only, the
+movements should be soft, yellow in color, and nearly odorless. Change
+in frequency of the movements, or appearance of undigested food or curds
+of milk in the stool, should be carefully noted and if continued,
+reported to a physician; they may be the first signs of serious
+digestive trouble.
+
+The urine of an infant should be odorless and colorless. It should be
+voided at least once during the first twenty-four hours, and much more
+frequently after the baby begins to nurse. Marked diminution in the
+amount of urine should be reported to a doctor.
+
+Efforts should be made early to develop habits of regularity in the
+evacuation of the bladder and bowels. If taken up regularly most
+children learn to use a chamber for bowel movements by the time they are
+three months old. Normal children, if properly trained, usually have no
+bladder discharge during the night after they are 18 months old, and
+they learn even earlier to indicate a desire to urinate during the day
+time.
+
+CLOTHING.--The amount and weight of a baby's clothing should depend upon
+the season; but garments worn next to the skin, except the diaper,
+should be wholly or partly of wool, the lightest weight in summer and
+heavier weight in winter. During the first few weeks a baby's abdomen
+should be supported by a flannel binder about six inches wide, applied
+snugly but not tightly enough to restrict either the abdomen or chest
+walls. It may be replaced later by a loosely fitting knitted band worn
+for warmth only. Such a band is especially necessary if there is
+tendency to diarrhœa, but in no case should it be discarded before
+the 18th month. All garments except the diaper and first flannel binder
+should hang from the shoulders, and should fit loosely but well.
+
+Clothing for babies should be of soft materials and should be simply
+made. Even the first clothes should not be very long. The weight of very
+long clothing is an unnecessary burden, and prevents free movements of
+the legs. At night an entire change of clothing should be made, and a
+nightgown of warmer material substituted for the petticoat and slip.
+Most children are dressed too warmly indoors, but in low temperatures
+they need to be well protected.
+
+Diapers should be soft and absorbent. It may be necessary to wash new
+diapers several times before using in order to make them soft enough.
+Care should be taken not to apply them too tightly, or in such a way as
+to cause pressure on the genitals. They should be changed during the day
+whenever wet or soiled, and at night when the baby is taken up to be
+fed. Proper care of diapers is highly important, however laborious. They
+should be well washed, boiled, and thoroughly dried before they are used
+a second time. Diapers that have been wet but not soiled should not be
+dried and used again before being washed. Much work can be saved if
+pads of loosely woven absorbent material are used inside the diaper to
+receive discharges. The pads can be burned, but even if washed the labor
+is less than washing full sized diapers. Like all other infant's
+garments, diapers should be washed with pure white soap and without
+starch. Waterproof material used to cover the diaper is almost sure to
+irritate the baby's skin, and is consequently harmful.
+
+SLEEP.--During his first few weeks a normal baby sleeps about
+nine-tenths of the time, and should be left undisturbed except for
+necessary care. He should sleep in a crib, bassinet or basket protected
+from light and drafts; in no circumstances should a baby sleep in the
+bed with his mother or any other person. Pillows are unnecessary for
+babies, and indeed for older children, but if used they should be thin
+and firm.
+
+The amount of sleep necessary gradually diminishes, but during all the
+years of growth a child needs more sleep than an adult. The amount of
+sleep required daily is approximately as follows:
+
+  First month                  18 to 20 hours
+  Second to sixth month        16 to 18 hours
+  Sixth month to one year      14 to 15 hours
+  One to two years             13 to 14 hours
+  Two to four years            11 to 12 hours
+
+After this time a child should sleep at least ten hours out of the
+twenty-four. During the first year a nap in the middle of the forenoon
+and another in the afternoon are desirable. A child who is inclined to
+sleep so long that his nap interferes with his night's sleep, should be
+waked from his nap, but at the same hour every day. When a child is a
+year old, one nap during the day is often sufficient, if he is doing
+well, but the habit of taking a nap at some time during the day should
+be continued through the fifth year if possible, or even later.
+
+Babies should not be rocked or otherwise coaxed to go to sleep; they
+should be made comfortable and then left alone. They learn to go to
+sleep by themselves as soon as they are convinced that sleep is expected
+of them, and that no unfounded objections on their part will be
+regarded. Continued inability to sleep normally usually indicates
+discomfort or poor general condition, and should be taken up with the
+doctor. Pacifiers and thumb-sucking should not be allowed, since they
+lead to changes in the shape of the jaw with resulting imperfect
+adjustment of the teeth. Soothing syrup and like medicines should never
+be given to a baby; death or permanent injury has resulted from their
+use. It is impossible to emphasize too strongly the danger of giving
+them even a single time.
+
+FRESH AIR.--All that has been said about the importance of fresh air
+for adults applies with even greater force to infants and children.
+During his first month especially a baby is susceptible to draughts;
+nevertheless, the room should be well ventilated and its temperature
+kept between 68° and 70° F. during the day, and at about 65° F. at
+night. Even in cold weather the room should be well aired two or three
+times a day; the baby should be removed to another room while the
+windows are open. After the baby is three or four months old the windows
+may be left open at night provided the outside temperature does not fall
+below freezing. A healthy baby two or three weeks old may be taken
+out-of-doors for a short time in mild weather; when he is three months
+old he may be taken out-of-doors even in winter on bright sunny days.
+The time spent out-of-doors should be gradually increased until the baby
+stays out the greater part of the day; but he should not be exposed to
+storms, wind, flying dust, dampness, extremes of temperature, or
+insects. The eyes should not be covered by veils, but they should be
+shielded from the direct rays of the sun at all times.
+
+DIET.--A baby, in order to thrive, must have suitable food, given at
+regular intervals. During the first few months of life no other food
+can take the place of mother's milk. Breast-fed babies are more robust
+than bottle-fed babies; more than this, they are less likely to contract
+infectious diseases or to suffer from digestive disorders. The number of
+bottle-fed babies who die every year is three times as great as the
+number of breast-fed babies who die. Many mothers do not understand the
+risk involved in weaning small babies; and so every year many little
+lives are lost, and lost needlessly. When poverty forces nursing mothers
+to wean their babies and seek work outside their homes, one can only say
+that a society which tolerates such a waste of infant life is indeed
+regardless of its own welfare.
+
+Special conditions, of course, may make it undesirable for a mother to
+nurse her baby. No one but the physician is competent to decide this;
+not even neighbors, grandmothers, other members of the family, or the
+mother herself. Where artificial feeding must be used, it should be
+carefully adapted to the individual child, and in consequence it must be
+prescribed by the doctor. Patent foods, notwithstanding the claims on
+their printed labels, should be used only under his advice.
+
+INTERVALS OF FEEDING.--Little milk is secreted during the first two days
+after the birth of a child. The baby should, nevertheless, be put to
+the breast as soon as he has had his first bath, if the mother is
+sufficiently rested. Always before and after nursing the mother's
+nipples should be washed in water that has been boiled. Nursing should
+be repeated at intervals of six hours during the first two days.
+
+The following schedule for the feeding of healthy babies is given by
+Holt in "Care and Feeding of Infants." (1917.)
+
+
+SCHEDULE FOR HEALTHY INFANTS FOR THE FIRST YEAR
+
+  ------------------+--------+----------+----------+-----------+--------
+                    |        |          |          |           |
+                    |Interval|   Night  | No. of   | Quantity  |Quantity
+       Age          |between | feedings,| feedings,|  for one  | for 24
+                    |meals by|  6 p.m.  | in 24    |  feeding  | hours
+                    |  day   |    to    | hours    |           |
+                    |        |  6 a.m.  |          |           |
+  ------------------+--------+----------+----------+-----------+--------
+                    |  Hours |          |          |   Ounces  | Ounces
+  2d to 7th day     |    3   |     2    |     7    |    1-2    |  1-14
+  2d and 3d weeks   |    3   |     2    |     7    |    2-3½   | 14-24
+  4th to 6th week   |    3   |     2    |     7    |    3-4    | 21-28
+  7th week to 3 mos.|    3   |     2    |     7    |   3½-5    | 25-35
+  3 to 5 months     |    3   |     1    |     6    |   4½-6    | 27-36
+  5 to 7 months     |    3   |     1    |     6    |   5½-6½   | 33-39
+  7 to 12 months    |    4   |     1    |     5    |    7-8½   | 35-43
+  ------------------+--------+----------+----------+-----------+--------
+
+During the period when seven feedings are given in 24 hours the
+following hours will be found convenient: 6 a.m., 9 a.m., 12 m., 3 p.m.,
+6 p.m., 10 p.m. and 2 a.m. The 2 a.m. feeding is the one omitted when
+the number of feedings is reduced from seven to six. Food should be
+given on exact schedule time; the baby if asleep should be waked for
+any meal except the one due at 2 a.m.
+
+WATER.--Pure boiled water should be given regularly even to a young
+baby. He is often satisfied with a little warm water if he is fretful
+between the hours of nursing. Water may be given from a cup, a spoon, or
+a bottle; it is desirable, however, for the baby to learn to drink from
+a cup before the period of weaning begins.
+
+WEANING.--Ordinarily, a baby should be fed from the breast until he is
+seven months old, either exclusively or with the exception after the
+second month of one bottle-feeding in twenty-four hours. This exception
+will do the baby no harm and may be a great relief to his mother.
+Partial breast-feeding should continue if possible through the ninth
+month, but every baby should be entirely weaned by the time he is one
+year old. It may be necessary, if either the baby or the mother is not
+thriving, to change the food before the ninth month; but it is desirable
+not to make the change in hot weather. Healthy babies, it should be
+remembered, increase in weight constantly, and steady gain in weight is
+the best indication that a baby's food is suitable.
+
+NURSING BOTTLES AND NIPPLES.--Nursing bottles should be of heavy glass,
+cylindrical in shape, without angles or corners to make cleaning
+difficult. The number of bottles provided should be two or three more
+than the number of feedings given in 24 hours.
+
+Short black rubber nipples which slip over the neck of the bottles
+should be selected. They should be of such a shape that they can easily
+be turned inside out; a nipple turner costs little, and is well worth
+the price. Nipples should be discarded when they become soft or when the
+opening grows so large that the milk runs in a stream rather than drop
+by drop.
+
+As soon as the baby has finished his meal, the bottle should be removed
+from his mouth, rinsed in clear hot water, and left standing filled with
+cold water until a convenient time for boiling all the bottles to be
+used during the next 24 hours. Sufficient time must be allowed for the
+bottles to cool thoroughly between the time when they are boiled and the
+time when they are refilled. When it is time to boil the bottles they
+should be placed in an agate or other suitable kettle, covered with
+water, and boiled vigorously for three minutes. A cloth placed in the
+bottom of the kettle will help to prevent the bottles from breaking.
+After the bottles have been removed from the boiling water, they should
+be stoppered at once, either with rubber stoppers or plugs of sterile
+cotton. The stoppers, if used, should be boiled with the bottles;
+sterile cotton may be purchased by the package.
+
+An easy and satisfactory method to care for rubber nipples is the
+following: Provide as many nipples as the number of feedings given in 24
+hours, and another, if desired, to be used in case of accident; provide
+also two cups of ordinary white enamel, each one large enough to hold
+all the nipples at once. One cup should have a cover; the other should
+not. To avoid mistakes it is well to have the cups different in shape.
+As soon as each feeding is finished the nipple should be thoroughly
+cleansed under running water by scrubbing it inside and out with a
+nipple brush. The nipple thus cleansed is placed in the cup without a
+cover. When all the nipples have been used, cleansed, and collected in
+the uncovered cup, they are transferred into the other cup; water is
+added, the cup is covered and its contents are boiled for three minutes.
+The nipples remain covered in the boiled water until needed; they are
+removed one by one for the successive feedings. Care must be used in
+removing a nipple to take it by the rim, not to touch other nipples
+during the process and not to dip the fingers into the water. The best
+way is to remove them by means of a glass rod, which is boiled with the
+nipples and kept with them in the cup when not in use. There are
+several advantages of this method of caring for nipples: it is easy; it
+reduces to a minimum the necessary handling of the nipples after
+boiling; and it reduces the probability of using the wrong nipple, since
+boiled nipples are always in one kind of receptacle and used nipples in
+another. It also prevents the too common practice of continuing to keep
+nipples in a supposedly antiseptic solution long after the solution has
+become badly soiled.
+
+TABLES of diet for children over one year of age may be found in the
+Appendix, page 322.
+
+BATHING.--Usually the cord has separated and the navel has entirely
+healed by the time a baby is 10 days old. After this time a daily tub
+bath should be given; it should be given not less than one hour after
+feeding. The temperature of the room should be from 70-72°, measured by
+a thermometer placed in the part of the room where the bath is to take
+place. In order to avoid chilling or tiring the baby the bath should be
+given quickly, without confusion or interruption; success can be
+achieved by using even a moderate amount of foresight. Before undressing
+the baby everything to be used should be collected and placed within
+easy reach,--clean clothing, soft towels, 2 wash cloths, pure white
+soap, powder, absorbent cotton, etc. The bath tub should last of all be
+filled with water, and its temperature tested by means of a bath
+thermometer. The temperature of the water should be from 98° to 100°.
+After the baby is three months old slightly cooler water should be
+splashed over his chest, back, neck, and arms just after he is removed
+from the tub, and as he grows older the temperature of his cool splash
+can be reduced. Children who become accustomed to cool water in this way
+take kindly to their cold showers later.
+
+The baby's face should be washed first and dried carefully, while his
+body is still covered. Next the head should be washed; a little soap
+should be used, but it must on no account enter the eyes. Next the
+entire body should be soaped with the hand; and then the baby should be
+placed gently in the bath, his head and shoulders supported by the
+attendant's left hand and forearm. Care should be taken to rinse off all
+the soap. The baby should not stay in the tub more than 2 or 3 minutes;
+after he has been removed from the tub he should be wrapped at once in a
+soft bath towel. He should be dried gently but thoroughly by patting
+with soft, warm towels rather than by rubbing. Folds of the skin should
+be dried with special care. A little powder may be applied, but a baby
+who is kept both clean and dry will not need much powder, if any. The
+baby should next be quickly dressed, with as little turning and moving
+as possible. Clothing should be drawn on over the feet instead of over
+the head, and the petticoat should be placed inside the slip so that the
+two garments may go on simultaneously.
+
+EYES.--Secretion accumulating in the corners of a baby's eyes should be
+removed by means of a bit of absorbent cotton moistened in boiled water.
+The secretion should be wiped away gently; a different piece of cotton
+should be used for each eye, and a piece that has been used should not
+be put back into the water. Further than this, eyes in a normal
+condition do not need cleansing.
+
+Every person who handles a baby should be very sure that her hands are
+clean; she should be doubly sure before she touches his eyes, since a
+baby's eyes are peculiarly susceptible to infection from any source.
+More than a quarter of all totally blind persons in the United States
+became blind by infection of the eyes at birth. Blindness of the new
+born can be prevented in practically all cases if the doctor uses a
+preparation of silver in the baby's eyes immediately after birth. This
+treatment is effective and entirely safe.
+
+If at any time the eyelids look red or swollen, or if a drop of matter
+appears between the lids, the physician should be summoned at once.
+Total blindness may result if treatment is delayed even a few hours.
+
+MOUTH.--The mouth should be rinsed after feeding by giving the baby a
+teaspoonful of boiled water. Until the teeth come it does not require
+other cleansing, and attempts to clean it may injure the delicate
+membranes that line it. Indeed, except in an emergency, fingers should
+not be inserted into a baby's mouth. The teeth when they appear should
+be cleaned by means of a soft tooth-brush.
+
+NOSTRILS.--The nostrils need no cleaning other than removal of mucus
+that can easily be reached by means of a piece of cotton. If a little
+vaseline is placed in the nostrils on a small piece of absorbent cotton
+in the early morning, collections of mucus will usually be softened so
+that they can be removed easily at bath time.
+
+GENITAL ORGANS.--The genital organs of girl babies should be gently
+washed twice a day, using absorbent cotton, and tepid water. Treatment
+other than cleanliness is ordinarily unnecessary. Vaseline may be
+applied if the genitals are slightly reddened; any discharge or abnormal
+appearance should be reported to the doctor. In the case of boy babies
+the foreskin should be gently drawn back twice a week after immersion in
+the tub; after the parts have been gently washed with absorbent cotton,
+it should be drawn forward again. No force should be employed in
+retracting the foreskin; the physician should be consulted if it cannot
+be retracted easily.
+
+THE DEVELOPMENT OF HABITS.--During his first few months crying is a
+child's only means of expression, and he quickly learns to make
+effective use of his limited opportunities. It is important for the
+mother to distinguish between crying caused by pain, illness, or hunger,
+and crying caused by temper. These cries are more or less distinctive,
+but no one can be sure in every case just what a crying baby is
+attempting to express.
+
+A cry caused by hunger is fretful and often interrupted by sucking the
+thumb; it ceases when the child is fed. A cry caused by indigestion is
+similar; the child is relieved for a short time by feeding, but soon
+begins to cry again. If he has acute pain, such as earache, the cry is
+sharp, repeated at frequent intervals and accompanied by other symptoms
+of distress, such as restlessness, contraction of the features, and
+drawing up the legs. In serious illness the cry is usually feeble,
+fairly constant except when the child is asleep, and exaggerated by
+slight causes.
+
+A limited amount of crying is useful exercise for a baby, and should not
+distress his mother unduly. Moreover, crying may be merely the
+expression of a wish to be taken up, to be played with, carried about or
+otherwise amused, to be given a pacifier, or to be indulged in other bad
+habits. If not indulged in these ways he may cry from temper. The cry of
+temper is loud and violent, accompanied by vigorous kicking or by
+holding the body rigid. Proper treatment of the baby may prevent many
+months of discomfort, and spare him the formation of his first bad
+habit. All other possible causes for crying should be eliminated. If the
+child continues to cry when he is warm and dry and comfortable, "It
+should simply be allowed to cry it out. This often requires an hour and
+in extreme cases two or three hours. A second struggle will seldom last
+more than ten or fifteen minutes and a third will rarely be necessary"
+(Holt). Gas may form in the child's stomach during prolonged crying. It
+is consequently permissible to take him up after 15 minutes, and hold
+him erect; he generally expels gas at once, and immediately experiences
+relief. As soon as he is relieved, he should go back to his crib.
+
+EXERCISE.--Exercise is essential to the development of the body, but
+during the first few weeks warmth and quiet are so important that a baby
+should not be disturbed except for necessary care. His position,
+however, should be changed occasionally; if he lies on the same side
+constantly the soft bones of the head may become misshapen from
+pressure. As the baby grows older he needs more exercise, and he may be
+given an opportunity for it by removing his outer clothing and placing
+him on a bed in a warm room for a short time each day. Unnecessary
+handling is not good for a baby at any age.
+
+After he becomes more active, he may play on a mattress or thick blanket
+placed on the floor. The blanket should be covered with a washable pad
+or rubber cloth and clean sheet, and the whole should be surrounded by a
+fence at least two feet high. In such an enclosure a baby may safely be
+left to play if protected from draughts and cold. Elevated pens that can
+be folded when not in use are more convenient but more expensive than
+the home-made arrangement. As soon as a child begins to run about he
+takes ample exercise, and he may even need to be guarded from too great
+fatigue, especially toward bedtime. Games and play should be adapted to
+the age of the child and sufficiently varied to exercise all portions of
+the body; but they should not be too violent nor too prolonged. Some
+supervision of children's play is necessary, but they should be given as
+much freedom as possible and allowed to develop their own initiative.
+
+PLAY AND TOYS.--The desire for play does not develop until a child is
+about six months old. At this age toys that can be washed, such as those
+of hard or soft rubber, should be selected. A baby instinctively carries
+everything to his mouth,--first his thumb, then playthings, and later
+whatever he may find, no matter how unsuitable. For his safety and
+protection this habit should be overcome as soon as possible, and he
+must learn to put nothing in his mouth except food and drink. Relatives
+are nearly always tempted to give too many and too fragile toys; they
+merely teach a child to be destructive and constantly to expect
+something new. Toys are the first possessions of which a child is
+conscious, and through them many desirable qualities may be developed:
+neatness and order, gentleness and a feeling of protection toward the
+helpless doll or Teddy bear, and unselfishness in sharing special
+treasures with playmates. Later the child may be given pets and made
+responsible for their care; but animals should not be subjected to
+unintentional cruelties from small children.
+
+
+EXERCISES
+
+1. What two factors are chiefly responsible for the deaths of babies
+under a year old? What other factors contribute? In your city or town
+what is the number of deaths per 1000 births of babies under one year
+old?
+
+2. Why is birth registration important to an individual? to a
+community? Is it required by law in your city?
+
+3. What is the average weight of babies at birth? Describe the rate at
+which they should gain.
+
+4. At what age may a normal child be expected to sit erect? to stand? to
+walk? to speak? When should his first teeth appear? his permanent teeth?
+
+5. Describe normal bowel movements of a baby.
+
+6. How should a young baby be dressed?
+
+7. Describe a baby's bath and toilet.
+
+8. Describe the surroundings that are suitable for a baby.
+
+9. What is the best food for a healthy baby? Why?
+
+10. Describe in detail a good daily program for a healthy baby four
+months old.
+
+11. What habits are desirable for a baby to form, and how may he be
+trained so that he will form them?
+
+12. Name all the indications that would tell you when a baby was not
+thriving, and in each case tell what you would do about it.
+
+
+FOR FURTHER READING
+
+The Care and Feeding of Children--Holt.
+
+The Care and Feeding of the Baby--Truby King.
+
+The Baby's First Two Years--R. M. Smith.
+
+The Care and Feeding of Children--J. L. Morse.
+
+Preventive Medicine and Hygiene--Rosenau, Section III, Chapter II.
+
+Pamphlets:
+
+  Prenatal Care, Mrs. Max West.
+
+  Infant Care, Mrs. Max West.
+
+  Child Care, Mrs. Max West. Published by the Children's Bureau,
+  United States Department of Labor, Washington, D. C. (Free on
+  request.)
+
+The Care of the Baby--Supplement No. 10 to the Public Health Reports,
+1913, Government Printing Office, Washington, D. C.
+
+Your Baby: How to Keep It Well--New York State Department of Health,
+Albany.
+
+Publications of the American Association for the Study and Prevention of
+Infant Mortality--1211 Cathedral Street, Baltimore, Md. (Free on
+request.)
+
+Publications of the National Committee for the Prevention of
+Blindness--130 East 22d Street, New York City. (Free on request.)
+
+
+FOOTNOTES:
+
+  [1] An area including about two-thirds of the population of the United
+  States.
+
+
+
+
+CHAPTER IV
+
+INDICATIONS OF SICKNESS
+
+
+By indications of sickness we mean all evidences of deviation from a
+normal physical condition. They may be apparent only to the person in
+whom they occur, or to a second person only, or to both. These
+deviations, commonly called the symptoms of sickness, are always
+important to notice, whether the conditions they indicate are serious or
+not.
+
+Early symptoms of sickness are often slight; hence they easily pass
+unnoticed. Yet a slight trouble, easily checked in its early stages,
+may, if neglected, grow into a serious or even fatal disorder: just as a
+burning match, which anyone could extinguish instantly, may kindle a
+fire beyond the power of an entire city to control.
+
+It is important, then, to notice even slight symptoms of sickness,
+first, in order to determine the nature of the trouble, and second, in
+order to institute treatment as early as possible. It is, however,
+hardly less important to observe symptoms accurately during the entire
+course of an illness. A patient's progress can be determined only by
+careful comparison between present and past conditions.
+
+Many symptoms can be detected only by methods requiring scientific
+apparatus as well as the knowledge and skill of a physician, but very
+pronounced symptoms are generally evident to anyone. The neighbors do
+not need to be told when a person has advanced tuberculosis; neither is
+an expert required to see that something ails a man with a broken leg.
+Furthermore less pronounced symptoms may often be clearly seen by any
+observant person, even by those not specially trained. Accordingly it is
+important for every woman who has charge of others, sick or well, to
+form the habit of noticing unusual appearances of any kind. This habit
+is one that most people must take pains to acquire, because people
+generally see only the things that their own experience in life has
+taught them to see. An added difficulty is the fact that when illness
+begins it is not a trained observer, but the untrained sufferer or
+untrained member of his family who decides whether to send for the
+doctor and thus to set in motion the machinery for treatment and cure.
+
+All the training and experience of a physician are required in order to
+decide what symptoms indicate, and to prescribe proper remedies.
+Diagnosis, or the process of determining the nature of illness from the
+symptoms observed, is often exceedingly difficult; it must take into
+consideration not one symptom only but the presence or absence of a
+number of symptoms. Untrained persons who attempt to make diagnoses are
+frequently led astray by the fact that actual causes of trouble may be
+situated far from the places where symptoms are felt or observed. For
+instance, the real cause of headache may lie in a region far removed
+from the head; and so-called heart-burn, which is caused by disordered
+digestion, has nothing to do with the heart. Again, an early symptom of
+tuberculosis of the hip joint is pain under the knee; a mother is
+clearly not doing the best thing when she assumes that any pain in a
+joint means rheumatism, and therefore doses her suffering child with the
+medicine that "helped" his rheumatic grandfather. No untrained person is
+equipped to make a diagnosis, and still less to prescribe medicine or
+treatment.
+
+Symptoms, like all other forms of discomfort, tend to trouble a patient
+in proportion to the amount of attention that he gives them. Hence, in
+order to avoid calling his attention to them unnecessarily they should
+be observed so far as possible without his knowledge; when it is
+unavoidable for him to realize what is going on, observation should be
+made a matter of routine, so that his interest may not be especially
+excited. For instance, everyone who has seen the routine medical
+inspection of school children realizes how little attention the children
+themselves give to the process, apparently regarding it merely as one of
+the many inexplicable proceedings of grown people. On the other hand,
+children who know their symptoms are over-anxiously watched soon learn
+to watch themselves and to exaggerate every little ache and pain.
+
+Symptoms may be divided into two classes: first, objective symptoms, or
+those that can be noted by an observer, like cough, pulse rate, or color
+of the skin; and second, the subjective symptoms, which are apparent
+only to the person affected, like pain and fatigue. The success of any
+woman who cares for the sick depends to a large extent upon her
+quickness and accuracy in noticing and reporting these symptoms and
+their variations. It should be remembered that pronounced symptoms are
+not the only ones of importance: even slight symptoms that continue over
+an appreciable length of time may be of very great importance. A brief
+description of some important symptoms follows, in order to help persons
+without technical training to describe the symptoms as well as to
+observe them.
+
+
+OBJECTIVE SYMPTOMS
+
+TEMPERATURE.--Bodily heat is produced by slow burning of food materials,
+which goes on for the most part in actively working muscles and glands.
+Heat thus generated is distributed by the blood to all parts of the
+body, but the surface of the body is generally cooler than the interior.
+In health the body temperature varies only a few degrees, no matter how
+much the temperature of its surroundings varies; consequently a
+temperature is abnormal if it is higher or lower than the usual
+temperature of a healthy person.
+
+The temperature is taken by means of a clinical thermometer placed
+either in the mouth, the rectum, or the armpit (axilla).
+
+[Illustration: FIG. 10.--CLINICAL THERMOMETER.]
+
+To take the mouth temperature, first wash the thermometer, using cold
+water and absorbent cotton or clean soft cloth. Next shake it until the
+mercury thread registers 96° or below. It is well before purchasing a
+thermometer to see whether it can be shaken down easily. Next place the
+thermometer in the patient's mouth, with its bulb under his tongue; he
+must then keep his lips closed until it is removed. Leave the
+thermometer in his mouth for two minutes. Then remove the thermometer,
+read the temperature and record the result. Clean the thermometer at
+once, using first cold water and soap, and then alcohol, 70%.
+
+The mouth temperature of a healthy person is about 98.6° F. This
+statement holds true if the person has been sitting with his mouth shut
+for a little while before his temperature is taken; but a hot bath,
+breathing through the mouth, eating or drinking, and so forth may cause
+marked temporary changes.
+
+The temperature in the rectum generally varies less than the temperature
+in the mouth unless it is taken when the rectum contains fecal matter.
+The temperature should be taken by rectum in babies and young children,
+restless, drowsy, or delirious patients, patients who cannot be trusted
+to keep the thermometer under the tongue, mouth breathers, and in any
+patients who have difficulty in keeping the mouth shut. The temperature
+is normally about half a degree higher in the rectum than in the mouth.
+
+In order to take a temperature by rectum, adults generally find it more
+convenient to lie on the side and prefer, if they are able, to insert
+and hold the thermometer themselves; but the attendant should be
+certain that they can do so without breaking the thermometer. Rectal
+thermometers should be lubricated with oil or vaseline before using;
+they should be inserted about two inches, left in three minutes, and
+cleansed in the same way as the mouth thermometer. A thermometer used to
+take rectal temperatures should never be used in the mouth.
+
+In taking the temperature of a baby place him on his back, hold him
+firmly with his legs elevated, and carefully insert the bulb of the
+thermometer, well oiled, for about one inch. Keep the child quiet, and
+hold the thermometer in place three minutes. Great importance should not
+be attached to a slight fever of short duration. The temperature of a
+child is much more easily affected by slight causes than that of an
+adult, and rectal temperatures between 97.5° and 100.5° should not cause
+anxiety unless continued.
+
+Temperatures taken in the axilla are less accurate than those taken by
+mouth or rectum. Consequently the method is less often used. The axilla
+should first be wiped; then the thermometer should be inserted and held
+for 5 minutes by pressing the arm tightly against the chest wall. The
+temperature in the axilla is normally about half a degree lower than in
+the mouth.
+
+The temperature varies somewhat according to the time of day. It is not
+unusual for the mouth temperature of persons who are entirely healthy to
+be as low as 97° in the early morning, or as high as 99° in the late
+afternoon, and probably most people's temperatures vary as much as a
+degree during the twenty-four hours. Even greater variations that are
+not long continued have little if any significance in people who feel
+well.
+
+Decided variations either above or below normal are highly important
+symptoms. A temperature below 98° is called subnormal, and one above
+99.5° is called fever. The number of degrees of fever does not
+necessarily bear a direct relation to the severity of an illness. Thus,
+it does not follow that one person is twice as sick as another, because
+his temperature is twice as many degrees above normal. All symptoms,
+including variations in temperature, must be considered in connection
+with one another, and it is generally impossible to state the
+significance of any one symptom taken by itself.
+
+The temperature should be taken once or twice a day as a matter of
+routine in almost every form of illness, and oftener when the patient's
+condition requires it. Also it should be taken as a matter of routine
+whenever there is indication of beginning sickness; especially when
+there is headache, pain, sore throat, coated tongue, cough or cold,
+chill, vomiting, diarrhœa, or rash. It is not a good plan to take
+one's own temperature oftener than necessary, or indeed anyone's;
+certainly not a baby's, since frequent use of the thermometer may
+irritate the rectum.
+
+PULSE.--Each time the heart beats, blood is forced out from the heart
+into the arteries, thus causing an expansion of the arterial walls. This
+expansion, called the pulse, can be felt in some places where arteries
+lie close to the surface of the body. The character of the pulse beat
+and its rate, or the number of times the beat occurs each minute, give
+information about the heart and blood vessels; taken together they are
+perhaps more important than any other one symptom.
+
+[Illustration: FIG. 11.--TAKING THE PULSE AT THE WRIST. NOTE THE
+POSITION OF ARM. (_From "Elementary Nursing Procedures," California
+State Board of Health._)]
+
+The pulse rate varies much more than the temperature. It differs in
+different individuals and at different ages, and it often shows great
+temporary changes, especially during exercise or eating, or as a result
+of excitement, fear, or other emotion. Definite statements in regard to
+normal pulse rates are hard to make, because different individuals
+though in perfect health show marked variations; we generally say,
+however, that the pulse rate of a normal man at rest is about 72 a
+minute, and that of a normal woman is about 80 a minute. At birth the
+pulse is quickest; it may then be from 124 to 144. From the 6th to the
+12th month it may be from 105 to 115 a minute, and from 90 to 105
+between the 2d and 6th years. About the time of puberty it reaches the
+adult rate, and during old age it may be decidedly slower than the adult
+rate.
+
+What we chiefly want to know about the pulse is
+
+1. Its rate, or number of beats per minute,
+
+2. Its force,--whether weak or strong,
+
+3. Its rhythm,--whether regular or irregular.
+
+Much practice is necessary before the pulse rate can be counted with any
+degree of accuracy, and wide experience with both normal and abnormal
+pulses is required in order to judge its strength, rhythm, or other
+characteristics.
+
+The pulse may be felt most conveniently on the thumb side of the front
+of the wrist. The pulse should be counted while the patient is lying
+down, and the watch used must have a second hand. To count the pulse,
+one should place two or three fingers (not the thumb) on the patient's
+wrist, and after the pulse has been felt distinctly for a few beats, the
+exact time by the second hand of the watch should be noticed and the
+counting begun immediately. It is generally best to count for half a
+minute, multiply the result by two to get the rate for a whole minute,
+and then to repeat for another half minute. The two results should agree
+within two beats, if the patient is quiet. A greater variation than two
+beats may mean that the pulse rate is varying, but when it is counted
+by inexperienced persons the apparent difference is generally the result
+of inaccurate counting, and it may be necessary to count two or three
+times more. The force of the pulse varies also in different individuals;
+it is, however, important to notice when it grows stronger or weaker in
+the same person. Normally the pulse-beat is regular like the ticking of
+a clock; it is called irregular if a few rapid or slow beats are
+followed by others of a different rate. During sickness the pulse should
+be counted whenever the temperature is taken, or oftener; and the result
+should be written down at once. The pulse of a sick person often shows
+changes both in rate and character; these changes are generally
+important and should be noticed.
+
+RESPIRATION.--Variations in the rate and character of respiration or
+breathing should be noticed. The normal rate of respiration for an adult
+at rest is 16 to 20 each minute, but it may be much faster, especially
+during muscular exercise. In babies the rate is about 30 to 35 a minute,
+and 20 to 25 in little children. The respirations, especially of babies,
+can best be counted during sleep by placing the hand lightly on the
+chest or abdomen. Since the respiration rate is partly under a person's
+control, it is almost sure to alter if the patient knows it is being
+counted; hence when the patient is awake it is better to keep one's
+fingers on his wrist, to place his hand upon his chest, and then to
+count the rise and fall of the chest while apparently counting the
+pulse. Sometimes it is possible to count the respirations merely by
+watching the rise and fall of the nightgown or bed clothes. The
+respiration is usually counted for a full minute. A watch with a second
+hand must be used, and the result should be recorded immediately.
+
+In certain forms of sickness breathing may become rapid, especially if
+the lungs or air passages are affected. In addition to the rate anything
+unusual about the breathing should be noticed whether it seems difficult
+or painful; if noisy, whether the sound is like snoring, or wheezing, or
+sighing, and so on.
+
+GENERAL APPEARANCE.--Any unusual expression of the face should be noted;
+whether it is drawn, pinched, anxious, excited, or dull and stupid; and
+also, whether the face is thin, swollen, or puffy under the eyes. The
+condition and appearance of the skin are significant: the skin may be
+dry, moist and clammy, hot or cold; its color, and the color of the face
+especially, may be flushed or pale or slightly yellow or blue. A bluish
+tinge about the nose, tips of the fingers, or the feet should be
+specially noticed. Reddened or discolored areas on any part of the body
+may be important, and also eruptions, rashes, swellings, or sores. It
+should be noticed whether the abdomen is normal or whether it is
+distended and hard.
+
+Strength or weakness is indicated to some extent by the way the patient
+moves, and by his ability to walk, stand, sit, hold up his head, feed
+himself, or turn in bed without assistance. The position he habitually
+takes is sometimes significant; in heart affections, for instance, he
+may be unable to lie down, in pleurisy he ordinarily lies on the
+affected side, and during abdominal pain he generally draws the knees
+up.
+
+SPECIAL SENSES.--The special senses are frequently disturbed in
+sickness. The eyes may be blood-shot; the patient may be over-sensitive
+to light, or see spots floating before the eyes, or he may be unable to
+see at all. The pupils of the eyes may be unusually large or small, or
+one may be large while the other is small. Swelling, redness, or
+discharge from the eyes should be noticed. Hearing and touch and smell
+may be impaired; or they may be abnormally acute, and cause real
+suffering. Taste may be impaired, especially when the nose is affected
+or when the mouth is not clean. Discharge from the nose or ears should
+be reported. Not only discharge, but also trouble of any kind, such as
+pain, tenderness, or swelling, is important if situated in or near the
+ears.
+
+THE VOICE is often much altered in sickness. It may be weak, hoarse, or
+whispered. Speech may be clear or thick, or the ability to speak may be
+entirely lost; in extreme weakness speaking is generally difficult, and
+may be impossible. Moaning, groaning, and other unusual sounds should be
+noted. A loud, sharp cry at night with or without waking, if a repeated
+occurrence, may be an early symptom of some diseases of children.
+
+THE TONGUE in health is red and moist; when extended it is somewhat
+pointed and can be held steadily. In sickness it may be cracked, dry and
+parched, or if the patient is not properly cared for, it may be covered
+with white, yellow, or brown coating; in many exhausting illnesses it is
+flabby and trembling. In scarlet fever the tongue is often a vivid red
+color, and is then called strawberry tongue. The odor of the breath may
+be foul from decay or neglect of the teeth, from indigestion,
+constipation, nasal catarrh, or special diseases.
+
+THE THROAT and tonsils are sometimes red and swollen as in simple sore
+throat; or they may be covered by white patches.
+
+THE GUMS may be swollen, tender, or bleeding. A collection of sticky
+brownish material may appear on the teeth and gums of neglected
+patients.
+
+COUGH when present may be: dry, or accompanied by expectoration;
+painful, frequent, loud, or whooping; and worse by day or by night. The
+sputum may be yellow, white, gray, rusty, blood-streaked, dark, or
+frothy. The amount of sputum should be noticed as well as its
+appearance.
+
+APPETITE or absence of appetite should be noted, and also the amount of
+food actually eaten by a patient; the amount eaten is frequently not the
+same as the amount carried to him on a tray.
+
+If VOMITING occurs, the color, consistency, amount, and general
+appearance of the vomitus should be noted; if its appearance is unusual
+the vomitus should be saved for the doctor's inspection.
+
+EXCRETIONS.--The number of bowel movements is important, and also their
+character. The consistency of the feces may be hard, soft or fluid;
+their color may be any shade of brown, yellow or green, from black to
+clay color. They should be saved for the doctor to see if appearance or
+odor is unusual.
+
+THE URINE in health is clear, amber colored, and slightly acid. From 30
+to 50 ounces should be excreted in 24 hours; the amount varies, however,
+especially according to the amount of fluid taken. It is important to
+notice whether the urine is scanty or greatly increased in amount, dark
+or pale, clear or cloudy, and whether sediment is deposited after
+standing. It is essential that urine should be voided in sufficient
+amount; the necessity for watching its quantity is frequently overlooked
+in the home care of the sick. Frequency of urination should also be
+noted. Inability to urinate, particularly where the urine has previously
+been scanty, is serious if continued; it should be reported to the
+doctor without delay. Inability to control the bladder and bowels are
+also symptoms to be reported.
+
+LOSS OF WEIGHT is significant in both adults and children, and failure
+of babies and children to gain in weight is a danger signal.
+
+SLEEP.--The number of hours a patient sleeps should be noticed and
+recorded as accurately as possible. The word of the patient on this
+subject is not sufficient evidence. Character of sleep should also be
+noted, whether it is quiet or restless, and whether the patient sleeps
+lightly or is difficult to arouse.
+
+MENTAL CONDITIONS.--It is important to watch carefully the mental
+condition of a patient; whether, for example, he is normal, or
+depressed, irritable, restless, apathetic, dull, excited, wandering,
+delirious, or unconscious. Hasty judgment of mental conditions should
+be avoided, but close attention to them is necessary.
+
+
+SUBJECTIVE SYMPTOMS
+
+PAIN is the most important subjective symptom and should never be
+disregarded. Bodily pain does not occur in persons who are in all
+regards physically and mentally well; hence pain is a sign that
+something, small or great, is out of order.
+
+      "Of all symptoms pain is the one which interests patients
+      the most. We here emphasize the truth, too little
+      understood, that pain is an unpleasant sensation, nothing
+      more, and is _never_ imagined. Imagination may be its
+      cause, but the pain thus produced hurts just as truly as
+      pain produced by a real disease. Pain is only a phenomenon
+      of consciousness; it is always real, even that felt in a
+      dream. If the patient is too unconscious to feel it, there
+      simply is no pain, no matter how badly the person's body is
+      injured." (Emerson: Essentials of Medicine, p. 356.)
+
+One should remember that no possible method exists to measure the
+intensity of pain exactly, or to describe its quality accurately.
+Therefore in describing pain, it is best to use the patient's own
+language. Four points should especially be observed, (1) its location;
+(2) its character, which may be dull or sharp, stabbing, throbbing or
+continuous, slight or severe; (3) the time at which it is worst; certain
+diseases, for instance, are characterized by more severe pain at night;
+(4) it should be noticed whether the pain is relieved or increased by
+change of position, eating or drinking, heat or cold, or the like. Pain
+may be felt in a part far from the place where the trouble really lies;
+thus a dislocated shoulder causes pain in the elbow.
+
+Pain is always a danger signal, although the significance is not always
+so great as the sufferer thinks. The more attention a patient gives to
+his pain, the more severe it always becomes, therefore his attention
+should not be called to it unnecessarily. A good observer, however, can
+get much information by noticing the patient's expression, position,
+motions, etc., without constantly asking him how he feels. Although many
+persons overestimate pain, others persistently disregard it, either
+because they are unwilling to take the necessary measures to remedy it,
+or because they wish to appear heroic. Both courses of action are
+mistaken; everyone should realize the folly and danger of bearing pain
+if it is possible to remove the cause.
+
+Nausea, fatigue and malaise are other subjective symptoms; malaise is
+the name given to a general feeling of physical discomfort not
+restricted to any one part of the body. All three are abnormal when
+there is not apparent or sufficient cause.
+
+RECORDS.--An accurate record should be kept of the patient's symptoms,
+medicine, diet, treatment, etc., so that the doctor may have a
+continuous record, and so that another person taking charge temporarily
+may know just what has been done for the patient. The record must be
+written; otherwise details cannot be remembered exactly. It should be as
+simple and concise as possible; it is the place for facts, not for
+opinions, and if inaccurate it is worse than none. It is better not to
+keep the record in the patient's room, for the patient should not see
+his own record, nor hear its contents discussed. The doctor usually
+writes his orders on the record sheet itself, or on a separate sheet to
+be attached to the record for reference. Blank record forms can be
+purchased, but a form that is made at home is entirely satisfactory. An
+example of a daily record sheet follows.
+
+
+                                  RECORD
+
+  ------+----------+----+-----+-----+----------------+----+-----+-------
+   Date |  Hour    |Tem.|Pulse|Resp.|   Diet and     |B.M.|Urine|Remarks
+        |          |    |     |     |   medicine     |    |     |
+  ------+----------+----+-----+-----+----------------+----+-----+-------
+  1916  |          |    |     |     |                |    |     |
+  Jan. 1|4 p.m.    |100°| 76  | 24  |Medicine        |    |     |
+        |5 p.m.    |    |     |     |                | 1  |℥ vii|
+        |6 p.m.    |    |     |     |Supper:         |    |     |
+        |          |    |     |     | Baked potato,  |    |     |
+        |          |    |     |     | toast, fruit,  |    |     |
+        |          |    |     |     | tea.           |    |     |
+        |8 p.m.    |    |     |     |Medicine        |    |     |Sponge
+        |          |    |     |     |                |    |     |bath.
+        |9:30 p.m. |    |     |     |                |    |     |Asleep.
+  Jan. 2|3 a.m.    |    |     |     |                |    |℥ ix |
+        |8 a.m.    |99° | 74  | 22  |Medicine        |    |     |Patient
+        |          |    |     |     |                |    |     |slept
+        |          |    |     |     |                |    |     |most
+        |          |    |     |     |                |    |     |of the
+        |          |    |     |     |                |    |     |night.
+        |8:30 a.m. |    |     |     |Breakfast:      |    |     |
+        |          |    |     |     | Cereal, orange,|    |     |
+        |          |    |     |     | toast, coffee. |    |     |
+        |9:30 a.m. |    |     |     |Bath.           |    |     |
+        |11:30 a.m.|    |     |     |                |    |     |Sat up
+        |          |    |     |     |                |    |     |1 hour.
+  ------+----------+----+-----+-----+----------------+----+-----+-------
+
+TUBERCULOSIS, CANCER, AND MENTAL ILLNESS.--As we have seen, early
+symptoms of sickness are always important; yet it seems worth while to
+mention particularly the early symptoms of tuberculosis, cancer, and
+mental disorders, because each of these diseases, though curable in
+many cases when taken in the early stages, is serious and often fatal
+if neglected. Certain facts relating to their cause and prevention
+should be known to everyone. Tuberculosis, long our greatest cause of
+death, is gradually growing less; but cancer and mental disease are now
+on the increase.
+
+TUBERCULOSIS.--Every year tuberculosis causes the death of about 150,000
+people in the United States. It is caused by the bacillus tuberculosis,
+a germ which may attack any tissue of the body, although it most
+frequently affects the lungs of grown people, and the bones and glands
+of children. The disease is not inherited, but susceptibility to it
+appears to be; it is readily communicated from person to person. The
+germ of tuberculosis is so widely distributed that probably few persons
+over 30 years of age have not been infected with it at some time,
+although the infection may have been too slight to be noticed. Indeed,
+most people have probably been infected many times, though without
+serious results.
+
+Tuberculosis is spread chiefly in two ways: (1) through any bodily
+discharges from infected persons, especially through the nose and mouth
+discharges; (2) through milk from infected cows. The ways by which the
+disease is spread indicate methods of prevention. Milk, especially for
+children, should either be pasteurized or should come from cows that
+have been tested and proved to be free from the disease. Other methods
+of prevention include avoiding any and all bodily discharges of infected
+persons, and increasing bodily resistance as far as possible. Good food,
+sufficient rest and fresh air are not only important preventives, but
+also the most efficacious means of cure. Persons who suffer from
+insufficient food, exposure, bad housing, long hours, and bad conditions
+of work are especially susceptible to tuberculosis, and thus it is
+rightly called a disease of poverty.
+
+Early symptoms of tuberculosis include cough, hoarseness, loss of
+appetite, pain in the side, loss of weight, getting tired easily,
+feeling run down, rise in temperature in the afternoon, night sweats,
+expectoration, and spitting blood. No one, nor even several, of these
+symptoms necessarily indicates the presence of tuberculosis; on the
+other hand, even the cough is not necessarily present when tuberculosis
+actually exists. When one or more of these symptoms appears and
+continues, a thorough examination should be made by a doctor;
+examination can do no harm, certainly, if tuberculosis is not found, and
+if it is, immediate treatment is of the greatest importance. No known
+drug or medicine is a cure for tuberculosis. Successful treatment
+depends on taking the disease in time and in following the doctor's
+advice unremittingly.
+
+CANCER.--The cause of cancer is not known. All the evidence, however,
+goes to show that it is neither communicable nor hereditary. Cancer may
+occur on the skin, stomach, or other organs; in women it most commonly
+occurs in the breast or uterus (womb). In both sexes it occurs most
+frequently after 40 years of age. No known medicine will cure cancer;
+salves and ointments have no effect. Radium and _x_-ray should not be
+relied upon if the cancer can be removed by operation. Safety consists
+in removing the growth entirely, and complete removal is possible only
+in the early stages.
+
+Early diagnosis is consequently of the greatest possible importance, and
+an examination can do no harm in any case. Warts and moles on the skin
+may develop into cancer, and should be removed if they show signs of
+irritation. Loss of appetite and weight, any disturbance of the stomach
+or intestines, and sores that refuse to heal should lead a person to
+consult a physician; the same is true of any lump in the breast, and of
+irregular or persistent bleeding from the uterus in women over forty.
+The fact that pain is not present in cancer until the late stages leads
+many persons to neglect the trouble until it is too far advanced for
+operation. Time is all-important; hope depends on operation in the early
+stages when there is a very great probability of permanent cure.
+
+MENTAL ILLNESS.--Insanity, like cancer, is increasing. Like both cancer
+and tuberculosis, hope lies in prevention and early treatment; and like
+them both, in its early symptoms it is too often unrecognized or
+neglected.
+
+Many people are surprised to learn that known, avoidable causes are
+responsible for the condition of about 50% of the insane patients now
+under treatment. Chief among these known causes is a communicable germ
+disease called syphilis, to which is due the disease called paresis, or
+"softening of the brain." About 25% of patients admitted to hospitals
+for the insane are there from the effects of habitual use of alcohol,
+even in "moderate" quantities. Other cases of insanity result from
+diseases of the heart, arteries, and kidneys, and still others have been
+traced to the poisons of tuberculosis, typhoid, diphtheria, and other
+communicable diseases. Prevention of insanity caused by these diseases
+depends upon prevention or complete cure of the diseases themselves.
+
+Still other causes of insanity are known. Hereditary nervous weakness
+may predispose to insanity, and for such persons, those whose nervous
+resistance is naturally not very great, the stress of living may prove
+too much. Mental breakdowns are rarely caused by overwork unless
+accompanied by worry or bad hygienic conditions, but they result not
+infrequently from bad mental habits.
+
+      "The average person, little realizes the danger of brooding
+      over slights, injuries, disappointments, or misfortunes, or
+      of an unnatural attitude towards his fellowmen, shown by
+      unusual sensitiveness or marked suspicion. Yet all these
+      unwholesome and painful trains of thought, may if persisted
+      in and unrelieved by healthy interests and activities, tend
+      towards insanity. Wholesome work relieved by periods of
+      rest and simple pleasures and an interest in the affairs of
+      others, are important preventives of unwholesome ways of
+      thinking. We should train ourselves not to brood, but to
+      honestly face personal difficulties."--(Why Should Anyone
+      Go Insane?, by Folks and Ellwood.)
+
+Prevention of insanity consequently depends chiefly upon avoiding
+alcohol and communicable diseases, especially syphilis; upon good
+hygiene, self-control, and avoidance of bad mental habits; and upon
+adopting a program of living and working that will not overtax one's
+nervous strength. Sleeplessness, unusual nervous fatigue following
+slight exertion, and diminished power to control the emotions, are among
+the danger signals. And when a person becomes unusually depressed or
+morose, excited or irritable, suspicious, unreasonable, or "queer," it
+is probable that expert medical advice should be obtained as quickly as
+possible.
+
+
+EXERCISES
+
+1. What is a symptom? Why are early symptoms especially important?
+
+2. Distinguish between objective and subjective symptoms.
+
+3. Tell all you can about normal and abnormal variations in the body
+temperature. What symptoms would lead you to take a person's
+temperature?
+
+4. Describe the method of taking temperatures.
+
+5. How should you cleanse a clinical thermometer? What are the dangers
+of neglecting to cleanse it properly?
+
+6. Describe both normal and abnormal pulse and respiration.
+
+7. Discuss the significance and importance of pain.
+
+8. Describe early symptoms of tuberculosis, cancer, and mental illness.
+What is the first step to be taken when any one of these symptoms
+appears?
+
+9. What symptoms of all those mentioned in this chapter did you notice
+in the last sick person with whom you had anything to do?
+
+10. What are the essentials of a good daily record? The following is an
+account that a mother gave of the first twenty-four hours of a child's
+illness. Make a chart for the patient, and include in it all the
+information the mother gave. Which do you consider more useful, your
+chart or the narrative?
+
+"Yesterday, October 10th, Johnny came home from school about half past
+three, and said he was too cold to play outdoors. He lay down and slept
+till about five, when he vomited a large amount of undigested food. I
+took his temperature and found that it was 103.8°, pulse 126, and
+respiration 28. At 10 that night his temperature was 102.5°, pulse 116,
+and respiration the same as before. The next morning at 8 he had a
+temperature of 100.6°, pulse 114, respiration 24. At noon his
+temperature was 101°, pulse 118, respiration 24; and at 4 o'clock his
+temperature was 100.6°, pulse 122, respiration 22. The doctor came at 6
+o'clock yesterday afternoon; according to his orders I put Johnny to
+bed, gave him half a tablespoonful of castor oil at 6.30, and a special
+gargle. His throat was red and sore and he seemed to feel very
+miserable. The doctor took a culture from the child's throat. At 8.15
+and again at 8.50 he had fluid bowel movements. At 9.30 he had a glass
+of milk, after which he slept until 6 a.m. when his bowels moved again
+and urine was passed. He passed eight ounces of urine at noon and four
+ounces at 3.30. He drank a glass of water at 6 this morning, and at 6.30
+I gave him a cup of hot broth. At 8 he had a glass of milk, but at 10 he
+refused everything but a glass of water. At 1.30 he had a large dish of
+ice cream. He had a cool sponge bath last night at 9, and a cleansing
+bath this morning at 8.45. This morning his throat was still sore but
+not so red, and I saw that he gargled every half hour when he was awake.
+This afternoon he seems brighter and asked for his harmonica, so his
+throat is probably more comfortable."
+
+
+FOR FURTHER READING
+
+Essentials of Medicine--Emerson, Chapters XVI, XVII.
+
+The Human Mechanism--Hough and Sedgwick, Chapter XII.
+
+Notes on Nursing--Florence Nightingale, Pages 105-136.
+
+Why Worry?--Walton.
+
+Those Nerves--Walton.
+
+Tuberculosis: Its Cause, Cure, and Prevention--Otis.
+
+Publications of the National Association for the Study and Prevention of
+Tuberculosis--105 East 22d Street, New York City. (Pamphlets free on
+request.)
+
+Publications of the National Committee for Mental Hygiene--50 Union
+Square, New York City. (Pamphlets free on request.)
+
+Publications of the Mental Hygiene Committee of the State Charities Aid
+Association--105 East 22d Street, New York City. (Pamphlets free on
+request.)
+
+Publications of The American Society for the Control of Cancer--25 West
+45th Street, New York City. (Pamphlets free on request.)
+
+
+
+
+CHAPTER V
+
+EQUIPMENT AND CARE OF THE SICK ROOM
+
+
+Adequate care of the sick consists to a large extent in rendering their
+physical and mental surroundings as favorable as possible. Obviously, a
+sick person, since his strength is already depleted, needs not only to
+have his resistance increased in all possible ways, but also to have all
+his remaining strength conserved by eliminating every unnecessary tax
+upon it. In sickness even slight fatigue, chill, or nervous strain,
+insufficient ventilation, or improper feeding, may become factors of
+immense importance. Nothing is trivial if it affects the welfare and
+comfort of a patient.
+
+Even when perfect provision for the care of the sick is out of the
+question, every effort should be made to insure as satisfactory
+arrangements as possible. Ideal conditions are seldom found except in
+buildings originally planned for the sick; yet in many houses a few
+simple changes will produce excellent results. Of course, it is not
+necessary in every case to adopt all the following suggestions. Common
+sense must be the guide. For instance, in illness that is slight and
+likely to be of short duration, a patient may be more distressed than
+benefited by radical changes in his surroundings. Except when certain
+essentials are concerned, great consideration should be given to a
+patient's preferences; yet on the other hand it is not reasonable to
+make an entire family miserable in order to gratify some slight whim.
+
+CHOICE OF A SICK ROOM.--A south or east exposure is generally best for a
+sick room. A south room may be undesirable in very hot weather, but
+sunshine during a part of the day is essential. The room should be
+quiet, near the bath room, and well removed from odors from the kitchen.
+It should be situated so that good ventilation is possible. It is
+desirable though not necessary for it to have more than one window; in
+summer the windows must be thoroughly screened. It should be possible to
+open the window without exposing the patient to a direct current of air,
+and to open the door without placing him in full view of all who pass
+through the hall.
+
+It is essential for the patient to have a room to himself. Unless he
+needs care or help or watching at night, not even the person caring for
+him should sleep in the room. Neither should the rest of the family
+keep their possessions in the sick room. Closets opening into the room,
+bureaus, and chiffoniers should be emptied of the belongings of other
+members of the family, to prevent people from tiptoeing into the sick
+room at all hours to remove garments. The sick room should for the time
+belong exclusively to the patient, and resulting inconvenience should be
+borne by well members of the family.
+
+Every possible precaution should be taken to exclude from a sick room
+unnecessary noises of all kinds; flapping curtains, squeaky doors and
+rocking chairs, heels without rubber, creaking corsets, noisy
+petticoats, ticking clocks, refractory bureau drawers, and rustling
+newspapers are among the everyday sounds that irritate the nerves of
+sick and well alike. Ordinary out-of-door noises do not usually disturb
+the sick, except when the country patient is brought to the city, or the
+reverse; but nearby and generally avoidable noise is the kind that
+distracts and harasses nervous patients.
+
+Whispering is an annoying sound and should not be allowed, either in the
+patient's room or just outside the door. Whatever the subject of
+conversation may be, the patient thinks that he is under discussion.
+Anything undesirable for him to hear should be settled well out of his
+hearing, and in speaking to him there is no possible objection to an
+ordinary well modulated voice.
+
+Usually a person's own room is more restful and less disturbing than a
+strange place, but if it serves as a work room as well as a bed room, it
+may easily be the worst place during sickness. The sight of a desk piled
+high with papers or a basket overflowing with accumulations of family
+mending may actually delay recovery; even the room itself may constantly
+suggest work, and work necessarily left undone. The essential thing to
+remember is that mental rest is no less important than physical, and
+every effort should be made to secure them both.
+
+FURNISHING.--Superfluous articles add to the care of a sick room, and in
+consequence they should be removed at the outset. All the furnishings
+that remain should be easy to clean, but it is not necessary for a sick
+room to look bare and desolate.
+
+The woodwork as in any other room should have a hard finish, and angles
+and corners that harbor dust should be as few as possible. Hard wood
+floors without cracks are best from the point of view of cleanliness and
+convenience. A few light, washable rugs make the best floor covering,
+but very small rugs on highly polished floors slide easily and are
+decidedly dangerous. Carpets diminish noise, but are objectionable from
+every other point of view.
+
+In furnishing houses people ought to realize more frequently than they
+do how greatly nervous fatigue may be increased by ill chosen wall
+coverings. Plain papers or tinted walls are best for bed rooms and the
+color should not be harsh or striking; soft gray, green, or buff is
+good. The design is no less important than the color; a design that on
+casual inspection appears quite harmless may become an instrument of
+torture to a person unable to escape from it for a single hour. Weak or
+nervous patients sometimes become quite exhausted from attempting to
+follow an intricate pattern, or from counting over and over a design
+that is frequently repeated on the wall. If the patient sees grotesque
+faces and figures in the design the paper is more objectionable still.
+
+Necessary furniture includes the bed, which will be discussed in detail
+later, a small table to stand by the head of the bed, a dresser, two
+chairs, and a wall thermometer. If the patient is able to sit up three
+chairs are needed, of which one should be an armchair with a high back.
+No rocking chair should be allowed in the room unless the patient
+himself prefers to sit in one; no one else should be allowed to rock in
+the room, since the motion is almost always annoying to patients.
+Elaborate, carved, or upholstered furniture is unsuitable in a sick
+room, but if it must be used it should have washable covers.
+
+Other desirable articles of furniture are a couch, screen, foot-stool
+and a second, larger table. In few cases, if any, is anything further
+really necessary, although patients frequently desire special articles
+to which there can be no objection.
+
+Most ornaments add much work and little beauty, and have no place in a
+sick-room. No heavy unwashable curtains or hangings should be allowed,
+but simple washable curtains and clean white covers for the tables and
+dresser are desirable. Pictures, if suitable, give much pleasure, but
+must be used with discretion. It goes without saying that the subjects
+should be pleasant, but not everyone realizes that complicated subjects
+are undesirable and that pictures of people or things in motion should
+be avoided; patients are sometimes worried to see motion that is forever
+incomplete.
+
+Flowers give great pleasure to the sick by adding color and variety and
+interest to their surroundings. They should be carefully tended and
+given fresh water daily. Fading flowers and forlorn plants should be
+removed from the sick room, and those having strong, heavy odors should
+not even be admitted. They do not need to be very many or very
+expensive; indeed, a potted plant or a few cut flowers are often more
+acceptable than the great masses of costly flowers that are daily
+brought to the private wards of hospitals.
+
+VENTILATION.--A patient needs fresh air certainly as much as a well
+person, and probably even more. His room should be thoroughly ventilated
+night and day. A fireplace makes the problem easier, but in most cases
+an open window is the main dependence. It should be possible to open
+windows at the top as well as at the bottom, and the patient may be
+protected from a direct draught by a screen, or by a sheet stretched
+along the side of the bed and fastened at the head and foot by tying it
+around the posts.
+
+Ventilating a room without subjecting the patient to draughts is not
+always easy. One method is to insert a board three or four inches high
+under the lower sash so that air is admitted between the two sashes.
+Another way to ventilate without causing a draught is to remove one or
+two panes of glass and tack cheese cloth over the opening; or to tack
+cheese cloth to the lower edge of the upper window casing and to the
+upper edge of the upper sash, after the sash has been lowered about a
+foot. Once or twice a day the room should be thoroughly aired by opening
+windows and doors until the air has been completely changed. The
+patient, including his head, must be well-covered during the process.
+An electric fan is useful in summer, but it should not be close enough
+to the bed for the patient to feel air blowing upon him.
+
+HEATING.--Great care should be taken to maintain a suitable temperature
+in the sick-room, and for this purpose a thermometer in the room is a
+necessity. Between 65° and 68° is generally the best temperature, and
+hot water bags and extra covers may be given if the patient is chilly.
+During a bath or other treatment in which the patient is more or less
+exposed the temperature should be 70°. The temperature at night may be
+lower; how low will depend largely on the patient's condition and on
+what must be done for him during the night. Hot water, steam heat, or
+electricity is best for the sick room. Gas or oil stoves should never be
+used except in emergencies, and then for a short time only.
+
+LIGHTING.--Sunlight is one of the most powerful disinfectants, and for
+this reason if for no other it is needed in every sick room. Sunless
+rooms, moreover, even if they were wholesome, are too depressing to a
+patient's spirits for use except perhaps in hot summer days. Ordinary
+well-regulated light is best in a sick room, and except in a few
+diseases, especially those in which the eyes are affected, it is
+undesirable to darken the room or to encourage in any way an appearance
+of gloom. The patient's eyes, however, should be protected from bright
+lights shining directly upon them; in this connection it is well to
+remember that lights and their reflections strike differently upon the
+eyes of a person lying down from the way in which they strike the eyes
+of persons sitting or standing, and a light that seems agreeable to the
+attendant may therefore be painful to the patient.
+
+Almost all persons sleep best in dark rooms, and in most cases it is
+undesirable for a sick room to be lighted at night. The attendant,
+however, must be able to see what she is doing and generally needs a
+shaded candle, small night light, or electric flash. It should be
+possible to see the patient clearly in case of need, otherwise serious
+changes in his condition occurring in the night may pass unnoticed.
+
+A reading lamp on the bedside table is desirable for patients allowed to
+read, but reading in bed even with a well-regulated light is fatiguing,
+and should not be continued for long uninterrupted periods. A pocket
+flash light is safer than matches and a candle for patients who wish to
+consult their watches in the night; indeed, matches in the hands of
+patients always involve risk. Some patients find twilight a time of
+great depression. In such a case it had best be shortened by drawing
+the shades early, turning on the lights, and remembering not to leave
+him alone.
+
+CLEANING.--The sick-room should be kept thoroughly clean at all times,
+and the less dust stirred up in doing so the better. Dry sweeping or
+dusting should not be allowed. Ordinary brooms should be dampened or
+covered with damp cloths, and dust cloths should be dampened also; but
+dustless mops and dusters are still better. Vacuum cleaning is very
+desirable; the noise, which is its only disadvantage, is not a serious
+objection in most cases. The cleaning of rooms after a communicable
+disease will be considered later.
+
+A sick room must be kept tidy as well as clean. The effect of order is
+quieting, but it should be maintained whether the effect upon the
+patient is apparent or not. Food and medicine should not be kept in the
+sick-room, and all used dishes, tumblers, soiled linen, etc., should be
+removed at once. Unnecessary articles should not be found in the room at
+any time; every necessary article should be kept in its place, and its
+place should be a good one.
+
+Maintaining order in the room does not mean that patients should be made
+uncomfortable. All patients, especially old people, want certain
+possessions within reach, and their wishes should be considered in spite
+of the fact that the æsthetic effect is generally far from good. For
+instance, a perfectly smooth bed is undesirable if in order to make it
+smooth the patient must be tucked in so tightly that he is
+uncomfortable. And it would be a mistake to remove an old man's
+newspapers before he has read them, even if he persists in strewing them
+all over the floor.
+
+THE ATTENDANT.--One person and one person only should carry the entire
+responsibility for the patient. She should plan for him as well as care
+for him, should see the doctor and take the doctor's orders. Confusion
+and innumerable mistakes result when several members of the family
+attempt to do the talking and directing.
+
+The attendant should wear washable dresses with sleeves that can be
+rolled up, washable aprons, and shoes with rubber heels. All her
+clothing should be comfortable. She should be neat in appearance,
+scrupulously clean in person, and should keep her finger nails short and
+smooth. Jewelry, especially rings and chains that rattle, and finery of
+any sort are all out of place in a sick-room.
+
+The attendant must learn that her own sleep, her diet, and her
+out-of-door exercise are essential to the patient's well-being hardly
+less than to her own. An amateur nurse often considers that going
+without food and sleep is a proof of her devotion. In a passion of
+self-sacrifice she neglects herself utterly for the first few days, and
+as a consequence is quite useless at a later period when her services
+may be most needed. An exhausted, sleepy nurse, trained or untrained, is
+wholly unfit to be trusted with medicines and doctor's orders, to note
+changes in the patient's condition, or to give him kindly attention.
+Efficiency and fatigue have never pulled together since the world began,
+and no one can do good work when suffering from lack of sleep and rest.
+
+The person, then, who genuinely wishes to give her patient the best
+possible care should not make a martyr of herself. She should go out of
+doors daily; both fresh air and occasional absence from the patient are
+essential to her physical and mental well-being. Moreover, she will be
+showing her patient the greatest kindness in the long run if during her
+recreation time she thinks of him as little as possible. Indeed, she
+need not consider herself inhuman if she has a thoroughly good time.
+
+On the other hand, a person who is responsible for the care of a patient
+must be made to realize that she and she only is ultimately responsible
+during the entire 24 hours of every day. Being responsible for a patient
+does not mean that she should be with him every minute, or do everything
+herself: it does mean that she should plan so effectively that
+everything necessary is done, either by herself or by another competent
+person. When she goes away for even half an hour, she should appoint
+someone else to be responsible in her place and to her when she comes
+back. She must consequently make very clear just what she wants done. If
+there is medicine, nourishment, or treatment to be given, she can easily
+make a list, with the time for each, and ask that each item be crossed
+off the list as soon as the work has been done. She should not forget to
+ask for the list when she returns.
+
+What is really needed is a little executive ability. As Florence
+Nightingale said:
+
+      "It is impossible in a book to teach a person in charge of
+      the sick how to _manage_, as it is to teach her how to
+      nurse. Circumstances must vary with each different case.
+      But it is possible to press upon her to think for herself.
+      Now what does happen during my absence? I am obliged to be
+      away on Tuesday. But fresh air, or punctuality is not less
+      important to my patient on Tuesday than it was on Monday.
+      Or: At 10 p.m. I am never with my patient; but quiet is of
+      no less consequence to him at 10 than it was at 5 minutes
+      to 10. Curious as it may seem, this very obvious
+      consideration occurs comparatively to few, or, if it does
+      occur, it is only to cause the devoted friend or nurse to
+      be absent fewer hours, or even fewer minutes from her
+      patient--not to arrange so as that no minute and no hour
+      shall be for her patient without the essentials of her
+      nursing."--(Notes on Nursing.)
+
+It is exceedingly difficult to care for members of one's own family or
+to be cared for by them. Too much or too little is almost invariably
+expected by one person or the other, and where great affection is
+involved not only is the strain increased on both sides, but often harm
+results from too great unselfishness on either side or both. But
+sometimes the reverse is true, and then one should remember that normal
+behavior may be impossible for the sick. During weakness and pain,
+irritability and unreasonableness are as characteristic as other
+symptoms, and it is as foolish to demand a normal mental state from a
+sick person as it would be to demand a normal temperature. For a
+cheerful, reasonable, and unselfish patient--and there are surprisingly
+many--one should be devoutly thankful, but patience and pity should be
+given no less to those whose tortured nerves cause suffering to others
+as well as to themselves.
+
+Every woman who cares for the sick should remember that she is the
+patient's chief if not his only link with the normal world, and that his
+plight is pitiful indeed if she is complaining or irritable or
+unwilling. Anyone who cares for the sick should remember also that she
+is necessarily in a most intimate relation with the patient, and that
+such enforced intimacy calls for extra consideration on her part, and
+for the most scrupulous respect for confidential matters. It is
+inexcusable even for members of the patient's family to discuss with one
+another the patient's private concerns, or his queer or unreasonable or
+annoying ways. During sickness the skeletons in most people's mental
+closets walk forth, and anyone who misuses special opportunities to know
+intimate affairs can only be classed with eavesdroppers and village
+gossips.
+
+
+EXERCISES
+
+1. What are the essentials of a good sick room as to:
+
+  (_a_) Situation and exposure.
+  (_b_) Lighting and heating.
+  (_c_) Furnishing.
+  (_d_) Ventilation.
+
+2. How may a sick room be ventilated without exposing the patient to
+draughts?
+
+3. How should the bed be placed in relation to doors, windows, and
+walls?
+
+4. How should a sick room be cleaned?
+
+5. What in general are the duties of the attendant?
+
+6. Make a plan of your own bedroom, and show what changes, if any, would
+be desirable if it were to be used as a sick room.
+
+
+FOR FURTHER READING
+
+Notes on Nursing--Florence Nightingale, Pages 1-63, 84-105.
+
+
+
+
+CHAPTER VI
+
+BEDS AND BEDMAKING
+
+
+The common saying that the best bed for an invalid is his own bed
+contains an element of truth. Taking from a patient his own accustomed
+bed, even when a better is substituted, sometimes disturbs him greatly
+and makes him feel that he is indeed very ill. Nevertheless, a suitable
+bed is essential to the proper care of a helpless person, and no patient
+should continue to use an unsuitable one, unless his illness is slight
+and also likely to be of very short duration.
+
+Besides being comfortable, a bed suitable for the sick must be clean and
+easy to keep in a sanitary condition. The springs should be firm, and
+the mattress should be elastic and should give an even support without
+lumps and hollows. The bed covers should be clean, light, and warm; the
+pillows should be sufficient in number not only to make the head and
+shoulders comfortable, but also any other part of the body in need of
+support. Moreover, the bed should be so placed and of such a kind that
+the work of caring for the patient may be rendered as easy for the
+attendant as possible. In every household at least one bed suitable for
+a sick person should be available in case of need.
+
+BEDSTEADS.--Beds of white enameled iron, brass, or brass and iron
+combined are most easily kept clean, and are the best in every way. The
+frame should be strong enough to stand firmly, yet not so heavy that it
+is hard to move. It should have as few angles as possible, and all its
+joints should be smooth and well finished. The springs should be made of
+wire stretched tightly on a metal frame that fits smoothly into the head
+and foot pieces. Large castors should be used; they may be removed from
+the foot if the bed moves too easily.
+
+A bed to be used in sickness should have the following
+dimensions--length, 6 ft. 6 in., height 24 to 26 inches, width, 36
+inches. If a bed is either too high or too low the labor of lifting and
+moving the patient is greatly increased. If the bed is too narrow the
+patient is insecure. If the bed is too wide, its center is difficult or
+impossible to reach without leaning or kneeling upon it; and if too
+short, it will prove uncomfortable for a tall person. A bed that is too
+low may be raised on four heavy boxes of the same height; or still
+better, upon heavy wooden blocks which any carpenter can easily make,
+and which are well worth a little trouble to obtain. In the top of each
+block a hollow should be made into which the leg of the bed will fit
+after the castor has been removed. A broad firm stool or a low chair may
+be provided for a patient who has difficulty in getting in and out of a
+high bed.
+
+Beds with complicated attachments for moving patients are not
+recommended for family use. They are expensive, likely to get out of
+order, seldom needed, and generally unsatisfactory. In some surgical
+cases a bed with a firm, flat surface is necessary. Such a surface may
+be secured by placing between the mattress and springs two boards
+slightly separated, or one wide board with holes bored in it to afford
+ventilation.
+
+Wooden beds are undesirable: they are difficult to keep clean, they
+readily absorb moisture and odors, they cannot well be disinfected, and
+their solid frames prevent a free circulation of air. Moreover, it is
+almost impossible to render fit for use again a wooden bed into which
+vermin have once made their way. Folding beds and lounges even of the
+best type are unhygienic, usually too low for the patient's comfort, and
+often insecure.
+
+A bedstead should be wiped frequently with a damp cloth; if it is of
+enameled iron it may be washed with soap and water. The springs may be
+cleansed with a stiff brush dipped in kerosene oil. Excessive use of
+water upon the springs is likely to make them rust.
+
+MATTRESSES.--Various substances are used in the manufacture of
+mattresses, but nothing has yet been found that is as satisfactory as
+curled hair. It is light and clean and elastic, it does not readily
+absorb odors, and it is easily renovated. Although hair is more costly
+than other materials, a hair mattress may be used almost indefinitely if
+it is occasionally made over.
+
+Felt or cotton mattresses are firm, but heavy, difficult to keep clean,
+and likely to absorb odors. A useful mattress made from straw is
+sometimes found in country districts. Such a bed is thoroughly hygienic,
+for the worn straw may be burned and the tick washed and refilled with
+clean straw; but straw beds are generally hard and lumpy. The least
+desirable of all mattresses is the old fashioned feather bed, and it
+should never be used if a better can by any possibility be obtained; but
+a feather bed should not be arbitrarily taken away from an old person
+accustomed to its use, unless his welfare is really at stake.
+
+A mattress made in two sections is unnecessary for a single bed; indeed,
+a mattress made in one piece is more easily kept in place if the
+patient is restless. A good quality of blue and white ticking makes a
+serviceable cover for both mattress and pillows since its color is not
+likely to run.
+
+CARE OF THE MATTRESS.--A mattress should be brushed frequently with a
+whisk broom, especially around the tufts and edges. If a patient is long
+confined to bed, a fresh one should occasionally be substituted so that
+the regular mattress may be removed, well brushed, beaten with a carpet
+beater, and left exposed to the sun and air for a day or two. A mattress
+that is badly soiled should be sent to a cleaner and made over; it
+cannot be cleaned properly at home. It is generally possible to remove
+blood stains, if they have not soaked through the ticking, by applying a
+thick cream made from raw starch and cold water. When the starch becomes
+dry it should be brushed away, and the application should be repeated
+until the stain has disappeared. For the best results the starch should
+be applied before the stain is dry.
+
+PILLOWS.--One patient can use an almost unlimited number of feather
+pillows. Some should be soft and others firm, some large and some small;
+but pillows that are very large and thick are less useful than a greater
+number of smaller ones. It is well to have several small pillows of
+varying size and thickness to support different parts of the body.
+
+Hair pillows are often acceptable in warm weather, and they are also
+desirable for patients with high fever or excessive perspiration. Rubber
+air pillows are a convenience in traveling and add much to the comfort
+of a patient when he first goes out in a carriage or motor car, but air
+pillows are not sufficiently durable for general use.
+
+If a pillow tick becomes soiled, the feathers may be transferred to a
+clean tick by making an opening about six inches long in the end of each
+pillow, sewing the ticks together, and then shaking the feathers from
+one tick to the other. The soiled tick can then be washed. If the
+feathers themselves have become soiled they should be renovated by a
+cleaner. Pillows, like mattresses, should be frequently brushed, sunned,
+and aired. They should not be held in the mouth while a clean
+pillow-case is adjusted.
+
+PROTECTION OF THE MATTRESS AND PILLOWS.--In all cases of sickness the
+mattress must be adequately protected. Neglect is inexcusable and may
+cause expense and trouble as well as discomfort to the patient.
+
+The following may be used to protect the mattress or pillows: large
+quilted pads, small pads of cotton batting covered with old muslin or
+cheese cloth, slip covers for the mattress, rubber sheets and
+pillow-cases, old blankets and quilts that may be washed easily. Heavy
+wrapping paper, builders' paper, and newspapers serve well in
+emergencies, or for a short time.
+
+RUBBER SHEETS AND PILLOW-CASES.--Soft rubber cloth, single or double
+faced, is most frequently used when it is necessary to protect the bed
+from discharges. It may be purchased by the yard. Rubber sheets should
+not be used unless they are really necessary. They are hot and
+uncomfortable, and increase the tendency to perspire. When used, a
+rubber sheet should be 1 yard wide or wide enough to reach from the
+lower edge of the pillows down to the patient's knees, and long enough
+so that it can be tucked in securely on both sides of the bed. Rubber
+sheets may be cleaned by laying them on a flat surface and washing on
+both sides with soap and water, using a small brush if necessary. After
+rinsing they should be wiped, and when thoroughly dry they should be
+rolled rather than folded, to prevent the rubber from breaking.
+
+Rubber pillow-cases are used for a patient who perspires profusely, or
+who has a discharge of any kind from the head or neck, and also when
+substances which may wet or stain the pillow are applied to the head.
+They should be put on next to the pillow, securely fastened with tapes,
+snap hooks, or buttons, and covered with the regular pillow slip.
+
+Rubber sheets and pillow-cases are not durable. They should be used
+carefully, and frequently examined for holes or worn places by holding
+them up to the light. Even a pin hole near the center may render a
+rubber sheet or pillow-case as useless as a sieve.
+
+SHEETS.--Sheets of ample proportions are necessary for comfort, and
+important for sanitary reasons as well. For a bed of the dimensions
+mentioned in this lesson sheets should be three yards long, and two
+yards wide. A safe rule for any bed is to have the sheets one yard
+longer and one yard wider than the mattress. A sheet of these dimensions
+is large enough to be tucked under the sides and foot of the mattress,
+while at least twelve inches are left to fold over the blankets at the
+top. Cotton sheets are as good as linen for general use, or even better,
+and are far less expensive.
+
+DRAW SHEETS are used to cover rubber sheets, and to protect beds when
+the rubbers are not used. In hospitals special draw sheets are usually
+provided, but an ordinary sheet folded answers every purpose. New and
+expensive sheets should not be used for draw sheets, since they are
+more likely than other sheets to become stained. Draw sheets should be
+wide enough to extend about four inches beyond the rubber sheet at the
+top and bottom.
+
+PILLOW COVERS.--Pillow covers are generally made of cotton, but persons
+who can afford the cost frequently prefer linen, especially in hot
+weather. Unless fastened with buttons or tapes, a pillow case should be
+several inches longer than its pillow. It should be wide enough to slip
+on easily, but not so wide that it wrinkles or allows the pillow to
+turn. If it is too small the pillow will become hard and uncomfortable.
+These small things, unimportant as they are to the well, may cause much
+discomfort to a restless or nervous patient.
+
+BLANKETS.--All wool blankets are both light and warm, and are
+consequently the most comfortable bed covering. But unless they can be
+dry cleaned frequently, it is better to select blankets made from one
+part wool and two parts cotton. Blankets containing equal parts of wool
+and cotton are warmer, but are more injured by washing. Very light
+blankets of wool or outing flannel are useful in summer. Double blankets
+should always be cut in two and bound at the ends, since single blankets
+are easier than double blankets to handle and wash. Patients are
+frequently too warmly covered by day. Too much warmth is enervating, it
+causes the patient to perspire, and makes him restless and more
+susceptible to draughts and to changes of temperature. Two light
+blankets are warmer and more comfortable than one heavy blanket.
+
+COMFORTERS AND QUILTS.--Heavy cotton comforters are burdensome without
+being correspondingly warm. Eiderdown quilts or those padded with wool
+are good for a patient who sleeps out of doors, or whose room is kept at
+a low temperature. Bed covers that cannot be laundered readily should be
+protected by basting on both sides of the top a wide piece of muslin or
+linen, which can be removed and washed.
+
+COUNTERPANES.--White dimity counterpanes are desirable, since they are
+light in weight, easily laundered, and inexpensive. A heavy counterpane
+is uncomfortable at any time, and still more uncomfortable in sickness.
+If a light spread is not available, a sheet makes a good substitute. A
+counterpane should be wide enough to cover the sheets and blankets at
+the sides when the bed is open, and long enough to protect the bedding
+at the top and bottom.
+
+
+BED MAKING
+
+All methods of making beds for the sick are based upon a few underlying
+principles. The aim in every case is to obtain the following results
+with the least expenditure of time and labor: first, to secure comfort
+for the patient, and to eliminate all causes of friction, irritation, or
+pressure upon his skin; next to keep the covers firmly in place, so
+that the bed will not easily become disarranged; then to protect the
+mattress, and last, to secure as good an appearance as possible.
+
+[Illustration: FIG. 12.--THE DRAW SHEET IN PLACE. (_From "Elementary
+Nursing Procedures," California State Board of Health._)]
+
+TO MAKE AN UNOCCUPIED BED, proceed as follows: remove the pillows and
+covers one at a time, and place them on chairs, near an open window if
+possible. Brush the mattress and then set it up on its ends to air, or
+turn it back over the foot board. Wipe the bedstead with a damp cloth.
+Replace the mattress after it has aired, turning it from side to side
+and from end to end on alternate days. Cover the mattress, unless it is
+enclosed in a slip cover, with a white quilted pad or an old blanket,
+and then spread the lower sheet over the mattress, so that the middle
+fold of the sheet lies upon the center of the mattress in a straight
+line from the head of the bed to the foot. Tuck the sheet under, first
+at the top and then at the bottom, drawing it so that it is firm and
+tight. If the sheet is of proper length tuck fourteen or sixteen inches
+under at the top, but take care to cover the mattress at the foot also.
+Next tuck the sheet under at the side, folding its corners to make a
+neat finish like an envelope. Place the rubber sheet, if it must be
+used, across the bed, with its upper edge where the lower edge of the
+pillows will come. A draw sheet somewhat wider than the rubber sheet is
+needed next; an ordinary sheet, folded once the long way of the sheet,
+may be used, with the fold toward the head of the bed. Tuck both rubber
+and draw sheet securely under the mattress at the side. In some cases
+the rubber sheet may be placed next to the mattress, and covered by the
+mattress pad and lower sheet. Place the draw sheet as directed, whether
+the rubber is used or not. After the lower, rubber, and draw sheets have
+been adjusted on one side of the bed, go to the opposite side, draw them
+over smoothly, and tuck them under the mattress as tightly as possible.
+
+Next spread the upper sheet over the bed so that its upper edge reaches
+to the upper edge of the mattress, and its middle crease lies over the
+middle line of the mattress, and place it right side down, so that the
+smooth side of the hem will be uppermost when the sheet is turned over
+the blankets. Place the blankets so that their upper edges lie a little
+higher than the place where the lower edge of the pillow will come, and
+tuck them in firmly at the bottom and sides. If the blankets are not
+long enough to tuck in at the foot, place the lower blanket as directed
+and the upper blanket five or six inches lower than the first. When
+tucked in, the upper blanket holds the lower one in place fairly well.
+Place the counterpane evenly and smoothly, tuck it under at the foot,
+turn its corners neatly, turn its upper edge under the upper edge of the
+blankets and fold the upper sheet down over the whole. Last of all,
+shake the pillows and place them neatly on the bed.
+
+[Illustration: FIG. 13.--THE CLOSED BED. (_From "Elementary Nursing
+Procedures," California State Board of Health._)]
+
+Practice is necessary before it is possible to make a bed quickly and
+well, and a certain amount of proficiency in making an unoccupied bed
+should be acquired before undertaking to make a bed with a patient in
+it. One should learn to work in an orderly way, without confusion,
+unnecessary motion, or jarring of the bed.
+
+TO CHANGE A PATIENT'S PILLOWS.--Stand preferably on the right side of
+the bed and slip the left arm under the patient's shoulders, supporting
+his head in the hollow of the arm. Raise him slightly and remove the
+pillows one at a time with the right hand, drawing them outward on the
+left side of the bed. Place a small pillow under his head. Shake the
+pillows, change the cases if necessary, and replace them on the left
+side of the bed, ready to be drawn back into position. Raise the patient
+as before, remove the small pillow and draw the others into place. It is
+sometimes better to hold the patient on the upper pillow while removing
+and replacing the under one.
+
+LIFTING A PATIENT IN BED.--Patients tend to slip down toward the foot of
+the bed, and they should be raised if unable to help themselves. To
+raise the patient, instruct him to flex his knees and to press his feet
+firmly upon the bed; place one arm under his shoulders, as when
+changing pillows, the other arm under the thighs, and lift him upward
+without jerking. The lifting can be done more easily by two people, and
+with less discomfort to the patient: if he is entirely helpless two
+people are necessary. Two people should proceed as follows: Let _A_
+place her left arm under the patient's head and shoulders as before, her
+right arm under the small of his back; let _B_ place her right arm also
+under the small of his back and her left arm under his thighs, and at a
+signal let them lift together. In this way the weight is so evenly
+distributed that a heavy person can be lifted without great difficulty.
+
+TO TURN A PATIENT IN BED.--A patient may be turned toward or away from
+you. In turning a patient toward you, place one hand over his farther
+shoulder and the other over his hip, and turn him toward you. Then flex
+his knees slightly. To turn a patient from you, pass one hand as far as
+possible under the shoulders, and the other as far as possible under the
+thighs. Then raising the patient slightly, draw him back toward you,
+turning him at the same time, and then flex the knees. Lastly place a
+pillow firmly against his back to support it.
+
+TO CHANGE THE SHEETS WHILE THE PATIENT IS IN BED proceed as follows:
+First collect the fresh linen and place it conveniently near the bed.
+Then draw the bedclothes from beneath the mattress, raising the mattress
+meanwhile with one hand to prevent jarring the bed. Remove first the
+spread and then the upper blanket if there are two, fold each once and
+place it on a chair. Hold the remaining blanket in place with one hand,
+while with the other you draw the upper sheet out from under it; then
+fold the edges of the blanket up over the patient to keep them out of
+the way. The upper sheet, unless soiled, may be folded once and used
+again as a draw sheet. Next remove all the pillows, unless the patient
+prefers to keep one. Then move the patient toward one side of the bed
+and turn him on his side so that he faces the edge nearest him. Roll the
+draw sheet and rubber sheet together if both are to be removed, or
+separately if the rubber sheet is to remain on the bed; then roll the
+bottom sheet throughout its entire length, and bring the three sheets,
+all rolled as flat and as tightly as possible, close to the patient's
+back. Pleat about half of the fresh lower sheet lengthwise and place the
+pleated portion as close as possible to the rolled soiled sheets. Tuck
+in the other half of the fresh sheet at the top, bottom and side, draw
+the rubber sheet if it is to be replaced back over the fresh lower
+sheet, arrange the fresh draw sheet in place, tuck it in at the side,
+and roll its free portion close to the patient's back. The fresh side of
+the bed is then ready for the patient. Lift his feet back over the
+rolled sheets keeping his knees flexed, then turn him back over the
+rolled sheets on to the fresh smooth part, remove the soiled sheets and
+arrange the fresh ones in place on the side where the patient has just
+been lying. Be careful to keep him well covered with the blanket. After
+the lower sheets are in place and firmly tucked in, spread above the
+blanket the fresh upper sheet, and over the sheet spread the second
+blanket. Hold the sheet and blanket in place with one hand while using
+the other hand to draw out the first blanket from beneath the sheet. In
+this way the patient is constantly covered by a blanket. Place the
+blanket just removed above the other and finish the bed according to the
+directions given for an unoccupied bed, using special care, however not
+to draw the covers too tightly over the patient's feet.
+
+[Illustration: FIG. 14.--CHANGING THE DRAW SHEET. (_From Pope "Home Care
+of the Sick," American School of Home Economics, Chicago._)]
+
+TO MOVE A PATIENT FROM ONE BED TO ANOTHER.--On the fresh bed have the
+lower sheets in place but not the upper covers. Place the two beds close
+together side by side, and draw one mattress a little over the place
+where the two sides meet. Loosen the draw sheet under the patient, roll
+it on both sides close to the body and draw him gently over by means of
+this sheet, moving his shoulders at the same time. If the beds are
+unequal in height, use firm pillows or folded blankets to make an
+inclined plane.
+
+[Illustration: FIG. 15.--CHANGING A PATIENT FROM ONE BED TO ANOTHER.
+(_From Pope "Home Care of the Sick," American School of Home Economics,
+Chicago._)]
+
+If the beds differ greatly in height and indeed in most cases, it is
+better to carry the patient from one bed to the other. At least two
+people are needed; one alone should never attempt to carry anyone
+heavier than a small child. One method for lifting is as follows: Let
+two bearers, _A_ and _B_ stand on the same side of the bed. If the
+patient is to be moved into the right side of the fresh bed let both
+bearers stand on the right side of the occupied bed; if he is to go into
+the left side of the fresh bed, let them both stand on the left side of
+the occupied bed. Let _A_ place one arm under the patient's shoulders
+and her other under the small of his back, while _B_ places one arm
+under his hips and the other just below his knees. Draw the patient to
+the edge of the bed, instruct him to place his arms about the shoulders
+of _A_ and to hold the body rigid, and then lift together at a given
+signal, keeping his weight well up on the chests of the bearers.
+
+Whenever a patient must be turned, lifted, carried, or moved in any way,
+let him know beforehand just what you intend to do so that he may not be
+startled, and also that he may coöperate if possible. Grasp him firmly
+but gently, avoid pinching the skin, and move him steadily and
+smoothly, avoiding jerks and false starts. Do not attempt alone more
+than your strength is amply sufficient to accomplish, and endeavor at
+all times to handle the sick with the utmost gentleness and
+consideration.
+
+
+EXERCISES
+
+1. Describe a bedstead and mattress suitable for a sick person's use,
+and tell why they are to be preferred.
+
+2. How should the bedstead be cared for? the mattress? the pillows?
+
+3. How should a mattress and pillows be protected?
+
+4. Describe in detail the bed covers that are desirable for use in
+sickness.
+
+5. Name the results that a good method of bedmaking aims to secure.
+
+6. Describe the method of making an unoccupied bed.
+
+7. How should one change the pillows of a helpless patient?
+
+8. Describe the way in which you would lift and turn a patient in bed.
+
+9. Describe the method of changing sheets and remaking a bed while the
+patient is in it.
+
+10. Why are beds and bedmaking considered so important in the care of
+the sick?
+
+
+FOR FURTHER READING
+
+Notes on Nursing--Florence Nightingale, Pages 79-84.
+
+
+
+
+CHAPTER VII
+
+BATHS AND BATHING
+
+
+Bathing is necessary in sickness no less than in health. It stimulates
+and equalizes the circulation, is soothing in feverish conditions, is
+refreshing to most people, and by affording a certain amount of exercise
+it lessens the fatigue of lying in bed. Moreover, without frequent
+bathing it is impossible to keep the skin in good condition, since
+scales of dead skin, oily matter, and solid substances left by
+perspiration collect on the surface of the body when a person is lying
+still in bed as well as when he is leading an active life. The common
+belief that sick people are likely to catch cold from bathing is quite
+unfounded; every patient, unless his condition is such that the doctor
+orders otherwise, should have one complete cleansing bath each day. In
+addition to the regular cleansing bath other kinds are often prescribed
+as medical treatment.
+
+
+CLEANSING BATHS
+
+A _tub bath_ if allowed by a patient's condition, is the most
+satisfactory kind, but special precautions must be taken to guard her
+from fatigue and chill. The bath room and everything to be used should
+be made ready before she leaves her bed. Necessary clothing and toilet
+articles should be collected and arranged conveniently, a chair covered
+with a blanket and also a bath mat should be placed beside the tub, and
+the temperature of the bath room should be regulated so that it is about
+70° F., or a little lower if the room is likely to become overheated as
+the bath proceeds. The bath water should be drawn last. Its temperature,
+tested by a thermometer, should be between 96° and 100° at the
+beginning, and may be increased if desirable.
+
+If the patient is weak, wash and dry her face, neck, and ears, and if
+necessary cut the finger and toe nails before she leaves the bed, in any
+case before she enters the tub. As soon as the patient has left the bed,
+strip it and leave it to air; then assist her into the bath room and
+help her carefully into the tub. Do not allow her to stay in the water
+more than ten minutes at most, and stop the bath at once if she shows
+the slightest sign of faintness, dizziness, exhaustion, difficult
+breathing, marked change of color, or other unusual symptom. Indeed, if
+the patient is weak or her reaction to the bath uncertain, as when she
+takes her first tub bath after an illness, someone should always be
+within call to help the attendant in case of need. A faint, heavy
+patient in a bath tub is an impossible load for one person to handle.
+
+While the patient is in the tub, soap her well, brush her finger and toe
+nails, rinse, and rub her to stimulate the circulation. Then help her
+from the tub, seat her in the chair, draw the blanket closely about her
+from neck to feet, dry her with warm towels, exposing the body as little
+as possible, and, if she is to return to bed, put on a fresh night gown,
+and wrapper and slippers. Next place the lower sheet, the draw sheet,
+and one pillow on the bed as quickly as possible, help the patient into
+bed, keeping her well covered with a blanket, and finish making the bed.
+If she seems chilly, give a hot water bag and hot drink and leave the
+blanket next her in place. After the patient has been made comfortable,
+clean the tub and put the bath room in order.
+
+Even patients supposedly able to take tub baths without assistance
+should not lock the bath room door nor be left alone a long time.
+
+BED BATH.--Practice is essential in order to give a bed bath skillfully.
+The aim is to make the patient thoroughly clean and thoroughly dry,
+without chilling, fatiguing, or exposing her, without making the bed
+damp, and without unnecessary haste or delay. One method of giving a
+bed bath follows, but any method that accomplishes these aims is likely
+to be satisfactory.
+
+First see that the room is about 70° F. and likely to remain so, and
+exclude draughts. Collect everything to be used, including a blanket to
+cover the patient, an old blanket or large bath towel to protect the
+bed, at least two other towels, one a bath towel and the other a face
+towel, two wash cloths, soap, nail brush, powder, alcohol, comb and
+brush, nail file, scissors, etc.; fresh bed and personal linen; a large
+basin containing water at 105°, a jug of hotter water, and a slop jar.
+Remove the upper bed clothes except one blanket, which should cover the
+patient constantly during the bath, and spread them where they will air;
+remove all the pillows but one, and place the bath blanket under the
+patient as the under sheet is placed in bed making. If a bath blanket is
+not used, keep the bath towel under the part that is being bathed by
+moving the towel from place to place.
+
+Next remove the night gown in the following way: Let the patient lie on
+her back, with her knees flexed; draw the gown up as far as possible,
+then raise or get her to raise her hips so that the gown may be drawn up
+above the waist. Next raise her head and shoulders with one arm and draw
+the night gown up to the neck with the other; remove one sleeve, draw
+the gown over the head and then off the other arm.
+
+[Illustration: FIG. 16.--WASHING A PATIENT WITHOUT EXPOSURE. (_Sanders
+"Modern Methods in Nursing."_)]
+
+The patient is now ready for the bath. Wet the wash cloth thoroughly,
+but hold it gathered in the hand so that it will not drip. Wash the
+face, neck, and ears first, dry them thoroughly, and next, using the
+second wash cloth, wash the arms and hands, chest and abdomen, giving
+particular attention to the armpits and navel. Raise the blanket
+slightly with one hand to keep it from becoming damp, but expose the
+patient as little as possible; the arms and legs need not remain covered
+while being washed. Dry each part thoroughly before washing the next.
+Next turn the patient on her side and wash the back, the buttocks, and
+upper part of the thighs; give special attention to the fold between the
+buttocks. Then turn the patient on her back, and wash the thighs, legs,
+and feet. If it is important to move the patient as little as possible,
+leave the back until last so that the under sheet may be changed without
+turning her again. Cut the toe nails if necessary before washing, and
+clean them carefully afterward. Unless there is a reason to the
+contrary, wash the hands and the feet in the basin, first protecting the
+bed with a towel, newspaper, or clean wrapping paper. Be sure to clean
+well between the toes, and to dry the feet thoroughly; they may need
+some friction. Throughout the bath empty and refill the basin as
+necessary.
+
+Wash the genital region last. Let the patient lie upon her back with
+knees flexed and separated, or upon one side with the knees flexed and
+one slightly raised. Patients who are able may take this part of the
+bath themselves with whatever assistance may be necessary. The
+attendant, however, must either do it herself or make sure that the
+patient does it thoroughly. To neglect a helpless patient is always
+unkind, and no less unkind when the motive is a mistaken sense of
+modesty. If discharge from the genitals is present use absorbent cotton,
+or clean, soft old cloth to wash the parts, and burn it afterward. It is
+sometimes desirable to place the patient on a bedpan and rinse the parts
+by a gentle stream of warm water poured from a jug. After the attendant
+has completed this part of the bath she should wash her own hands
+thoroughly.
+
+After the bath rub the patient with alcohol. If a complete alcohol rub
+is impossible, at least rub the points where pressure comes, especially
+the back. After the rub apply a little toilet powder if the patient
+desires it. When the toilet is complete remove the bath blanket, remake
+the bed and put the room in order.
+
+CARE OF THE MOUTH AND TEETH.--In sickness the mouth and teeth require
+more than ordinary attention; indeed, the condition of a patient's mouth
+is a fair index to the quality of the care she is receiving. If the
+patient can brush her own teeth she should do so in the morning, at
+night, and after meals. At those times the attendant, without waiting to
+be asked, should bring her a towel, tooth-brush, cup of tepid water,
+tooth paste or powder, and a small basin or dish to receive the used
+water. The process is generally more thorough when the patient does it
+herself, and even a patient unable to sit up can brush her teeth
+successfully if the nurse holds the powder and cup of water, and
+provides a basin shallow enough for the patient to use by turning her
+head to one side.
+
+[Illustration: FIG. 17.--THE NURSE ASSISTING THE PATIENT IN BRUSHING THE
+TEETH. (_From "Elementary Nursing Procedures," California State Board of
+Health._)]
+
+The attendant must cleanse the mouth of a patient who is unable to do it
+herself. If this cleansing is neglected, a dark tenacious substance
+collects upon the teeth and gums, composed chiefly of food particles,
+bacteria, mouth secretions, and worn out cells of the mucous membrane.
+Once formed it is difficult to remove, hence the mouths of all patients
+and especially those who have fever, must receive proper care from the
+very beginning of illness. Cotton swabs are convenient for cleansing the
+mouth; they are made by winding a small piece of absorbent cotton upon a
+match or wooden tooth-pick.
+
+To cleanse the mouth of a helpless patient, take to the bedside the
+mouth wash prescribed by the doctor, a towel to protect the bedclothes,
+several swabs, and a receptacle for used swabs; the latter should be a
+strong paper bag or several thicknesses of newspaper. Clean the tongue,
+gums, teeth, and spaces between the teeth gently but thoroughly, using
+especial care if the gums are tender. Dip only clean swabs in the
+solution, discard each one after using it once, and burn it afterward.
+Let the patient rinse her mouth after cleansing it if she is strong
+enough. If the mouth is very dry, encourage her to drink more water.
+Notify the doctor if the gums and tongue crack or bleed since he may
+wish to order a special mouth wash. Cold cream or boracic ointment may
+be used if the lips are dry and cracked.
+
+False teeth should be thoroughly brushed and cleansed, and kept in cold
+water if taken out during the night.
+
+CARE OF THE HAIR.--Long hair, if neglected, becomes tangled and matted
+in a surprisingly short time. Unless the patient is actually in a dying
+condition she is not too sick to have it properly attended to at least
+once a day. Before combing the hair protect the pillow with a towel;
+then part the hair in the middle from the forehead to the nape of the
+neck, and draw it to either side. Begin to comb at the ends, holding the
+strand of hair firmly in one hand placed between the head and the comb;
+in this way tangles can be removed without hurting. After combing and
+brushing the hair, braid it in two braids, beginning near the ears; draw
+it as tightly or loosely near the head as the patient prefers, but
+remember that tight braids mean fewer tangles. If the hair is heavy or
+badly tangled the patient may be too much fatigued to have it all combed
+at one time; in this case braid the part that has been finished and
+complete the work later.
+
+TO WASH THE HAIR OF A BED PATIENT.--The hair of a patient can be
+successfully washed in bed if sufficient care is taken not to chill or
+tire the patient, or to wet the bed. The following articles are needed:
+one small jug of strong soap suds made by dissolving a pure soap in hot
+water, one large jug of hot water at about 112° F., one jug of cold
+water, a slop jar or foot tub, one long rubber sheet or piece of enamel
+cloth, and several towels including at least one bath towel. Let the
+patient lie as near the edge of the bed as possible. Roll one small
+towel lengthwise, place it below the hair at the back of the neck, bring
+it up above the ears to the forehead and pin tightly, in order to catch
+water that might wet the face and neck. Next make a kind of trough of
+the large rubber by rolling its long edges inward for a few inches.
+Place this across the bed under the patient's head so that her neck
+rests on the lower roll. Raise by means of pillows the end of the rubber
+trough that lies toward the middle of the bed, in order to prevent water
+from running into the bed or collecting under the patient's head. Let
+the other end of the rubber extend over the edge of the bed down into
+the slop jar or foot tub, which may be placed on a chair or stool. Then
+wash the hair and scalp with the soap solution, and rinse them
+thoroughly with water from the large jug. Squeeze as much water as
+possible from the hair, remove the rubber and substitute a heavy bath
+towel, and rub and fan the hair until dry. A shampoo in bed is tiring.
+Do not attempt it unless the patient is strong enough to stand not only
+the shampoo itself, but also a complete change of bed clothing, which
+will almost certainly be necessary if the attendant has been careless or
+clumsy in the slightest degree.
+
+HOT FOOT BATHS properly speaking are medical treatment, but they are
+taken by many persons to relieve colds, headache, or insomnia. Let the
+patient sit, well wrapped, with her feet in water at about 105°, and
+then increase the temperature gradually by adding hotter water. Take
+care to add hot water slowly and not to pour it directly upon the
+patient's feet or ankles; otherwise she may be scalded. Mustard may be
+added to the bath water in the proportion of one tablespoonful of
+mustard to each gallon of water. If mustard is to be used make it into a
+smooth paste with cold water, thin the paste with warm water, and when
+thin enough to pour easily add it to the bath water and stir well. The
+bath may continue for 10 to 20 minutes, and the feet should be dried
+afterward without friction. The patient should go to bed at once; she
+should not wander about, clearing away her foot bath, doing forgotten
+things, getting herself chilled, and losing all the good effects.
+
+A foot bath may be given easily to a patient in bed. Bring to the
+bedside a blanket, a towel, the tub filled with water, and something
+with which to protect the bed; this may be a rubber sheet, bath towel,
+old blanket folded, or several thick clean newspapers. Loosen the upper
+covers at the foot of the bed, fold them back above the patient's knees,
+and cover her legs and feet with the extra blanket making it overlap the
+bed clothing so that it will not slip. Flex the patient's knees, put the
+bed protector under her feet, place the tub on the side of the bed,
+raise the legs and feet with one hand and arm, and slide the tub into
+place with the other, raising the elbow in such a way that it keeps the
+blanket out of the water. Lower the feet slowly into the water, fold the
+towel, and place it over the edge of the tub in order to protect the
+patient's knees from the cold rim; then tuck the blanket closely about
+the tub and legs and proceed as before. After the bath use the towel,
+unless it is wet, to receive the feet when they are withdrawn from the
+tub. Remove the tub, dry the feet thoroughly, cover them warmly, and
+remake the bed.
+
+COOL SPONGE BATH.--For feverish patients doctors often order cool sponge
+baths. In order to give a cool sponge bath, first protect the bed
+thoroughly, but leave the patient uncovered except for a towel laid over
+the hips. Use cool water, or cool water and alcohol, and have the wash
+cloth as wet as it can be without dripping. Bathe the body without
+friction, using long, light strokes, and leave each part wet until the
+bath has been completed. Do not use soap. Sponge in this way the arms,
+legs, chest, and back, but not the abdomen, for ten to twenty minutes,
+giving special attention to the neck and inner side of the arms and
+legs, because in those places large blood vessels lie nearer the surface
+of the body. After finishing the bath dry the body by patting it gently
+with towels.
+
+Take the patient's pulse occasionally during the bath, and stop the bath
+at once if the patient's pulse grows weaker, if she shivers violently,
+or if her face, fingers, or toes turn a bluish color. Babies react
+rapidly to cool sponging; for a baby use tepid water, sponge for five
+minutes only, and watch the child closely during the bath.
+
+
+EXERCISES
+
+1. What may a bath be expected to accomplish in addition to cleansing?
+
+2. In giving a tub bath, what precautions should be taken to avoid
+chilling the patient? to avoid tiring the patient?
+
+3. What symptoms would lead you to think that a tub bath was not
+agreeing with a patient? What should you do in such a case?
+
+4. Name six essentials of a skillfully given bed bath.
+
+5. What preparations should be made and what articles assembled before
+beginning a bed bath?
+
+6. Describe the method of bathing a patient in bed.
+
+7. What care should the mouth and teeth of every sick person receive?
+How should such care be given to a patient who is helpless?
+
+8. Describe the daily care of a patient's hair, and tell how a shampoo
+may be given to a patient in bed.
+
+9. How should you give a mustard foot bath to a patient in bed?
+
+10. When and how should you give a cool sponge bath?
+
+
+FOR FURTHER READING
+
+The Human Mechanism--Hough and Sedgwick, Chapter XI.
+
+
+
+
+CHAPTER VIII
+
+APPLIANCES AND METHODS FOR THE SICK-ROOM
+
+
+Patients who are confined to bed even for a few days often suffer
+acutely from muscular tension, from pressure, and from fatigue due to
+lack of exercise. Indeed, many a sick person is surprised to find that
+the bed which had seemed so infinitely desirable can change into a place
+of torment after a few short days of illness. "Bed-weariness" is hard to
+bear in any case of illness, but it is doubly hard for persons who are
+really helpless.
+
+Unless the patient is an experienced sufferer he often has no idea what
+should be done to make him comfortable; while an equally inexperienced
+helper, though full of good will, is often discouraged to find that the
+arrangement she had thought perfect soon fails to satisfy her restless
+patient. But if she is willing to devote thought and ingenuity to
+removing small annoyances, she can do many things to alleviate his
+misery.
+
+BED SORES, or pressure sores, are caused by continued pressure upon the
+skin. The weight of the body, or of a part of the body, if it comes for
+a long time upon one place finally interferes with the circulation in
+the tissues on which the part rests, and consequently interferes with
+the nutrition of the affected part. Any tissue to which the blood is not
+bringing all its necessary food supply tends to lose its tone, to become
+weak, and if the condition persists, to break down altogether.
+
+The direct cause of bed sores then is pressure, and pressure is
+aggravated by moisture, wrinkles in the bed clothes, crumbs or other
+hard particles, lack of cleanliness, friction of any kind, or by rough,
+careless handling. Bed sores occur most often over bony prominences,
+such as the end of the spine, elbows, heels, shoulders, hips, ankles,
+and knees, but they may form anywhere, even on the ears or back of the
+head. They are more likely to appear on thin, aged, or depleted
+patients. These painful and serious sores can be prevented almost always
+by faithful care. When they occur, they result in the great majority of
+cases purely from negligence, and a person who knows the danger and yet
+through carelessness allows one to develop upon a patient may justly
+feel herself disgraced.
+
+Prevention of bed sores depends upon keeping the skin dry and clean and
+upon relieving pressure by special devices and by turning the patient
+frequently. The parts where pressure comes should be washed at least
+twice daily with warm water and soap, rubbed frequently with alcohol to
+improve the circulation and to keep up the tone of the skin, and
+powdered with a little good toilet powder. Much powder is likely to do
+harm by collecting in hard, irritating particles. The bed should be kept
+constantly dry and smooth, and free from crumbs, lumps, wrinkles, or
+other inequalities. Prolonged pressure should be relieved by turning the
+patient often,--once every waking hour is not too often if the body is
+emaciated,--and by pillows, pads, and rings.
+
+Small pillows or thick pads of cotton should be placed under the
+patient's back and shoulders, between the knees and ankles when he lies
+on his side, and in other places where sores are likely to develop.
+Rubber rings are useful, but few patients like them for a long time.
+They should not be inflated more than necessary to raise the affected
+part from the bed; if much inflated, they are uncomfortable and may do
+harm. The ring may be covered with a muslin pillow case, or it may be
+wound smoothly with long strips of bandage or old muslin. Ordinary
+cotton batting wound with strips of muslin may be made into rings and
+used to remove pressure from heels, elbows, or other parts. These cotton
+rings are less heating than pads, and give better support.
+
+The first sign of a bed sore is either redness of the skin or a dark
+discoloration like a bruise. Every point where a bed sore may form
+should be inspected daily. If the slightest symptom of a sore appears,
+the patient must not lie on the affected part, and every effort should
+be made to keep the skin from breaking; vigorous rubbing at this stage
+is dangerous, and will by no means make up for previous neglect. The
+condition should be reported to the doctor at once. If in spite of all
+efforts the skin does break, a peculiarly difficult kind of open wound
+results which must be treated and dressed according to the doctor's
+directions.
+
+DEVICES TO GIVE SUPPORT.--The variety and number of pillows one patient
+can use is almost unlimited. A weak patient when lying on his side
+should have his back supported by a pillow. When he lies on his back a
+pillow should be placed under his knees to lessen muscular tension, and
+if he may be raised in bed, several pillows are needed to support him
+comfortably. A back rest is useful for a patient who can sit up in bed.
+Satisfactory back rests of several types can be purchased, or one may be
+improvised from a straight chair placed on the bed bottom side up, so
+that its legs lie against the head of the bed and its back forms an
+inclined plane. Back rest and chair alike should be covered by several
+pillows to make them comfortable, and other pillows should be used to
+support the patient's arms.
+
+A person who is sitting up in bed always tends to slip down toward the
+foot. This tendency may be corrected by using a foot rest, knee pad, or
+pillow. A hard pillow may be placed in the bed at the foot for the
+patient to brace his feet against; or a short board, well padded, may be
+arranged as follows for the feet to rest against: Fasten ropes to the
+board, as the ropes of a swing are fastened to the seat; set the padded
+board on edge at a convenient point below the patient's feet, and hold
+it in place by tying the ropes of the "swing" to the head of the bed. A
+pillow may be used in the same way, either at the feet or under the
+knees, by folding it over a long strip of muslin, the ends of which are
+then tied to the sides of the bed, brought up to the head, and there
+tied to prevent slipping. A cylindrical cushion six or eight inches in
+diameter and as long as an ordinary pillow, stuffed with firm material,
+may also be used for this purpose. It should be held in place by strips
+of strong muslin or ticking sewed to the ends of the cushion and tied to
+the head of the bed. The cushion should have a washable cover.
+
+[Illustration: FIG. 18.--SHOWING FOOT-SLING FOR SUPPORTING PATIENT IN
+THE UPRIGHT POSITION. (_Sanders "Modern Methods in Nursing."_)]
+
+Supports called _bed cradles_ are used to keep the weight of the bed
+covers from sensitive parts of the body, generally the feet or abdomen.
+They are semi-circular pieces of wood or iron fastened together so that
+they will stand up. A satisfactory cradle may be improvised as follows:
+Cut a barrel hoop in two, cross the halves at right angles and tie them
+together firmly; place the cradle over the affected part under the bed
+clothes. A smaller cradle may be made by taking sections that are less
+than half of the barrel hoop. If used for one foot only, the cradle
+should be small enough not to interfere with the motion of the other
+foot; if used for both feet, it should be large enough to allow some
+freedom of motion. Since the cradle leaves an air space, the feet should
+be wrapped in a piece of soft flannel. A cradle used for the protection
+of the abdomen should extend a little beyond the body on each side.
+
+[Illustration: FIG. 19.--ADJUSTABLE BED REST.]
+
+Adjustable tables are convenient for patients who are able to sit up in
+bed. These tables are supported on one side only so that they may extend
+over the bed. Another kind of bedside table has short legs and stands
+directly on the bed. Such a table can easily be made at home from a wide
+board with supports six or eight inches high nailed to each end. A lap
+board supported by heavy books may serve for temporary use. Indeed,
+home-made substitutes are often as good as expensive apparatus or even
+better. If sick-room appliances must be bought, it is well to remember
+that simple standard designs are best. Complicated apparatus is soon out
+of order, and is generally a trial both to the patient and to those who
+must adjust it. Persons taking care of chronic patients may often obtain
+valuable suggestions in regard to appliances by consulting a visiting
+nurse or the superintendent of the local hospital.
+
+[Illustration: FIG. 20.--ADJUSTABLE TABLE.]
+
+BEDPANS are utensils to receive bowel and bladder discharges of patients
+lying in bed. Enamel bedpans are better than porcelain, although more
+expensive. The shape known as the "Perfection" is best for general use.
+A "slipper" bedpan, although harder to clean and ordinarily less
+comfortable, may be preferable if it is especially difficult or
+undesirable to raise the patient. The square or douche pan is preferred
+by some people, and is especially useful when the quantity of discharge
+is large, as after an injection.
+
+When a patient asks for the bedpan it should be brought if possible
+without a moment's delay, not only because no other form of neglect
+makes a patient realize her helplessness more acutely, but also because
+the desire to use it often passes quickly and delay may encourage the
+habit of constipation. If the patient does not ask for the bedpan, the
+attendant should offer it at suitable times. Bedpans should be warmed
+before use. An easy way to warm one is to let hot water run over it; the
+outside should afterward be dried.
+
+To place the bedpan, first flex the patient's knees and push the night
+gown up; place one hand under the patient's hips, raise them slightly,
+and with the other hand slip the pan into place. If the patient is
+entirely helpless two persons are needed to lift her. Place a pad or
+folded cloth between the patient's back and the pan; then lower the
+patient gently. Before removing the pan, bring toilet paper, water and
+two pieces of soft old muslin or gauze. A patient, if able, prefers to
+use the toilet paper without assistance; her hands should afterward be
+thoroughly washed. If she is unable, the attendant must do everything
+needed. After the patient has been cleaned as thoroughly as possible
+with paper raise her hips with one hand and then remove the pan; it is
+important to raise her first because the skin often adheres and may be
+injured if the pan is suddenly pulled away; carelessness in managing the
+bedpan has caused more than one bed sore. Then remove the pan with one
+hand and cover at once. Turn the patient, if helpless, on her side, wash
+the parts with one piece of old muslin, thoroughly dry them with the
+other, and either burn or thoroughly wash both pieces afterward.
+
+Empty the bedpan and clean it at once; ordinarily one can clean it
+without wetting or soiling the hands. Use cold water first, removing all
+adhering solid particles with a tightly rolled piece of toilet paper. Do
+not use a brush for this purpose. After using cold water, rinse the pan
+thoroughly in hot water, and at least once a day wash it well in hot
+soapsuds. Directions for disinfecting the pan will be given later, but
+remember that a properly kept pan needs no deodorant solution. Glass
+urinals should be provided for men, and kept clean in the same way.
+Contents of both bedpan and urinal should always be carefully inspected;
+neither should be emptied in the dark.
+
+
+DAILY ROUTINE IN THE SICK-ROOM
+
+Obviously the routine of a patient's day must vary according to her
+condition, her preferences, and the amount of time the attendant has to
+give her. The temperature, pulse, and respiration must be taken and all
+medicine, nourishment, and treatment given at the exact times ordered,
+but the attendant should learn whether or not the doctor wishes her to
+wake the patient for food or treatment. Good management in the sick-room
+depends upon foresight and planning, and therefore it is well to keep in
+mind the following suggestions:
+
+Vitality is lowest in the early morning, hence baths and treatments,
+especially if they are fatiguing or painful, should if possible be left
+until after breakfast. Patients often wake early and wait, weak and
+miserable, for the day to begin. A hot drink at this time may give
+relief and enable the patient to sleep again. Even though breakfast time
+is near, nourishment should be given as soon as the patient wakes. She
+may not admit that she is hungry, but her nourishment should not be
+delayed until the family breakfast is ready, or still worse, finished.
+
+Before breakfast the bedpan should be offered, the patient's face and
+hands should be washed, her teeth brushed, her hair tidied, the bed
+straightened, and the room put in order. These services should require a
+few minutes only. The room if properly arranged at bed time needs only a
+little attention now unless untidy work has gone on during the night;
+disorder in a sick-room is as unnecessary in the early morning as at any
+other time.
+
+After the patient has finished her breakfast she may rest, or if
+allowed, read her mail or the newspaper while the attendant prepares for
+her day's work; about an hour after breakfast the patient should be
+bathed, unless she prefers her bath in the evening. After the bath some
+form of light nourishment should be given, even to a patient who has
+regular meals. If a patient is able to sit up in a chair, the best time
+for her to do so is generally just after the bath and toilet have been
+completed; but if she feels tired she had better wait until afternoon.
+The bed room can be better aired and cleaned if it is possible to take
+her into another room; and she herself generally profits by a change of
+scene.
+
+The doctor should definitely state when and for how long a patient may
+sit up for the first time after an illness, and an amateur who may be
+ignorant of the dangers involved should not assume the responsibility of
+deciding. When a patient is to sit up for the first time, put on her
+stockings, slippers, and wrapper before she leaves the bed. Arrange an
+arm chair with pillows in the seat and at the back, bring it close to
+the bedside and cover it with a large blanket unfolded. The chair may
+face either the head or the foot of the bed. Help the patient to a
+sitting position on the extreme edge of the bed, with her feet hanging
+down. Next, standing in front of her and supporting her well, let her
+slip down until she stands upon her feet, then let her turn, and gently
+lower her into the chair. See that the patient while sitting up is
+warmly covered, and that her foot-stool, pillows, etc., are adjusted
+comfortably. Move her chair so that the outlook may be as interesting as
+possible, and at least a little different from the view from the bed.
+Most patients like to look out of the window; children and old people
+enjoy it particularly.
+
+If the patient shows signs of fatigue, she should go back to bed even
+before the appointed time. To help her back to bed, reverse the process
+of helping her out. A footstool may be needed if the bed is high, or
+two people to lift her if she is weak or heavy. When a patient is in bed
+no one should ever sit on the bed, lean against it, use it as a table
+for folding linen, making pads, etc., take hold of the bed posts in
+passing, or touch the bed unnecessarily in any way.
+
+The best time for visitors is the last of the morning or the early
+afternoon. A judicious visitor may do an immense amount of good,
+especially to a chronic patient; indeed, she may be the only ray of
+light in a dark day. Subjects of conversation should be pleasant, but
+not too stimulating or exciting. The visitor should be prepared to carry
+the burden of the conversation, to drop topics skillfully that seem to
+involve fatigue or excitement, and either to go or to stop talking if
+the patient seems tired. Visitors should remember to talk naturally and
+cheerfully on ordinary topics, and to avoid excessive sympathy and
+labored attempts to cheer the patient. They should also remember that
+few patients bear well even the mildest forms of teasing. The patient's
+room is not the place to discuss personal or family troubles; yet it is
+only too often chosen for such purposes, probably because the complainer
+knows that in it an audience is always to be found.
+
+Visitors not belonging to the family should not be present in the
+sick-room during treatment of any kind, unless their help is required;
+neither, as a rule, should they stay during the patient's meals. A
+member of the family may stay with advantage if the patient tires of
+eating alone, but casual visitors almost invariably offend by undue
+urging if the patient's appetite is poor, or by facetious remarks if it
+is good.
+
+Ordinarily only one visitor should be admitted at a time, since a weak
+patient may be tired merely by looking from one to another. If it is
+desirable to limit the call, the attendant should tell the visitor
+beforehand how long to stay, or arrange a signal for the visit to end.
+To announce baldly in the sick-room that the patient is tired and the
+visitor must go, will only elicit aggrieved protests from both. In
+illness lasting only a day or two all visitors should be discouraged;
+during colds, because they are communicable; during general fatigue,
+headaches, digestive upsets, and painful menstruation, because rest and
+quiet are highly desirable. Visitors at such times too frequently give
+injudicious sympathy, and may actually delay the recovery of patients
+who enjoy playing the rôle of interesting invalid.
+
+The time when a trustworthy visitor is present may be the best time for
+the attendant to rest. The patient should be told when the attendant is
+going, and approximately when she will return. It is a mistake to slip
+away while the patient sleeps; she seldom fails to wake before the time
+scheduled and to resent the desertion. Surprises of any kind, pleasant
+or unpleasant, are seldom good for patients.
+
+Toward the end of the afternoon the patient is probably tired,
+especially if she has not slept during the day. When fever is present
+her headache and restlessness increase as the day goes on, but it should
+be remembered that uncomfortable beds and too heavy covers cause much of
+the restlessness attributed to fever. Rubbing the back and legs with
+alcohol, giving a tepid sponge bath, remaking the bed or changing her
+position may help to soothe her.
+
+The evening should be kept free from excitement, and every possible
+effort should be made to encourage sleep. It is a mistake to think that
+a better night results from keeping a sleepy patient awake all the
+evening; sick people should sleep when they can. Just before bedtime the
+attendant should prepare her own cot, and then make the following
+preparations for the patient to sleep: wash the patient's face and hands
+or give a sponge bath if it is desired, brush the hair, change the night
+gown, brush crumbs from the bed, tighten the sheets or remake the bed if
+necessary, rub the back and other pressure points with alcohol, shake
+the pillows, give liquid nourishment, preferably hot, cleanse the mouth,
+and give the bedpan. See that the patient's feet are warm, the bed
+covers right, the room ventilated properly and in good order, and the
+light extinguished or arranged for the night. If the patient is inclined
+to be wakeful a hot foot bath may help her, or sponging the entire
+length of the spine for fifteen minutes, using very hot water and long
+downward quiet strokes. No conversation should be encouraged during
+preparations for the night. Patients in bed all day often lose the habit
+of sleeping at the regular time, and lie awake far into the night from a
+vague feeling that someone else is coming or something further is to be
+done for them. Consequently last of all ask the patient if she wants
+anything more; if not, say good-night, go out and stay out, at least
+until she has had a chance to go to sleep. She is thus helped to realize
+that nothing further is likely to happen, and that it is time to go to
+sleep.
+
+Toward morning the patient grows weaker. More bed covers will probably
+be needed, and they may often be added without waking her. Night at the
+best is a dreary time for the sick. Pain and weariness and
+discouragement are less bearable in the darkness; nervous fears and
+morbid fancies defy control. Never is kindness more needed or more
+appreciated than it is by those who lie awake and watch for the morning.
+
+
+EXERCISES
+
+1. Name all the causes, direct and indirect, of pressure sores.
+
+2. Why are pressure sores generally more serious than injuries of equal
+extent to the skin of a well person?
+
+3. Where are pressure sores most likely to occur and what are their
+symptoms?
+
+4. What measures should be employed to prevent pressure sores?
+
+5. Describe ways to support a person lying down in bed.
+
+6. Describe ways to support a person sitting up in bed.
+
+7. How may the weight of the bedclothes be removed from any particular
+part of the body?
+
+8. How should a bedpan be cared for?
+
+9. Describe in detail a day's routine either of yourself the last time
+you were ill in bed, or of another patient personally known to you.
+Could the plan of the day have been improved, and if so, in what ways?
+
+
+
+
+CHAPTER IX
+
+FEEDING THE SICK
+
+
+Substances used for food are generally grouped into three classes,
+called the three nutrients. The nutrients are: first, the proteids or
+nitrogenous substances, which are found in meat, fish, eggs, milk,
+cheese, peas, beans, etc.; second, the carbohydrates, which include
+sugars and starch; and third, the fats, which are found in butter, oil,
+the fat of meat, etc. In addition to the nutrients, water and certain
+mineral salts are essential to life, while some indigestible material
+like the fibre of vegetables is needed to give bulk and to stimulate the
+action of the intestines.
+
+The nutrients furnish the body with materials for growth, and for repair
+of tissues worn out by use; they also furnish fuel substances from which
+the body obtains its heat and its energy. All three nutrients can serve
+as fuel, but the proteids alone can furnish materials for growth and
+repair of tissues. In order to be used by the body for any purpose,
+nutrients must first go through a series of complicated changes known as
+digestion, which renders them soluble so that they can soak through the
+walls of the intestine.
+
+
+THE DIGESTIVE PROCESS
+
+Digestion begins in the mouth. There the food is crushed and its fibres
+separated by the teeth, it is moistened by the saliva, and substances in
+the saliva begin a chemical action upon the starch. Chewing should be
+sufficient to reduce the food to a soft mass well moistened with saliva.
+Slow eating is desirable, but the emphasis should be placed on thorough
+chewing. For instance, long intervals between bites are of no special
+benefit if mouthfuls of food are washed down by swallows of water.
+
+After it has been swallowed, the food passes into the stomach and
+remains there for a variable length of time, while it undergoes further
+preparation for absorption. It is moved about by the contraction of the
+muscular walls of the stomach, so that it becomes mixed with the stomach
+juices and more thoroughly softened. Some digestion of proteids goes on
+in the stomach, and a little absorption through the walls.
+
+Little by little the food is discharged from the stomach into the small
+intestine, and the most important part of digestion then begins. It is
+acted upon chemically by a fluid flowing into the intestine from an
+organ called the pancreas; this pancreatic juice acts upon all three
+nutrients and is of great importance in the digestive process. The bile
+and other juices that flow into the intestine perform important
+functions also.
+
+The food masses are moved along by rhythmic contractions of the
+intestine, and absorption goes on when the food has been so changed that
+it can soak through the intestinal walls into the blood and lymph
+vessels. The small intestine is about 20 feet long, and consequently
+affords a large surface for absorption, as does also the large
+intestine, into which the small intestine opens. The blood and lymph
+carry the digested food substances to all parts of the body, and thus
+the different tissues are provided with the materials they need for
+growth, repair, and energy. Excess of food substances may be stored as
+fat or expelled from the body.
+
+As the blood and lymph go through the tissues they take from the tissues
+the refuse, or the part that remains after the fuel substances have been
+consumed. This refuse from the tissues may be likened to the ashes from
+a furnace; it is finally eliminated from the body through the kidneys
+and lungs, and to some extent through the skin and bowels. The part of
+the food that is not digested of course never soaks through the
+intestinal walls; it merely passes through the small and large
+intestines and is finally expelled as feces or bowel movements. The
+characteristic odor of fecal matter results from the action of bacteria
+upon it while in the large intestine.
+
+It must be remembered that the body is not nourished merely by
+swallowing food: in order to nourish the body food must also be
+digested, absorbed, and made use of by the tissues. Many factors may
+operate both in health and in sickness to render food indigestible. It
+may be originally unsuited to the human digestive apparatus, or spoiled,
+or poor in quality, or badly cooked. But even when wholesome in itself
+it may be ill-adapted to a particular person at a particular time; thus
+it may be too great in amount, or eaten at improper hours. Moreover a
+person's own idiosyncrasy or manner of living or fatigue or illness may
+render it especially indigestible for him.
+
+Experiments have shown that pain, fear, worry, and other unpleasant
+emotions actually stop the action of the digestive juices and check
+muscular contractions of the small intestine. Furthermore, even the
+absence of pleasant anticipation of food has been shown to delay
+digestion for hours. Thus scientific knowledge confirms our common
+experience that such mental states seriously interfere with digestion.
+The converse is also true. Agreeable taste and odor of food, or even
+pleasurable thought of it, start the secretion of digestive fluids. It
+is a common saying that the mouth waters at the prospect of inviting
+food, but it is less well known that appetizing food does actually start
+the stomach juices also. A person who understands the physiological
+effect that the emotions have upon digestion is in a far better frame of
+mind to cope successfully with the difficulties of feeding the sick than
+one who considers sick persons' likes and dislikes entirely irrational.
+
+
+FEEDING THE SICK
+
+Nourishing the sick is not always an easy problem, but its importance
+can hardly be overestimated. Indeed, proper feeding in many illnesses
+makes the difference between life and death. The actual amount of
+nourishment needed in sickness is often less than in health, but it may
+be just as great, or even greater if the illness causes increased tissue
+waste. Yet the digestive process of a sick person must be rendered as
+little laborious as possible, all foods ordinarily difficult to digest
+must be eliminated, certain others must be withheld or restricted
+according to the nature of the sickness, and in addition one may have to
+deal with an appetite that is capricious, diminished, or totally absent.
+
+Diet for the sick is often a part of medical treatment; in such cases
+the doctor will prescribe special diets and his orders must be carefully
+carried out. Except for special diets, food for the sick is generally
+divided into four classes: first, liquid or fluid diet; second,
+semi-solid diet; third, light or convalescent diet; and lastly, full
+diet. These diets are not very sharply distinguished.
+
+LIQUID DIET generally includes milk, eggnog, albumen water, broths,
+soup, beef juice, thin gruel, and beverages. Liquid diet makes least
+demand upon the digestive powers, because it consists of food already
+dissolved and therefore nearer the condition in which it can be
+absorbed. Moreover, it is less likely than other foods to contain excess
+of fat, improperly cooked starches, and other indigestible material.
+Liquids must be given at regular intervals and at shorter intervals than
+solid foods; 6 to 8 ounces every two or three hours is not too much if
+the patient can take it. The doctor usually specifies the amount and the
+interval. Some patients will take more nourishment at one time if the
+interval is slightly increased.
+
+SEMI-SOLID DIET includes all fluids and in addition soft milk toast,
+soft cooked eggs, well cooked cereal, custards, ice cream and ices,
+junket, and gelatine jellies. Liquid or semi-solid diet is commonly
+given in acute fevers because digestive juices and other fluids of the
+body are then diminished, and also because their digestion places a
+minimum of work upon a system already burdened with bacterial poisons.
+
+LIGHT OR CONVALESCENT DIET generally means a simple mixed diet. In
+addition to the articles in the two preceding diets it includes oysters,
+chicken, baked potatoes, most fruits except bananas, simple desserts,
+white fish, and other meats and vegetables added judiciously until full
+diet is reached. Fried foods should not be included.
+
+FULL DIET means an unrestricted menu, but even from full diets
+especially indigestible foods should be excluded. The principles of
+feeding sedentary persons as described in manuals of dietetics apply to
+patients who are obliged to be inactive although not really ill, as for
+example, a patient suffering from a broken leg. Ordinarily in such
+cases, as in other kinds of illness, the appetite is greatly diminished,
+but a word of warning should be given against overfeeding patients whose
+meals are their chief interest. Such patients are only too likely to
+interpret full diet as anything they desire in any quantity at any time
+of day or night, and then to attribute their discomfort and irritability
+to their illness rather than to overeating.
+
+Constipation is especially stubborn in sickness, since the patient is
+deprived of his usual exercise and variety of food. So far as possible
+the bowels should be regulated by diet. Laxative foods include most
+vegetables with a large amount of fibre, coarse cereals and flour, oils
+and fats, and most fruits and fruit juices. Unfortunately many laxative
+foods are difficult for sick persons to digest and must therefore be
+used with caution. A glass of hot or cold water or orange juice an hour
+before breakfast may be helpful, and at bed time hot lemonade, oranges,
+prunes, figs, or other fruit if allowed.
+
+It is essential for patients to drink water freely, and it should be
+given between meals and also between liquid nourishments. Persons
+inexperienced in the care of the sick frequently make the mistake of
+bringing water only when a patient asks for it.
+
+Many acute illnesses begin with fever, headache, sore throat, and
+especially among children with vomiting, diarrhœa, and other digestive
+disturbances. In such cases all food should be withheld until the doctor
+comes, but boiled water, hot or cold, should be given freely. Efforts to
+tempt the appetite are then mistaken; few people are injured and many
+are benefited by omitting food even for 24 hours at the beginning of an
+acute illness, and with few exceptions a doctor can be found in a
+shorter time.
+
+SERVING FOOD FOR THE SICK.--Food for the sick should always be most
+carefully prepared and of the best quality, and in addition it should be
+as inviting, as varied, and as well served as possible. Neglect in these
+respects is inexcusable. Even slight carelessness in preparing or
+serving food may arouse disgust and thus banish permanently some
+valuable article from the dietary.
+
+Trays, dishes, tray cloths, and napkins for the patient must be
+absolutely clean and as attractive as possible. Cracked or chipped
+dishes should not be used. Individual sets of dishes for the sick may be
+purchased, and their convenience makes them well worth their price.
+Paper napkins may be used in many cases to save laundry work; clean
+white paper is always superior to soiled linen.
+
+Before the tray is brought to the bedside, everything should be arranged
+so that the patient can eat in comfort. It is bad management to let the
+soup cool while the patient's pillows and table are being adjusted. In
+setting the tray great care should be devoted to placing the articles
+conveniently, and to the appearance and garnishing of the food. Careful
+serving requires more thought, but little if any more actual time than
+slovenly serving. Dishes should not be so full that food is spilled in
+transit; hot dishes should be covered; hot dishes should reach the
+patient hot, and cold dishes cold. Liquid nourishment in a glass or cup
+should be served on a small tray or plate covered with a doily. Neither
+glass nor cup should be held by the rim.
+
+It is not uncommon to overload trays and to serve everything at once in
+order to save steps, but a patient is ordinarily more interested in a
+meal that is served in courses unless very long intervals elapse
+between. Moreover, if the meal is served in courses he is not tempted to
+eat dessert first and then to refuse the rest of the meal. If food is
+given sufficiently often it is safer to err on the side of serving too
+little at a time rather than too much, since the sight of large amounts
+of food is often disgusting.
+
+The patient's likes and dislikes should be considered as far as
+possible, but most patients should not be consulted about their menus
+beforehand. Great variety in one meal is not necessary; it should be
+introduced by varying successive meals. An article that has been
+especially disliked should not be served a second time, unless it can be
+disguised beyond a possibility of detection. An article of food to which
+a patient objects should be removed at once; one may appear disappointed
+if it seems wise, but should never argue. When patients persistently
+refuse necessary nourishment a difficult situation is presented;
+persuasion and every form of ingenuity must be used, and the doctor's
+coöperation enlisted. When, for example, a strict milk diet is ordered
+for a patient who announces that he never takes milk in any
+circumstances the situation may seem hopeless but it is not necessarily
+so.
+
+TO FEED A HELPLESS PATIENT.--Helpless and weak patients must be assisted
+to eat or drink. A napkin should first be placed under the patient's
+chin. The attendant should place her hand under the pillow, raise the
+head slightly, and hold the glass to his lips with her other hand. An
+ordinary tumbler can be used by a patient lying down if it is not more
+than a quarter full, or a special feeding cup may be purchased. Bent
+glass tubes may be used for cool liquids; they should be washed
+immediately after use. A child who can sit up sometimes takes more
+nourishment if it is given through a soda water straw.
+
+If the patient must be fed with a spoon care should be taken that the
+liquid is not too hot, but the attendant should not blow upon it to cool
+it. It should be given from the point of a spoon placed at right angles
+to the lips, and plenty of time between mouthfuls should be allowed. A
+swallow should not be given at the moment when the patient is drawing
+the breath in. Great patience is required if a helpless person is to be
+fed acceptably. The attendant should sit by the bedside rather than
+stand, should present at least the appearance of having unlimited time,
+and should endeavor not to deprive the patient in any way of the
+satisfaction he may derive from his nourishment.
+
+
+EXERCISES
+
+1. What needs of the body do food substances supply?
+
+2. Give an outline of the digestive process.
+
+3. Describe the effect of different mental states upon digestion, and
+give examples of the ways by which a knowledge of these effects may be
+utilized in feeding patients.
+
+4. Why is the problem of nourishing the body of especial importance in
+sickness?
+
+5. Name the four ordinary classes of diet for the sick, and mention all
+the articles you can belonging to each class.
+
+6. Why is constipation a common ailment among patients confined to bed,
+and what attempts should be made to overcome it by the diet?
+
+7. Why is it necessary for sick persons to drink water freely, and what
+efforts should the attendant make to encourage them to do so?
+
+8. Describe the proper serving of a patient's tray.
+
+9. How should helpless patients be assisted to eat?
+
+
+FOR FURTHER READING
+
+Health and Disease--Roger I. Lee, Chapter II.
+
+The Human Mechanism--Hough and Sedgwick, Chapters VIII, XIII, XIX.
+
+Notes on Nursing--Florence Nightingale, Pages 63-79.
+
+How to Live--Fisher and Fisk, Chapter II.
+
+Bodily Changes in Pain, Hunger, Fear and Rage--Cannon, Chapter I.
+
+Food for the Invalid and the Convalescent--Winifred S. Gibbs.
+
+Practical Dietetics--Pattee, Chapters IV, V.
+
+Feeding the Family--Rose.
+
+Diet in Health and Disease--Friedenwald and Ruhrah.
+
+Feeding Children from Two to Seven Years Old--New York City Department
+of Health.
+
+American Red Cross Text Book on Home Dietetics--Ada Z. Fish.
+
+Emergency Cooking--Pamphlet 708, American Red Cross.
+
+War Diet in the Home--Pamphlet 706, American Red Cross.
+
+Red Cross Conservation Food Course for Children and Special
+Classes--Pamphlet 705, American Red Cross.
+
+
+
+
+CHAPTER X
+
+MEDICINES AND OTHER REMEDIES
+
+
+ACTION OF DRUGS.--Modern medical practice increasingly emphasizes diet,
+baths, exercises, and other hygienic measures in the treatment of
+sickness. Drugs are given far less than they were a generation ago; yet
+medicines are still the most familiar of all remedies, and the most
+abused by those who persist in treating themselves. Misuse of medicine
+even by intelligent people is astonishingly common.
+
+Problems of sickness and health would be enormously clarified if the
+uses and limitations of drugs were more generally understood. Many
+people still believe that every disease can be cured by a drug if only
+the doctor is clever or lucky enough to think of the right one to give.
+Such beliefs result naturally enough from centuries of faith in charms
+and magic, and occasionally are confirmed by remarkable cures apparently
+brought about by drugs, but really pure coincidence or the result of
+suggestion.
+
+It is a fact that a few medicines are known which if rightly used
+actually do cure certain diseases. An example of their action is the
+curative effect of quinine in malaria. Such medicines, unfortunately,
+are few. In the great majority of cases medicines do not cure disease;
+their beneficial action is ordinarily indirect and is due to their power
+either to increase or to check certain processes within the body.
+
+It is here that the abuse of drugs comes in. Disordered bodily processes
+give rise to symptoms of disease; and it is the symptoms of disease, not
+the disease itself, that trouble the patient. A patient with typhoid,
+for example, is not conscious of the toxins in his blood, but of
+headache, weakness, and fever; the man with eyestrain is not aware of an
+imperfectly shaped lens, but of headache and indigestion. What the
+patient wants is to have his symptoms relieved; in some cases they can
+be controlled by drugs, and the sufferer then considers himself cured.
+But the original condition persists: it may in the meantime be
+improving, but it may on the other hand be growing worse.
+
+Not infrequently it is best to check symptoms, and to check them by
+means of drugs. When they should be checked, only a thoroughly trained
+physician is qualified to decide. The question is not one for amateurs,
+since the whole practice of medicine, including the prescription of
+drugs, constantly becomes more nearly an exact science. People should
+obtain and follow expert advice in regard to health as they would in
+regard to other affairs of life. The constant self-dosing practised by
+thousands of people is harmful and unintelligent; it is, however, no
+less irrational to go to the other extreme and refuse to take medicine
+prescribed by a competent doctor.
+
+AMATEUR DOSING.--Amateur dosing either of oneself or of others is
+dangerous in more ways than one. In the first place, time is lost.
+Moreover, symptoms are characteristic; checking or altering them
+increases the difficulty of finding the real trouble. The man with
+eyestrain who takes one drug to stop his headache and another to "cure"
+his stomach, is simply delaying the time when properly adjusted glasses
+will relieve both. In this case the result may not be serious; but such
+a loss of time in finding the trouble and beginning proper treatment
+might prove fatal in the case of tuberculosis.
+
+Another objection to amateur prescription of medicine is the fact that
+most drugs have more than one effect. In addition to their main action
+they have others, subordinate or ordinarily less marked. These minor
+effects may be serious in some cases. Many headache remedies, for
+example, affect the heart; a dose that is harmless for a normal person
+may be strong enough to injure seriously a person with a weak heart. A
+doctor, and a doctor only, is competent to decide when and in what
+quantity medicines will be beneficial, because he alone understands both
+the condition of the patient and all the possible effects of the drug.
+
+In no circumstances should medicine prescribed for one person be taken
+by another. This rule seems obvious enough; yet every day people pass on
+their pet remedies to friends. Some medicines deteriorate after
+standing, and others grow stronger; nevertheless, medicine supposed to
+have cured a cough or a tonic supposed to have strengthened some member
+of the family after an attack of grippe is cheerfully administered
+months later to another member of the family, who, to make matters
+worse, may differ in age, strength, and probably in the nature of his
+sickness. Drugs are expensive, and it is considered economical to use
+them up; measured by lost time and impaired health such practices may be
+anything but thrifty.
+
+Cathartics, tonics, and various drugs to relieve pain and sleeplessness
+are among the remedies most commonly taken without medical advice.
+Enough has already been said about constipation to indicate proper
+hygienic treatment, but another warning should be given against
+habitual use of cathartics. Many of these drugs are irritating; even
+when not irritating, they are harmful, since the body depends more and
+more upon the drug to do for it what it should be enabled to do for
+itself, by remedying the original cause of the trouble. Licorice powder,
+cascara, saline cathartics such as Seidlitz powders and Rochelle Salts
+and some others are harmless for occasional use, if occasional is not
+too liberally interpreted.
+
+Tonics are poor substitutes for proper diet, rest, and fresh air. Using
+them may be likened to beating a tired horse; the horse goes faster, but
+he is not really stronger. In some emergencies the horse must go faster
+and there is nothing to do but beat him, and in some cases the tonic
+should be given; these, however, are cases for a doctor to decide.
+People persist in taking tonics because they are unwilling or unable to
+rest, or otherwise to change their ways of living.
+
+Medicines to stop pain or to induce sleep are probably the most
+pernicious of all self-prescribed remedies, for they add to other
+dangers the possibility of forming drug habits. These habits are so
+insidious and so powerful that it is not safe to take habit-forming
+drugs even once except by a doctor's direction. In short periods of time
+strong people, apparently firm in will and character, have acquired
+habits from supposedly moderate use of drugs like morphine, cocaine, and
+alcohol. No one, no matter how sure of his own self-control, can afford
+to run so grave a risk.
+
+PATENT REMEDIES.--Objections to self dosing in general apply even more
+strongly to using patent medicines. The ingredients of patent medicines
+are ordinarily unknown, so that using them is unintelligent at best.
+Sometimes they contain habit-forming or other harmful drugs. In other
+cases the ingredients are innocent enough, but totally unable to bring
+about the results claimed for them. The old story about a powerful
+remedy discovered by accident and thus unknown to the medical profession
+deceives only the ignorant or credulous; with our present knowledge of
+chemistry and physiology powerful remedies are not discovered in that
+way.
+
+Even to these comparatively harmless patent preparations there are two
+serious objections. One is the loss of time, during which the patient
+may grow worse. The other is that money is obtained under false
+pretenses; fraud is a common element in the success of patent remedies.
+One of the least harmful, a substance called "Murine" may be taken as an
+example[2]. This substance was widely advertised at one time as a
+"positive cure for sore eyes." Analysis showed it to be a solution of
+borax, which cost about five cents a gallon to prepare. It sold for one
+dollar an ounce, or at the rate of $128.00 a gallon. Although it could
+not bring about the wonderful cures advertised, it was practically
+harmless, and buyers of "Murine" must have been injured chiefly in
+pocket. But with "cancer cures" and "consumption cures" it is a
+different story. Early treatment of these diseases is essential to
+recovery; delay in many cases means robbing the sufferer of his only
+chance of life. No drugs are now known that will cure these diseases,
+and it seems incredible that anyone should be willing to practise such
+cruel deception upon ignorant people merely for the sake of making
+money.
+
+ADMINISTRATION OF MEDICINE.--Medicines may be introduced into the body
+in a number of ways. In the majority of cases they are swallowed and
+finally carried to the tissues by the blood just as digested food is
+carried.
+
+Except in rare emergencies no medicine should be given to a sick person
+without the doctor's order. The prescribed dose should be accurately
+measured in a medicine glass having a scale to show the number of
+teaspoonfuls. When measuring medicine, think only of what you are doing;
+neither talk nor listen to conversation. First read the label on the
+bottle. Next, shake the bottle, if the medicine is liquid, in order to
+mix the contents thoroughly. Then remove the cork with the second and
+third fingers, and hold it between them while pouring, thus keeping the
+cork clean and protecting the contents of the bottle. Hold the medicine
+glass on a level with the eyes, and in the other hand hold the bottle,
+with the side bearing the label uppermost to avoid soiling it; pour out
+the dose, measuring exactly, wipe the bottle, replace the cork, and
+again read the label on the bottle.
+
+Most medicines should be diluted with a little water. Pills and capsules
+should not be presented to patients in the attendant's fingers, but on a
+saucer or teaspoon. Acids and medicines containing iron should be taken
+through a glass tube kept for medicine exclusively. Tubes and glasses
+should be washed at once after use, and neither they nor the bottles
+should stay in the patient's room. If a dose is omitted for any reason,
+do not increase the next dose; give the regular dose at the next regular
+time.
+
+Serious mistakes in giving or taking drugs are far too common, and no
+precautions are too great to guard against them. Never use medicine from
+a box or bottle that has no label. Never take or give another person a
+medicine selected in the dark, even though you have positive knowledge
+that there is no other bottle or box of medicine in the whole house; in
+just such circumstances the fatal mistakes occur.
+
+A few things can be done to make medicines more palatable. The water
+used to dilute the dose and to be taken after it should be very cold.
+Holding the nose is helpful. A piece of cracker, a peppermint, or a
+slice of lemon or orange, if allowed, may be taken afterward. Giving
+disagreeable medicine in ordinary food, as lemon juice, orange juice, or
+milk, and giving bitter powders in jam or jelly, is unwise because it
+sometimes results in life long dislike for a useful article of diet.
+Where food is given directly after the dose to take away its taste, the
+association of dislike seems to be formed less frequently.
+
+The taste of castor oil is so disgusting that it often causes vomiting,
+but if skillfully given the oil need not be tasted by a patient who is
+willing to coöperate. Its way of sticking to the tongue and teeth
+constitutes the chief difficulty; the object therefore is to prevent it
+from sticking by swallowing the dose all at once. To administer the oil,
+wet the inside of a medicine glass or large spoon with very cold water,
+and leave a little water in the bottom. Pour the required dose in slowly
+and cover it with more cold water. Let the patient hold in his hand
+something to take away the taste,--cracker, bread, peppermint, or
+whatever is allowed; for castor oil water is not very effectual. Then
+direct him to hold his nose, open his mouth, and hold his breath;
+caution him to let the oil run down without swallowing until all has
+been taken, and afterward to chew the cracker, continuing to hold his
+nose until he has swallowed the cracker. When the patient understands
+and is ready, pour the dose in quickly as far back as possible, taking
+care not to spill the last drop on the lips. This process may seem
+unduly troublesome, but when castor oil is needed it is badly needed and
+efforts to make it stay down are worth while. The following method also
+effectually disguises the taste of castor oil: place in a glass a
+teaspoonful of baking soda, add the prescribed dose of oil and then the
+juice of half a lemon. Mix all together thoroughly and let the patient
+take the mixture while it is effervescing. This method may be used
+unless the patient is not allowed soda and lemon juice. Castor oil may
+be bought in capsules, but on account of their size many people find the
+capsules impossible to swallow.
+
+SUPPOSITORIES.--Sometimes medicines are given through the rectum. For
+this purpose they are combined with cocoa butter or other material, and
+made into small cones called suppositories. They melt at a low
+temperature and should be kept on ice until needed. A suppository
+should be lubricated with vaseline, and inserted very gently as far as
+the finger can be introduced, while the patient is lying on the back or
+left side.
+
+ENEMATA.--An injection of a fluid into the rectum is called an enema.
+(Plural, enemas, or enemata.) Enemas are generally used to cause
+evacuation of the bowels.
+
+For a simple purgative enema one of the following is generally used:
+plain water; or a solution of common salt in the proportion of one
+teaspoonful of salt to one pint of water; or soap suds made with a white
+soap such as castile or ivory. Unless otherwise ordered the temperature
+of the enema should be between 105° and 110° F.
+
+To give an enema, one should proceed as follows: First protect the bed
+by placing under the patient's hips a rubber sheet, covered by a draw
+sheet or large towel. Let the patient lie on the back, with the knees
+flexed and head low. Bring to the bedside a commode or bedpan, and
+lastly the solution contained in a fountain syringe having a long rubber
+tube, stopcock and short hard rubber nozzle. The bag of the syringe may
+be hung on the bed post or elsewhere, but it should not be more than
+three feet at most above the patient's head. Lubricate the nozzle with
+vaseline either from a tube, or removed from a jar by means of a piece
+of toilet paper; never dip the nozzle itself into a vaseline jar. Let
+the solution flow into the bedpan until it runs warm and smoothly; a
+jerky flow means presence of air bubbles which cause pain if injected
+into the bowels. Unless the patient is able to do it herself, gently
+insert the nozzle, and at the same time start the flow. Force must not
+be used in inserting the nozzle, and the flow should be gentle; if the
+solution goes in rapidly the patient may be unable to retain it. If
+there is a desire to expel the enema as soon as the injection has begun,
+shut off the current and wait a minute, meanwhile making gentle pressure
+upon the patient's abdomen with one hand; then lower the bag a little
+and begin again. A grown person should take from two to four pints, and
+a child from one to two pints. After the enema is finished give the
+bedpan immediately; the enema will, however, be more effective if
+retained a few minutes. The bedpan should be given and removed according
+to the directions on page 176. Sometimes an enema is expelled with such
+violence that it soils the upper sheet; to protect the covers a rubber
+sheet may be spread over the patient's knees and legs. Since an enema
+sometimes causes nausea or faintness, a patient should be watched
+constantly during the process.
+
+To give an enema to a baby one may use a small syringe having a soft
+rubber bulb with a nozzle directly attached, or the ordinary fountain
+syringe with the small, hard rubber tip designed for infants. The enema
+should be given in a warm room free from draughts, and the baby must be
+warmly covered throughout the process. First cover the lap with a pad or
+folded blanket. Upon the blanket place a warmed rubber sheet, and over
+the rubber a warm diaper. Hold the baby on your lap, so that he lies on
+his back with his knees drawn up. Hold his feet or legs firmly in your
+left hand. Lubricate the nozzle thoroughly with vaseline. Be sure that
+all the air is expelled from the syringe, and then proceed as already
+directed. A baby will take from two or three ounces up to half a pint or
+even more, according to the size of the child. After the injection is
+finished place a small vessel under the baby's hips, and hold it until
+the fluid has been expelled, keeping the child well covered all the
+time.
+
+After being used, the nozzle of a fountain syringe should be washed with
+soap and water, boiled, dried and put away in a clean place. Inserting
+the nozzle into the bag of the syringe immediately after withdrawing it
+from the rectum is a filthy but not uncommon practice. The syringe
+should be kept clean inside and out; it should be washed in hot
+soapsuds, rinsed in clean hot water, drained, and when thoroughly dry
+wrapped in a clean towel or tissue paper. The ordinary fountain syringe
+hanging for months by a dirty string on a hook in the bath room is an
+unpleasant and generally an unclean object.
+
+SPRAYS AND GARGLES.--Several other methods of administering medicines
+are occasionally employed. Some remedies may be applied directly to the
+throat by gargles, and to the nose and throat by sprays. The throat may
+be cleansed by gargling with a solution of a teaspoonful of baking soda
+or common salt in a glass of warm water. Nose sprays should not be used
+except under medical advice, and it is well to remember that if the
+mouth washes, gargles, and sprays advertised to be disinfectants were
+really strong enough to kill germs, they would be too harsh for common
+or continued use. The nozzles of nose and throat sprays should be boiled
+immediately after use. A surprising number of families who have
+progressed far beyond common drinking cups and towels, continue to use a
+common nose spray without even washing the nozzle. Children while they
+are well should be taught to gargle the throat; a child with a sore
+throat and an aching head is in a poor condition to learn anything.
+
+INHALATION or breathing in, is another method used to introduce drugs
+into the membranes of the nose, throat, and lungs. Smelling salts are an
+example of substances used for inhalation; they are used to stimulate
+persons who are faint. They should not be placed close to the nostrils,
+nor used at all when the patient is totally unconscious.
+
+Inhalations of steam are often used in asthma, croup, and bronchitis.
+Special croup kettles are made for the purpose, but an ordinary pitcher
+half full of boiling water may be used instead. The patient's head
+should be held closely over the pitcher, and a towel should be adjusted
+around the top covering the patient's nose and mouth, but admitting just
+enough air to make it possible for him to breathe. If a drug is ordered
+it should be added to the water.
+
+INUNCTION, or rubbing a substance into the skin, is sometimes ordered
+for delicate babies and children. After the skin of the abdomen has been
+washed with warm soapy water and thoroughly dried, the substance
+ordered, generally olive oil or cod liver oil, should be applied by
+means of a circular movement of the palm of the hand. The oil should be
+warm and the rubbing continued until it is absorbed.
+
+Ointments are also applied by inunction. A small quantity at a time
+should be rubbed in, using a circular motion. If an ointment is ordered
+to be applied where the skin is broken, the ointment should be spread
+upon gauze and applied without friction. Liniments are rubbed in in the
+same way as ointments. In many cases rubbing accomplishes more than the
+ointment or liniment itself, so that this part of the treatment must not
+be slighted.
+
+HOUSEHOLD MEDICINE CUPBOARD.--In every household a small cupboard is
+needed for medical and surgical supplies. Glass shelves are desirable,
+because they show when dirty and are easily cleaned, but a wooden
+cupboard can easily be lined with clean paper or white enamel cloth held
+in place with thumb tacks. Dirty, stained shelves should not be
+tolerated. The cupboard should be kept locked and the key put well out
+of the reach of children. In the cupboard should be kept medicines in
+daily use; they should not be paraded on family dinner tables.
+
+Poisonous drugs should have rough glass bottles and conspicuous labels.
+All medicine bottles should be kept well corked, since evaporation may
+take place and the remaining solution, by becoming stronger, may be
+dangerous to use in the ordinary amount. Pills and tablets sometimes
+deteriorate by standing, and may become so hard that they pass through
+the stomach and intestines without dissolving. It is best to buy drugs
+and surgical supplies in small quantities; when it is cheaper to buy
+more at a time the druggist should be asked whether they will
+deteriorate or not.
+
+Almost every family needs to keep on hand some cathartics, some
+disinfectants, some material for first aid, and a few simple appliances.
+Most families have certain other needs peculiar to themselves, and for
+those who live at a distance from drug stores a greater quantity and
+variety may be required. Elaborate equipment and extensive supplies of
+medicines are neither economical nor necessary for household use.
+
+Castor oil, Rochelle or other laxative salts, and two grain cascara
+tablets ordinarily constitute a sufficient supply of cathartics. The
+dose of castor oil is one or two teaspoonfuls for a baby up to a
+tablespoonful for an adult. Rochelle salts and seltzer aperient are
+given dissolved in water; the ordinary dose is from one to four
+teaspoonfuls. Seidlitz powders come in two packets, one white and one
+blue. The contents of the packets should first be dissolved in separate
+glasses each filled about a quarter full of water. One solution should
+then be poured into the other and the mixture taken while it is
+effervescing. Cascara tablets are generally given in one to ten grain
+doses.
+
+A small bottle of tincture of iodine and one of 70% alcohol should be
+kept for disinfecting. Neither one is for internal use. The iodine is
+used to disinfect small wounds and abrasions of the skin. It is applied
+with cotton swabs and several swabs should be made and kept on hand in a
+box or envelope. Alcohol is used to disinfect thermometers and other
+instruments that cannot be boiled, for rubbing, and may also be used for
+disinfecting the skin. A 90% solution is sometimes used for rubbing; it
+need not be bought until needed. Denatured and wood alcohol are poisons
+and should be used in households only in spirit lamps; they are not safe
+for other purposes.
+
+First aid materials may include two gauze bandages two and one-half
+inches wide and two bandages one inch wide, one American Red Cross First
+Aid Outfit, a small package of absorbent cotton, a roll of old muslin, a
+package of adhesive plaster one inch wide, boracic ointment, picric acid
+gauze or other application for burns, safety pins, and a pair of
+scissors.
+
+For use in cases of fainting or exhaustion it is well to keep aromatic
+spirits of ammonia on hand. Its bottle should have a rubber stopper. The
+dose is one-half to one teaspoonful, in a quarter to half a glass of
+water. Hot coffee and tea are also good stimulants, but the time
+necessary to prepare them makes it desirable to have aromatic ammonia
+on hand. Household or ordinary ammonia must not be used as a substitute.
+
+Olive oil, mustard, and baking soda may be brought from the kitchen when
+needed. It is assumed that vaseline, cold cream, hand lotion, talcum
+powder, and other toilet preparations will also be available.
+
+Only a few appliances are necessary. Among them are a medicine glass, a
+teaspoon, clinical thermometer, hot water bag, fountain syringe, and an
+alcohol lamp in houses without gas or electric stoves. It is better not
+to buy other appliances until they are needed, particularly rubber goods
+since they deteriorate rapidly.
+
+
+EXERCISES
+
+1. Why is it dangerous for persons without medical training to prescribe
+medicines? What is the especial danger of dosing oneself?
+
+2. What is meant by a habit-forming drug? Name all you can, and tell why
+they are peculiarly dangerous.
+
+3. What are the special objections to patent medicines?
+
+4. What precautions should be taken in order to administer medicine
+accurately? What precautions to avoid giving wrong medicines?
+
+5. How may some disagreeable medicines be made more palatable?
+
+6. Tell how to prepare and give a soapsuds enema.
+
+7. How should a fountain syringe be cared for? a throat spray?
+
+8. Describe methods for giving steam inhalations.
+
+9. Describe the equipment and care of a household medicine cupboard.
+
+10. What drugs is it well for a family to keep on hand? What appliances?
+What materials for first aid?
+
+11. How many drugs in addition to those prescribed by a physician have
+you or your family on hand at the present time? How many do you consider
+really necessary? Are any of these medicines used to remedy troubles
+that might be cured by sufficient attention to rest, exercise, diet, and
+fresh air?
+
+
+FOR FURTHER READING
+
+Health and Disease--Roger I. Lee, Chapter VI.
+
+How to Live--Fisher and Fisk, Supplementary Notes, Sections IV, V.
+
+Scientific Features of Modern Medicine--Frederic S. Lee, Chapters III,
+VIII.
+
+The Human Mechanism--Hough and Sedgwick, Chapter XX.
+
+The Conquest of Nerves--Courtney.
+
+Primitive Psychotherapy and Quackery--Lawrence, Chapters I-V.
+
+Nostrums and Quackery--American Medical Association. (See especially
+"Cancer Cures" and "Consumption Cures.")
+
+
+FOOTNOTES:
+
+  [2] See "Nostrums and Quackery," p. 445.
+
+
+
+
+CHAPTER XI
+
+APPLICATION OF HEAT, COLD, AND COUNTER-IRRITANTS
+
+
+INFLAMMATION.--A process called inflammation sometimes occurs in tissues
+that have been injured or invaded by bacteria. Although painful, it is
+nevertheless one of the reparative processes of the body, and therefore
+beneficial. Common examples of inflammation are boils, sore throat, and
+the swollen, painful condition resulting from sprains and fractures.
+Characteristic symptoms of inflammation are heat, redness, swelling, and
+pain.
+
+When a tissue has been invaded by bacteria, nearby blood vessels dilate,
+thus bringing an increased supply of blood to the affected part. This
+extra supply serves to wash away the offending substance, and at the
+same time it brings more white blood corpuscles, one function of which
+is to destroy bacteria. From the increased supply of blood the affected
+part becomes red and hot, and so much blood may come that the vessels
+further on are unable to carry it away fast enough. Some of the fluid
+part of the blood is then forced out into the tissues, and the part
+becomes swollen. Distension of the tissues and pressure on the nerve
+endings cause pain, and the injured part now exhibits the characteristic
+symptoms of inflammation.
+
+[Illustration: FIG. 21.--"THE HISTORY OF A BOIL." This figure represents
+a cross-section of normal skin. Note the surface layer, or cuticle, and
+the "true skin," or cutis. In the cutis one sees that the blood
+capillaries are just wide enough for the blood-cells to pass through "in
+single file." The skin has just been pricked by a dirty pin. On the
+point of this pin were several poisonous germs which were deposited at
+_a_. (_From Emerson's "Essentials of Medicine."_)]
+
+[Illustration: FIG. 22.--"THE HISTORY OF A BOIL" (continued). The poison
+from these germs diffuses through the cutis. The capillaries dilate. The
+leucocytes force their way through the walls of the capillaries and
+travel towards these germs. Note the dumb-bell shape of the leucocytes
+as they pass through the minute holes in the capillary walls, and their
+pseudopods as they travel towards their common destination, attracted by
+the poison from the germs. The skin in this region is now swollen, red,
+hot, and painful. (_From Emerson's "Essentials of Medicine."_)]
+
+At this point, if the injury begins to heal or the bacterial infection
+to yield, the extra blood supply is gradually carried off, the blood
+vessels resume their normal size, and the tissues return to their usual
+condition. If, however, the infection does not yield so quickly, more
+and more white blood corpuscles assemble and pass through the walls of
+the tiny blood vessels into the tissues. Here the struggle continues.
+Some bacteria and some white blood corpuscles are killed, and substances
+are formed which liquify these dead cells and also some cells of the
+surrounding tissues. The resulting fluid is called pus or matter, and in
+the case of a boil we then say it has come to a head. If the infection
+occurs near a cavity or near the surface of the body, the pus may escape
+by breaking through at the point of least resistance, and may carry most
+of the poisons along with it. If the pus finds no outlet it may be
+gradually absorbed by the blood stream, and healing may result without
+discharging. On the other hand, the germs may make their way into the
+circulation, thus causing the serious condition known as blood
+poisoning.
+
+[Illustration: FIG. 23.--"THE HISTORY OF A BOIL" (continued). The
+migration of leucocytes has continued until now they form a dense mass
+surrounding the germs. The poison of the germs has killed all the
+leucocytes and also all the cutis immediately around them, and now
+digestive fluids from the dead leucocytes is turning the whole dead mass
+into liquid pus. The boil has "come to a head." There is a little lump
+on the skin and through its thin covering of cuticle can be seen the
+yellow pus. (_From Emerson's "Essentials of Medicine."_)]
+
+Inflammation may be treated by means of hot applications, cold
+applications, or counter-irritants. The effect of heat is to dilate the
+vessels and hence to increase the flow of blood to the injured part.
+This increased blood supply makes the reparative process go on more
+vigorously, and also makes it possible for the accumulated fluid to be
+more rapidly carried away. Moist heat softens the tissues so that pus,
+if formed, can escape more easily.
+
+[Illustration: FIG. 24.--"THE HISTORY OF A BOIL" (concluded). The boil
+has finally ruptured. The liquid pus has escaped carrying with it the
+germs and most of their poisons; the migration of leucocytes has
+stopped; the capillaries are returning to normal size and now new tissue
+will grow and fill up this hole. (_From Emerson's "Essentials of
+Medicine."_)]
+
+Cold acts in just the opposite way. It decreases the size of the blood
+vessels so that less blood comes to cause pain and swelling; at the same
+time it diminishes the number of white blood corpuscles and the
+nutritive substance brought by the blood. The nature and location of the
+infection determine whether heat or cold is to be preferred.
+
+Counter-irritants, of which mustard is an example, have a complicated
+action. A counter-irritant affects the blood circulation of the place to
+which it is applied, and at the same time it irritates the superficial
+nerves, which in turn stimulate other more distant nerves. The latter
+nerves control the circulation in tissues not adjoining those to which
+the counter-irritant is applied, and thus it is possible for a mustard
+paste, for example, if applied at one point to bring about changes in
+the blood supply of another part of the body. The mechanism by which
+counter-irritation is brought about is an intricate nervous process
+called reflex action.
+
+
+HOT APPLICATIONS
+
+In applying either moist or dry heat the danger of burning or scalding a
+patient must be constantly kept in mind. This danger is always great,
+but it is especially great when the skin is tender like that of babies,
+children, and old people, or when the vitality is low as in cases of
+chronic or exhausting illness. Unfortunately accidents in applying heat
+are not uncommon; a moment's carelessness may cause serious injury and
+prolonged suffering.
+
+DRY HEAT.--Hot water bags are used to apply dry heat. They should be
+filled not more than two-thirds full of hot water, but the water must
+not be so hot that there is the slightest possibility of scalding the
+patient if the bag should leak. Boiling water should never be used.
+Before the stopper is screwed on, expel the air by squeezing the bag or
+by resting it upon a flat surface until the water reaches the top. After
+closing the bag make sure that both bag and stopper are in order, by
+noting whether leakage occurs when the bag is inverted and pressed
+moderately. Before it is placed near the patient the bag should be dried
+and entirely covered with a towel or canton flannel bag.
+
+Strong bottles, jugs, and jars, if they can be securely stoppered, may
+be used sometimes instead of hot water bags. The same precautions are
+necessary. Bricks, flat irons, or thick flannel bags containing salt or
+sand may be heated in the oven and used in the same way. Salt and sand
+retain heat for a long time, but are correspondingly slow to heat;
+therefore one bag should be heating in the oven while the other is in
+use. Their effect on the skin must be no less carefully watched than the
+effects of other hot applications.
+
+Hot dry flannel may be used without fear of burning a patient, and it
+sometimes yields sufficient warmth to relieve pain, particularly
+abdominal pain of babies. After it has been heated on a radiator or in
+an oven, it should be applied quickly and covered closely with another
+flannel to prevent escape of heat.
+
+Dry heat can be applied conveniently by an electric pad. The part to be
+heated may be wrapped in flannel or placed directly above or below the
+pad. The pad should be carefully watched to see that the switch is not
+accidentally turned, as it is possible for the pad to become hot enough
+to burn the patient or to set fire to the bed covers.
+
+MOIST HEAT.--To apply moist heat poultices or fomentations (stupes) are
+used.
+
+_Poultices_ may be made of various heat-retaining substances, but
+flaxseed meal is generally used. The poultices when ready should be
+applied without delay, therefore all preparations should be made in
+advance. To prepare a poultice, first provide a piece of gauze or thin
+old muslin about two inches wider than you wish the poultice to be when
+finished, and about two inches more than twice as long. In a shallow
+saucepan boil water, varying in amount according to the size of the
+poultice desired; about equal parts of water and meal will be needed.
+When the water is boiling briskly add the meal gradually, beating
+constantly with a spatula or knife. The poultice is done when the
+mixture coheres and is thick enough to drop from the spatula leaving it
+clean. Quickly spread a layer of the hot flaxseed from a quarter to half
+an inch thick on one-half of the muslin, leaving a margin on three sides
+of about an inch (Fig. 25). Fold in the margins of the cloth (Fig. 26)
+and then bring the other half of the cloth over the flaxseed so that the
+top of the poultice is covered. Tuck the free end of the upper half of
+the cloth under the turned in edges of the long sides.
+
+[Illustration: FIG. 25.--Turn the edges of the muslin over the flaxseed
+by folding first on the line _AA'_, and then on the lines _BB'_ and
+_CC'_.]
+
+[Illustration: FIG. 26.--Fold on the line _EE'_, bringing _FF'_ up over
+the flaxseed and tucking it under at _D_ and _D'_.]
+
+Carry the poultice on a hot plate, or rolled in a newspaper or hot
+towel. Test it carefully with the back of the hand, apply it to the skin
+gradually, cover it with cotton batting, oiled muslin, or several
+thicknesses of flannel, and keep it in place with a bandage or towel.
+Remove it as soon as it has become cold, and unless the skin is much
+reddened apply a fresh poultice. If the skin is much reddened, anoint it
+with vaseline or sweet oil, wrap it warmly, and apply the next poultice
+as soon as the appearance of the skin is normal.
+
+_Stupes_ or _hot fomentations_ are cloths, preferably of flannel or
+flannelette, wrung out of boiling water and applied to the skin. Each
+stupe should be three or four times as large as the area to be covered.
+Two are needed, so that one may be prepared before removing the other.
+To prevent escape of heat and moisture the stupe should be covered after
+it has been applied, first with a piece of rubber cloth or oiled silk or
+muslin, and next with several thicknesses of flannel, or cotton batting
+made into a pad. The whole should be kept in place with a bandage or
+towel used as a binder. The doctor will tell how often the stupes are to
+be applied, but if the skin becomes irritated they must be stopped until
+its appearance is again normal.
+
+[Illustration: FIG. 27.--WRINGING STUPE. (_From "Elementary Nursing
+Procedures," California State Board of Health._)]
+
+Great care must be taken in applying fomentations. They do little good
+unless very hot, but if applied too hot the patient is likely to be
+scalded. They must be wrung as dry as possible; but it is difficult to
+wring them without scalding the hands unless stupe wringers are used.
+Stupe wringers are heavy pieces of cloth, like roller towels or pieces
+of ticking, long enough to extend over opposite sides of the basin in
+which the stupe is to be boiled, and wide enough to hold the stupe
+easily. The wringer should be placed in the basin with the stupe
+arranged upon it. Boiling water should then be added, or the water,
+stupe, and wringer may be boiled together in the basin. After the stupe
+is ready, the wringer with the stupe upon it should be removed from the
+water by grasping the dry ends of the wringer. Then the ends should be
+twisted in opposite directions until the stupe inside is as dry as
+possible. Wringing is made easier if the wringer has wide hems into
+which sticks such as pieces of broom handles are inserted. By twisting
+the sticks in opposite directions the stupe may be wrung out easily.
+
+
+COLD APPLICATIONS
+
+DRY COLD.--Cold, like heat, may be used either dry or moist. Bags of
+rubber or of Japanese paper filled with small pieces of ice are used to
+apply dry cold. When weight is to be avoided, the bag should not be
+completely filled. After the bag has been filled and the air has been
+expelled, it should be stoppered securely and wrapped in a towel or
+piece of flannel, since it is possible for an uncovered ice bag to
+freeze the skin. Ice bags are easily punctured, and care should be taken
+not to bring pressure upon them especially when filled with sharp pieces
+of ice. An ice bag not in use should be thoroughly dry inside and out;
+it should be put away with enough absorbent cotton inside to keep the
+surfaces from adhering. Bags of Japanese paper are less costly than
+rubber, but less durable. To close them one should roll the top over and
+then tie it tightly with string.
+
+MOIST COLD.--Cold compresses for the head are often used for patients
+with fever or headache; they sometimes quiet a patient who is restless.
+An old handkerchief or piece of soft linen folded with the raw edges
+inside may be used as a compress. It should be large enough to cover the
+forehead. Two compresses at least should be provided, and a large piece
+of ice in a basin. One compress should be wrung so that it will not
+drip, and then applied to the head. The other meanwhile should be placed
+on the ice to cool. As soon as the first compress becomes warm, the
+second should be applied in its place.
+
+_Cold Compresses for the Eyes._--Soft material should be selected for
+eye compresses. Each one should be cut only a little larger than the eye
+and should fit neatly over it. Several compresses should be placed on a
+block of ice while one is applied to the eye, and every few minutes the
+compress should be changed. If there is discharge from the eye, each
+compress should be used but once; when used, they should be collected in
+a paper and afterward burned. Separate compresses should be used if both
+eyes are being treated. Definite directions in regard to changing
+compresses and the length of time the applications should be continued
+are generally given by the physician.
+
+
+COUNTER-IRRITANTS
+
+To some extent all hot applications are counter-irritants, but mustard
+pastes, mustard leaves, and the mustard foot-bath already described are
+the counter-irritants most commonly used.
+
+_Mustard Paste._--To make a mustard paste, mix dry mustard with flour,
+using for adults one part of mustard and six of flour to make a weak
+paste; increase the proportion of mustard up to equal parts of mustard
+and flour, according to the strength required. Use a smaller proportion
+of mustard for children; one part of mustard with from 6 to 10 parts of
+flour is generally enough. Add to the mustard and flour enough tepid
+water to make a paste, which must be absolutely free from lumps. Do not
+use hot water for this purpose, because it destroys some of the active
+properties of the mustard. Spread the paste on thin muslin, apply it to
+the skin, and remove it as soon as the skin is reddened so that its
+color resembles that of a strong sun-burn. If the skin is especially
+sensitive, mix a little sweet oil or vaseline with the paste.
+
+_Mustard leaves_ should be dipped in tepid water and may then be applied
+to the skin directly, but if specially sensitive, the skin should be
+protected by thin muslin or gauze. The leaf should remain until the skin
+is well reddened; a few minutes are generally sufficient.
+
+Care must be taken not to leave either a mustard leaf or a paste in
+place long enough to blister the skin. After the application has been
+removed; the part should be protected by a soft cloth until redness
+disappears. Vaseline or sweet oil should be applied to the skin if it is
+greatly irritated.
+
+Other counter-irritants in common use are iodine, turpentine, ammonia,
+kerosene, camphorated oil, capsicum vaseline, and various liniments.
+Tincture of iodine may be diluted with alcohol for especially sensitive
+skins; it sometimes causes blisters, and should not be applied more than
+once a day at most. Ammonia and turpentine cause blisters; they should
+not be used as counter-irritants except by a doctor's order, and then
+only after exact directions have been obtained. Turpentine and kerosene
+are inflammable and hence dangerous to use. It should be remembered that
+the action of all counter-irritants is physiologically the same, so that
+no advantage is obtained from the use of dangerous substances like
+kerosene and turpentine.
+
+
+EXERCISES
+
+1. What are the causes and symptoms of inflammation?
+
+2. Describe the process of inflammation.
+
+3. What is the effect of heat on an inflamed area? of cold?
+
+4. What are the dangers from hot applications, and how may they be
+guarded against?
+
+5. How should you fill a hot water bag? How should you cover it?
+
+6. Describe the method of preparing and applying a flaxseed poultice.
+
+7. Tell how to prepare and apply fomentations.
+
+8. How should you apply cold compresses to the head? to the eyes?
+
+9. How should you make a mustard paste for a baby six months old? for a
+grown person only slightly ill? for a feeble old person with a sensitive
+skin?
+
+
+FOR FURTHER READING
+
+Essentials of Medicine--Emerson, Chapter I.
+
+The Human Mechanism--Hough and Sedgwick, Chapter IX.
+
+
+
+
+CHAPTER XII
+
+CARE OF PATIENTS WITH COMMUNICABLE DISEASES
+
+
+The first chapter of this book described the ways in which communicable
+diseases are carried from person to person, and also some principles
+underlying methods of prevention. This chapter aims to show how these
+principles apply in the actual care of patients whose diseases are
+transmissible. In order to apply them intelligently, it is necessary to
+keep in mind certain facts in regard to the transmission of infections.
+A brief summary of these facts follows.
+
+Disease germs are present in the bodies of persons suffering from
+communicable disease, but they may also exist in the bodies of persons
+in good health; if present in the body, they may leave it in any bodily
+discharge. While every kind of germ does not leave the body by all the
+different routes, it is nevertheless true that most germs expelled from
+the body are carried in discharges from the nose, throat, bladder or
+bowels. Germ-laden discharges of an infected person may be distributed
+to other persons by water, milk and other foods, by certain insects, by
+unclean hands, by common drinking cups, towels, handkerchiefs, and
+similar articles, and directly by nose and throat spray. After they have
+been thus conveyed to other persons, the germs make their entrance into
+the body of their new victims through the digestive tract, through the
+nose, throat, and other mucous membranes, or through breaks in the skin.
+Prevention of communicable diseases, therefore, depends upon the measure
+of success attained in blocking the transit of germs from person to
+person; but methods of prevention, though easy to understand, are
+unfortunately sometimes difficult to carry out. In order to carry them
+out effectively one must devote to the problem great accuracy,
+unremitting care, considerable intelligence, and a highly developed
+conscience.
+
+Care of a patient suffering from transmissible disease is adequate only
+when it accomplishes two definite results. One result, which concerns
+the patient primarily, is to bring about his recovery as rapidly and as
+surely as possible; the other result, which concerns the community
+rather than the individual, is to make it impossible for the patient to
+infect others with his disease. In every case of communicable disease,
+from a slight cold in the head up to serious cases of pneumonia or
+typhoid fever, both the patient and the community must be constantly
+safe-guarded.
+
+INCUBATION PERIOD.--The interval between the moment when pathogenic
+germs enter the body, and the time when symptoms first appear and the
+patient begins to feel ill, is called the incubation period. Incubation
+periods vary according to the disease from a few hours to two or three
+weeks. The length of the period also varies somewhat in different cases
+of the same disease.
+
+CARE OF PATIENTS WITH COLDS OR OTHER SLIGHT INFECTIONS.--The usual
+symptoms of infectious diseases include fever, chill, sore throat, nasal
+discharge, cough, headache, vomiting and other digestive disturbances,
+and a general feeling of being sick all over. When one or more of these
+symptoms appear, unless they are very slight, a doctor should be sent
+for. The patient, whether child or grown person, should go to bed in a
+room alone and should stay in bed at least as long as the fever and
+symptoms of cold in the head continue, in order to protect others as
+well as himself. Persons in active life, it is true, are not always able
+to go to bed during colds; but there is no doubt that ultimately they
+would save time by doing so. It is especially necessary for children to
+remain in bed when suffering from colds, not only to insure their own
+well-being but also to protect others, since children are notably
+careless in regard to coughing, sneezing, and borrowing handkerchiefs.
+The patient needs mental rest as well as physical, and should not be
+allowed to work in bed.
+
+The patient's nose and throat discharges should be received only in
+material that can be burned, like old linen or muslin, gauze, or paper
+napkins. As soon as they are soiled these handkerchief substitutes
+should be placed in strong paper bags and afterward burned. Soiled
+handkerchiefs lurking under pillows or in other parts of the bed may
+infect other people or re-infect the patient. Handkerchiefs that may not
+be burned should be placed as soon as soiled in a covered receptacle
+filled with cold water containing a little washing soda; when several
+have been collected they should be boiled in the same covered receptacle
+for 20 minutes. After boiling they may go to the regular laundry.
+
+The patient's diet at first should be liquid or semi-solid. Large
+amounts of nourishment are not necessary during the first day or two,
+especially if the illness is likely to be short, but water should be
+taken as freely as possible. Cold drinks are generally acceptable during
+the feverish stage, but lemonade and other acids should be used with
+caution, since they sometimes irritate a sore throat. When the active
+symptoms have subsided the patient will need more food than usual, and a
+liberal, nourishing diet for a few days will do much to prevent the
+weakness and depressed vitality that often follow colds, tonsilitis, and
+other comparatively slight infections.
+
+The bowels should be carefully regulated, and a mild cathartic is often
+beneficial at the outset.
+
+Even during slight illness a patient should receive the daily care
+already described, and should be made as comfortable as possible. As in
+any illness, sponging and alcohol rubs are refreshing. An ice bag or
+cold compress may relieve headache, and hot applications or a cold
+compress on the throat are often soothing. The throat may be gargled
+with a solution of one teaspoonful of common salt dissolved in a pint of
+boiled water. If the patient perspires profusely he should be rubbed
+with a towel until dry, and provided with fresh warm, night clothes. An
+alcohol rub may well follow. It is most unwise for a patient who is
+perspiring freely to get up in a cold room and attend to himself.
+
+Common colds are far more serious than they are usually supposed to be.
+
+      "More people suffer from common colds than from any other
+      single ailment.... Could the sum total of suffering,
+      inconvenience, sequelæ, and economic loss resulting from
+      common colds be obtained, it would at once promote these
+      infections from the trivial into the rank of the serious
+      diseases.... Colds are contracted from other persons having
+      colds, just as diphtheria is contracted from diphtheria.
+      Arctic explorers exposed to all the conditions ordinarily
+      supposed to produce colds do not suffer from these ailments
+      until they return to civilization and become infected by
+      contact with their fellowmen.... While common colds are
+      never fatal, the complications and sequelæ are serious.
+      These are rheumatic fever, pneumonia, sinusitis, nephritis,
+      and a depressed vitality which favors other infections and
+      hastens the progress of organic diseases.
+
+      "Common colds are perhaps most contagious during the early
+      stages. If persons isolate themselves by remaining in bed
+      during the first three days of a cold, they would not only
+      benefit themselves, but would largely prevent the spread of
+      the infection. The contagiousness and severity of colds
+      differ in different epidemics and in different seasons of
+      the year, depending upon the particular micro-organism
+      involved and other factors not well understood.
+
+      "PREVENTION.--The prevention of colds consists, first in
+      avoiding the infection, and, secondly, in guarding against
+      the predisposing causes. Contact should be avoided with
+      persons who have colds, especially in street cars, offices,
+      and other poorly ventilated spaces where the risk of
+      persons coughing or sneezing directly in one's face is
+      imminent. Contact with the infection may further be guarded
+      against by a careful self-education in sanitary habits and
+      cleanliness, based upon the modern conception of contact
+      infection.
+
+      "Colds, like other diseases conveyed in the secretions from
+      the nose and mouth, are often conveyed by direct and
+      indirect contact through lack of hygienic cleanliness and a
+      disregard of sanitary habits. Kissing, the common drinking
+      cup, the roller towel, pipes, toys, pencils, fingers, food,
+      and other objects contaminated with the fresh secretions
+      will transmit the disease."--("Preventive Medicine and
+      Hygiene," Rosenau.)
+
+CARE DURING MORE SERIOUS INFECTIONS.--When a patient is suffering from
+serious transmissible disease, he needs the most skillful care
+available, and for the sake of others he must be strictly isolated or
+quarantined. By isolating or quarantining a patient is meant making such
+arrangements that germs expelled by the patient are necessarily
+destroyed before they can enter the body of another person. Isolation,
+therefore, includes disinfection, and while methods vary according to
+the nature of the particular disease, yet the principles given below are
+applicable in most cases.
+
+The first essential is that the patient should have a room to himself.
+No one except those caring for him should enter the sick-room for any
+purpose whatever; visitors should be rigidly excluded. At the outset all
+unnecessary articles should be removed from the sick-room, and it
+should be possible to boil, burn, scrub, or otherwise thoroughly clean
+everything allowed to remain. The windows should be screened in summer,
+and flies must be excluded. Fresh air is especially needed by patients
+with communicable diseases, and ventilation of the room must be adequate
+both day and night. Foul odors plainly indicate that the patient or
+something in the room is not clean. The remedy is obvious and deodorants
+are quite unnecessary if the patient and the room are properly cared
+for. It is highly desirable to reserve a bath room for the exclusive use
+of the patient and his attendant and also to reserve a room adjoining
+the patient's room for the exclusive use of the attendant. When it is
+impossible, as it often is, to give up so much space, each family must
+make the best arrangement it can to separate the patient and his
+attendant from the rest of the family.
+
+The attendant must remember that her ten fingers are the ten most active
+agents in distributing the communicable diseases. After handling the
+patient or anything that the patient has touched, and whenever she
+leaves the patient's room, she must scrub her hands thoroughly with warm
+water, soap, and a nail brush. She should not soil her hands
+unnecessarily, even though she intends to scrub them later. She must
+remember for her own protection to keep her hands away from her mouth
+and face, and to cleanse them with special care just before eating. If
+disinfection is needed in addition to the scrubbing, she must use
+conscientiously whatever solution the doctor orders.
+
+At the same time that she is caring for a patient with a communicable
+disease, the attendant ought not to care for children or other members
+of the family, she ought not to prepare food, and she ought not to
+handle dishes or utensils used by other persons. Every day, however,
+many women are doing just these things, and it is true that in many
+instances no bad results are observed. Yet if any arrangement to insure
+safety can possibly be made, it is inexcusable to run the risk of
+spreading diseases which kill thousands of persons every year and injure
+many more for life.
+
+When home conditions render adequate care and strict isolation of the
+patient impossible, hospital care should be seriously considered. No
+personal or sentimental objections should be allowed to influence the
+decision, if removing the patient to a hospital is necessary to
+safeguard his welfare or the welfare of the family. Hospital care should
+be considered especially for patients with typhoid fever, because
+untrained persons cannot safely care for patients so seriously ill.
+Since a patient with typhoid needs skilled care, and since he greatly
+endangers other persons, most authorities consider hospital care
+essential unless the patient can have the continuous services of a
+trained nurse and almost ideal home conditions. Many cases of typhoid,
+it is true, are successfully nursed at home in extremely adverse
+conditions by visiting nurses; yet in few kinds of sickness is
+continuous care by a graduate nurse more necessary to protect the
+community as well as to safeguard the patient himself.
+
+Members of a family in which there is typhoid should be immunized if the
+doctor advises it. This process, which is performed by the doctor, in
+the majority of cases renders a person immune to typhoid fever for three
+or four years.
+
+The question of home or institutional care for persons with tuberculosis
+must also be carefully considered. In some cases tuberculosis may be
+cared for at home with comparative safety, and in some other cases the
+risk is not very great if the patient is intelligent, careful, and well
+supervised. But everyone should face the fact that all cases of
+tuberculosis of the lungs involve some risk to others in the family, and
+most cases involve great risk. The danger to children is greater than to
+adults. Most tuberculosis infections, it is now believed, are acquired
+in childhood. The bad results of an infection acquired in childhood may
+not show themselves for years, since the germs may remain inactive until
+the person's resistance is lowered by some unfavorable condition.
+
+THE CHILDREN'S DISEASES.--The so-called children's diseases are probably
+the most familiar and the least regarded of all those belonging to the
+communicable group. Most persons, it is true, realize that scarlet fever
+is serious; everyone should also realize that measles and whooping-cough
+are serious. For example, in the State of New York during the year 1916,
+more children died from each of these diseases than from scarlet fever:
+in that year 745, or four times the number that died of scarlet fever,
+lost their lives from whooping-cough, while 913 died of measles. If
+diseases that kill hundreds of children every year are not serious, one
+is at a loss to know what a serious disease is.
+
+Some parents even expose children unnecessarily to these infections on
+the fatalistic theory that they must have the diseases sometime, and
+therefore the sooner the better. Nothing could be more mistaken; the
+diseases are not inevitable, and there is no advantage whatever in
+having them if escape is possible. Moreover, serious as the children's
+diseases are in themselves, their after-effects may be even more
+serious. At this very moment hundreds of people are going through
+life handicapped by weakened hearts or kidneys, by defective sight or
+hearing, merely because their parents considered the children's diseases
+necessary. The common belief that children should have these diseases as
+early as possible is also erroneous, since statistics show that the
+younger the child the more likely is the disease to prove fatal.
+
+Every mother should realize that the children's diseases are most
+infectious in the early stages. Early symptoms include fever, sore
+throat, and nasal discharge, and the trouble at first often resembles a
+severe cold. During this stage the diseases are most easily
+communicated. Measles in particular is generally not recognized until
+its most infectious stage has passed. The moral to be drawn is that sore
+throats, coughs, and colds should never be regarded lightly, and that
+their spread should be prevented by all possible means.
+
+The accompanying table taken from the regulations of the New York State
+Department of Health, gives symptoms of communicable diseases among
+children, and rules for isolation and exclusion from school.
+
+  NEW YORK STATE DEPARTMENT OF HEALTH
+  COMMUNICABLE DISEASES AMONG CHILDREN
+  RULES FOR ISOLATION AND EXCLUSION FROM SCHOOL
+
+  HERMAN M. BIGGS, M.D.
+  Commissioner
+
+  Issued by the
+  Division of Public Health Education
+
+  =======================================================================
+     DISEASE   |      PRINCIPAL SIGNS         |         METHOD OF       |
+               |       AND SYMPTOMS           |         INFECTION       |
+  -------------+------------------------------+-------------------------+
+  CHICKENPOX   | Rarely begins with fever.    | Contact with discharges |
+               | Rash appears on second day   | from nose and throat of |
+               | as small pimples, which in   | a patient.              |
+               | about a day become filled    |                         |
+               | with clear fluid. This fluid |                         |
+               | becomes yellow colored, a    |                         |
+               | crust forms and the scab     |                         |
+               | falls off in about 14 days.  |                         |
+               | Successive crops of papules  |                         |
+               | appear until tenth day.      |                         |
+  -------------+------------------------------+-------------------------+
+  DIPHTHERIA   | Onset may be rapid or        | Contact with discharges |
+               | gradual. The back of the     | from nose and throat,   |
+               | throat, tonsils, or palate   | occasionally by         |
+               | may show patches. The most   | drinking infected milk. |
+               | pronounced symptom is sore   |                         |
+               | throat. There may be hardly  |                         |
+               | any symptoms at all.         |                         |
+  -------------+------------------------------+-------------------------+
+  MEASLES      | Begins like cold in the      | Contact with discharges |
+               | head, with running nose,     | from nose and throat    |
+               | sneezing, inflamed and       | of a patient.           |
+               | watery eyes and fever.       |                         |
+               | Mulberry-tinted spots appear |                         |
+               | about the third day; rash    |                         |
+               | first seen behind the ears,  |                         |
+               | on forehead and face. The    |                         |
+               | rash varies with heat; may   |                         |
+               | almost disappear if the air  |                         |
+               | is cold, and come out again, |                         |
+               | with warmth.                 |                         |
+  -------------+------------------------------+-------------------------+
+  MEASLES      | Illness usually slight.      | Same as above.          |
+  (LIBERTY)    | Onset sudden. Lymph nodes in |                         |
+               | back of neck enlarged. Rash  |                         |
+               | often first thing noticed;   |                         |
+               | no cold in head. Usually     |                         |
+               | have fever, sore throat, and |                         |
+               | the eyes may be inflamed.    |                         |
+               | Rash sometimes resembles     |                         |
+               | measles and scarlet fever,   |                         |
+               | variable.                    |                         |
+  -------------+------------------------------+-------------------------+
+  MUMPS        | Onset may be sudden,         | Same as above.          |
+               | beginning with sickness and  |                         |
+               | fever, and pain about the    |                         |
+               | angle of the jaw. The        |                         |
+               | parotid glands become        |                         |
+               | swollen and tender. Opening  |                         |
+               | the mouth is accompanied by  |                         |
+               | pain.                        |                         |
+  -------------+------------------------------+-------------------------+
+  POLIOMYELITIS| Onset sudden, fever,         | Contact with discharge  |
+               | excitable, pain on bending   | from nose, throat or    |
+               | neck forward, pain on being  | bowels of a patient     |
+               | handled, headache, vomiting. | or carrier.             |
+               | Sometimes sudden development |                         |
+               | of weakness of one or more   |                         |
+               | muscle groups.               |                         |
+  -------------+------------------------------+-------------------------+
+  SCARLET      | The onset is usually sudden, | Discharges from nose    |
+  FEVER        | with headache, fever, sore   | and mouth, suppurating  |
+               | throat, and often vomiting.  | glands or ears of a     |
+               | Usually within twenty-four   | patient.                |
+               | hours the rash appears as    | Milk may convey         |
+               | fine, evenly diffused, and   | infection.              |
+               | bright red dots under skin.  |                         |
+               | The rash is seen first on    |                         |
+               | the neck and upper part of   |                         |
+               | chest, and lasts three to    |                         |
+               | ten days, when it fades and  |                         |
+               | the skin peels in scales,    |                         |
+               | flakes, or even large        |                         |
+               | pieces.                      |                         |
+  -------------+------------------------------+-------------------------+
+  SMALLPOX     | Onset sudden usually with    | All discharges of a     |
+               | fever and severe backache.   | patient and particles   |
+               | About third day upon         | of skin or scabs.       |
+               | subsidence of constitutional |                         |
+               | symptoms red shot-like       |                         |
+               | pimples, felt below the      |                         |
+               | skin, and seen first about   |                         |
+               | the face and wrists most on  |                         |
+               | exposed surfaces, develop.   |                         |
+               | They form little blisters    |                         |
+               | and after two days more      |                         |
+               | become filled with yellowish |                         |
+               | matter. Scabs form which     |                         |
+               | begin to fall off about the  |                         |
+               | fourteenth day.              |                         |
+  -------------+------------------------------+-------------------------+
+  SORE THROAT, | Begins with sore throat and  | Discharges from nose    |
+  ACUTE,       | weakness. Throat diffusely   | and mouth of a          |
+  SEPTIC       | reddened and may show        | patient.                |
+               | patches like diphtheria.     |                         |
+  -------------+------------------------------+-------------------------+
+  WHOOPING     | Begins with cough which is   | Discharges from nose    |
+  COUGH        | worse at night. Symptoms may | and mouth of a          |
+               | at first be very mild.       | patient.                |
+               | Characteristic "whooping"    |                         |
+               | cough develops in about 2    |                         |
+               | weeks, and the spasm of      |                         |
+               | coughing sometimes ends with |                         |
+               | vomiting.                    |                         |
+  =======================================================================
+  ===============================================================
+               |             EXCLUSION FROM SCHOOL              |
+               |-------+-------------------+--------------------+
+               |       | OTHER CHILDREN    |    OTHER SCHOOL    |
+               |       |    OF SAME        |     CHILDREN       |
+    DISEASE    |       |   HOUSEHOLD       | ESPECIALLY EXPOSED |
+               |       +--------+----------+--------+-----------+
+               |Patient|        |          |        |           |
+               |       | Non-   |          | Non-   |           |
+               |       | immunes|Immunes[3]| immunes| Immunes[3]|
+               |       |        |          |        |           |
+  -------------+-------+--------+----------+--------+-----------+
+  CHICKENPOX   |  Yes  |   Yes  |    No    |   Yes  |    No     |
+  -------------+-------+--------+----------+--------+-----------+
+  DIPHTHERIA   |  Yes  |   Yes  |    Yes   |   Yes  |    Yes    |
+  -------------+-------+--------+----------+--------+-----------+
+  MEASLES      |  Yes  |   Yes  |    No    |   Yes  |    No     |
+  -------------+-------+--------+----------+--------+-----------+
+  MEASLES      |  Yes  |   Yes  |    No    |   Yes  |    No     |
+  (LIBERTY)    |       |        |          |        |           |
+  -------------+-------+--------+----------+--------+-----------+
+  MUMPS        |  Yes  |   Yes  |    No    |   Yes  |    No     |
+  -------------+-------+--------+----------+--------+-----------+
+  POLIOMYELITIS|  Yes  |   Yes  |    Yes   |   Yes  |    Yes    |
+  -------------+-------+--------+----------+--------+-----------+
+  SCARLET      |  Yes  |   Yes  |    Yes   |   Yes  |    Yes    |
+  FEVER        |       |        |          |        |           |
+  -------------+-------+--------+----------+--------+-----------+
+  SMALLPOX     |  Yes  |   Yes  |    Yes   |   Yes  |    No     |
+  -------------+-------+--------+----------+--------+-----------+
+  SORE THROAT, |  Yes  |   No   |    No    |   No   |    No     |
+  ACUTE,       |       |        |          |        |           |
+  SEPTIC       |       |        |          |        |           |
+  -------------+-------+--------+----------+--------+-----------+
+  WHOOPING     |  Yes  |   Yes  |    No    |   Yes  |    No     |
+  COUGH        |       |        |          |        |           |
+  ===============================================================
+  ================================================================================
+              |               DURATION OF EXCLUSION FROM DATE OF ONSET           |
+              +--------------+------------+-------------------------+------------+
+              |              |  PATIENT   |      PATIENT REMAINS    |            |
+              |              |  GOES TO   |        ISOLATED AT      |            |
+              |              |  HOSPITAL  |           HOME          |            |
+    DISEASE   |              +------------+------------+------------+            |
+              |  PATIENT     | Other      | Other      | Children   |  Children  |
+              |              | children   | children   | who leave  |  exposed   |
+              |              | of         | who        | household  |  at        |
+              |              | the same   | remain at  | as soon as |  school    |
+              |              | household  | home       | disease is |            |
+              |              |            |            | discovered |            |
+  ------------+--------------+------------+------------+------------+------------+
+  CHICKENPOX  | Until all    | Exclude if non-immune until          |Exclude     |
+              | scabs are    | 21st day after child last            |from        |
+              | shed and     | saw patient.                         |school if   |
+              | disinfection |                                      |non-immune  |
+              | of person;   |                                      |during      |
+              | at least     |                                      |11th to 22d |
+              | 12 days.     |                                      |days after  |
+              |              |                                      |child last  |
+              |              |                                      |saw patient.|
+  ------------+--------------+--------------------------------------+------------+
+  DIPHTHERIA  |Until         | Until two cultures at least 24       |            |
+              |patient is    | hours apart are reported             |            |
+              |recovered     | negative. Those showing              |            |
+              |and has two   | diphtheria bacilli should not        |            |
+              |cultures      | necessarily be immunized             |            |
+              |from throat   | unless symptoms appear.              |            |
+              |and nose which|                                      |            |
+              |contain no    |                                      |            |
+              |diphtheria    |                                      |            |
+              |bacilli;      |                                      |            |
+              |cultures not  |                                      |            |
+              |to be taken   |                                      |            |
+              |until 9 days  |                                      |            |
+              |from date of  |                                      |            |
+              |onset.        |                                      |            |
+              |Disinfection  |                                      |            |
+              |of person.    |                                      |            |
+  ------------+--------------+--------------------------------------+------------+
+  MEASLES     | Until        | Exclude non-immunes until            |If          |
+              | recovery and | 15th day after child last            |non-immune  |
+              | disinfection | saw patient.                         |exclude     |
+              | of person;   |                                      |from school |
+              | at least 7   |                                      |during 8th  |
+              | days from    |                                      |to 15th     |
+              | onset.       |                                      |day after   |
+              |              |                                      |child last  |
+              |              |                                      |saw patient.|
+  ------------+--------------+--------------------------------------+------------+
+  MEASLES     | Until        | Exclude if non-immune until          |Exclude from|
+  (LIBERTY)   | recovery and | 22d day after child last             |school if   |
+              | disinfection | saw patient.                         |non-immune  |
+              | of person;   |                                      |during 11th |
+              | at least 8   |                                      |to 22d days |
+              | days.        |                                      |after       |
+              |              |                                      |child last  |
+              |              |                                      |saw patient.|
+  ------------+--------------+--------------------------------------+------------+
+  MUMPS       |Two weeks     | Exclude 15th to 22d day after        |Exclude     |
+              |after onset   | child last saw patient.              |from 15th   |
+              |and one week  |                                      |to 22d day  |
+              |after         |                                      |after child |
+              |disappearance |                                      |last saw    |
+              |of swelling   |                                      |patient.    |
+              |and after     |                                      |            |
+              |disinfection  |                                      |            |
+              |of person.    |                                      |            |
+  ------------+--------------+------------+------------+------------+------------+
+  POLIO-      | Until        | 14 days    | Until 14   | 14 days    |            |
+  MYELITIS    | patient is   | from time  | days       | from time  |            |
+              | recovered.   | child      | after      | child      |            |
+              | Disinfection | last saw   | quarantine | last       |            |
+              | of person at | patient.   | raised.    | saw        |            |
+              | least 21     |            |            | patient.   |            |
+              | days.        |            |            |            |            |
+  ------------+--------------+------------+------------+------------+------------+
+  SCARLET     |At least 30   | Seven days | Until      | Seven      |            |
+  FEVER       |days and until| from time  | seven days | days from  |            |
+              |discharges    | child      | after      | time       |            |
+              |have ceased   | last saw   | quarantine | child      |            |
+              |and           | patient.   | raised.    | last saw   |            |
+              |disinfection  |            |            | patient.   |            |
+              |of person.    |            |            |            |            |
+  ------------+--------------+------------+------------+------------+------------+
+  SMALLPOX    |Recovery and  |Exclude if  |Exclude if  |Exclude if  |Exclude 20  |
+              |disinfection  |non-immune  |non-immune  |non-immune  |days unless |
+              |of person     |until 21st  |until 20    |until 21st  |they have   |
+              |at least 14   |day after   |days after  |day after   |been        |
+              |days.         |child last  |quarantine  |child last  |successfully|
+              |              |saw patient,|has been    |saw patient,|vaccinated  |
+              |              |or 7 days   |raised or   |or 7 days   |within 1    |
+              |              |after       |7 days after|after       |year in     |
+              |              |successful  |successful  |successful  |which       |
+              |              |vaccination |vaccination |vaccination |case they   |
+              |              |and         |and         |and         |may return  |
+              |              |disinfection|disinfection|disinfection|at once.    |
+              |              |of person.  |of person.  |of person.  |            |
+  ------------+--------------+------------+------------+------------+------------+
+  SORE THROAT,|Until         |                                      |            |
+  ACUTE,      |recovery.     |                                      |            |
+  SEPTIC      |              |                                      |            |
+  ------------+--------------+--------------------------------------+------------+
+  WHOOPING    |Eight weeks   | Fourteen days provided no cough      |            |
+  COUGH       |or until 1    | develops.                            |            |
+              |week after    |                                      |            |
+              |last          |                                      |            |
+              |characteristic|                                      |            |
+              |cough and     |                                      |            |
+              |disinfection  |                                      |            |
+              |of person.    |                                      |            |
+  ================================================================================
+  =================================================================
+     DISEASE   |                  Remarks                         |
+               |                                                  |
+  -------------+--------------------------------------------------+
+  CHICKENPOX   | A mild disease and seldom any after effects.     |
+  -------------+--------------------------------------------------+
+  DIPHTHERIA   | Very dangerous, both during attack and from      |
+               | after effects. When diphtheria occurs in a       |
+               | school all children suffering from sore throat   |
+               | should be excluded and the health officer        |
+               | notified. The medical school inspector or        |
+               | health officer should take cultures from all     |
+               | inflamed throats and noses. There is great       |
+               | variation of type, and mild cases are often      |
+               | not recognized, but are as infectious as         |
+               | severe cases. There is frequently no immunity    |
+               | from further attacks.                            |
+  -------------+--------------------------------------------------+
+  MEASLES      | After effects often severe. Period of greatest   |
+               | risk of infection three days, before and after   |
+               | the rash appears. Great variation in type        |
+               | of disease. Dangerous in children under 2        |
+               | years of age. During an outbreak all children    |
+               | having a temperature over 99°F. should           |
+               | be sent home and the health officer notified.    |
+  -------------+--------------------------------------------------+
+  MEASLES      | After effects slight. Regulations strict,        |
+  (LIBERTY)    | because frequently confused with scarlet fever.  |
+  -------------+--------------------------------------------------+
+  MUMPS        | Seldom leaves after effects. Very infectious.    |
+               | Inflammation of genital organs of male or        |
+               | female may occur.                                |
+  -------------+--------------------------------------------------+
+  POLIOMYELITIS| Disease is most communicable in the early        |
+               | stages. After effect is paralysis of certain     |
+               | muscle groups, transitory or permanent.          |
+               | Death is due usually to paralysis of             |
+               | respiratory muscles.                             |
+  -------------+--------------------------------------------------+
+  SCARLET      | Dangerous both during attack and from after      |
+  FEVER        | effects. Great variation in type of disease.     |
+               | Slight attacks are as infectious as severe       |
+               | ones. Many mild cases not diagnosed and          |
+               | many concealed. A second attack is rare.         |
+               | When scarlet fever occurs in a school, all       |
+               | cases of sore throat should be sent home and     |
+               | health officer notified. Most fatal in           |
+               | children under ten years.                        |
+  -------------+--------------------------------------------------+
+  SMALLPOX     | Peculiarly infectious. When smallpox occurs      |
+               | in connection with a school or with any of       |
+               | the children's homes all persons exposed         |
+               | must be vaccinated or quarantined for a          |
+               | period of 20 days. Cases of modified smallpox    |
+               | in vaccinated persons, may be, and often         |
+               | are, so slight as to escape detection. Fact      |
+               | of existence of disease may be concealed.        |
+               | Mild or modified smallpox is as infectious as    |
+               | severe type.                                     |
+  -------------+--------------------------------------------------+
+  SORE THROAT, | Often leads to serious results, affections of    |
+  ACUTE,       | heart, kidneys, etc. Very apt to occur in        |
+  SEPTIC       | epidemics due to milk contaminated by a          |
+               | patient suffering from the disease.              |
+  -------------+--------------------------------------------------+
+  WHOOPING     | After effects often very severe and disease      |
+  COUGH        | causes great debility. Relapses are apt to       |
+               | occur. Second attack rare. Specially             |
+               | infectious for first week or two. If a child     |
+               | vomits after a paroxysm of coughing, it is       |
+               | probably suffering from whooping cough.          |
+               | Great variation in type of disease. Often        |
+               | fatal in young children.                         |
+  =================================================================
+
+  [3] Immunes are those who have had the diseases or in smallpox, who
+  have been successfully vaccinated within a year.
+
+  DISINFECTION: The cleansing and disinfection of the person includes
+  washing the entire body and the hair with soap and water; thorough
+  brushing of the teeth; rinsing the mouth; gargling the throat, and
+  douching and spraying the nose with an antiseptic solution; and
+  finally, a complete change of clothing (or a change of underwear and
+  a thorough shaking and brushing of the outer garments out of doors
+  before these are put on again). (_Facing p. 247_)
+
+It may be added that the ways by which poliomyelitis, or infantile
+paralysis, is spread are not definitely known at the time of writing.
+We are justified, however, in believing that investigation now in
+progress will make exact information available in the near future.
+
+      "The weight of present opinion inclines to the view that
+      poliomyelitis is exclusively a human disease, and is spread
+      by personal contact, whatever other causes may be found to
+      contribute to its spread. In personal contact we mean to
+      include all the usual opportunities, direct or indirect,
+      immediate or intermediate, for the transference of body
+      discharges from person to person, having in mind as a
+      possibility that the infection may occur through
+      contaminated food.
+
+      "The incubation period has not been definitely established
+      in human beings. The information at hand indicates that it
+      is less than two weeks, and probably in the great majority
+      of cases between 3 and 8 days."--(Report of Special
+      Committee on Infantile Paralysis, American Journal of
+      Public Health, November 1916.)
+
+
+DISINFECTION
+
+Specific directions for disinfecting in every kind of communicable
+disease would be too extended to be given here. In each case the
+attendant should learn from the doctor just how that particular disease
+is communicated, just what discharges, utensils, linen, etc., need to be
+disinfected, and just what disinfectants he prefers to have used. The
+following general methods are now in use, but it must be remembered that
+from time to time new methods are devised and new disinfectants are
+discovered.
+
+CARE OF NOSE AND THROAT DISCHARGES.--The care of handkerchiefs has
+already been described on page 239. Cloths or cotton used to wipe the
+eyes or to receive any other bodily discharge including vomitus, should
+be collected in the same way and burned. Everyone should be taught in
+early childhood to cover the nose and mouth with a handkerchief during
+coughing and sneezing; if the patient has not already learned to do so
+he must be taught now. If the amount of expectoration is great,
+waterproof receptacles should be provided, which should be burned with
+their contents.
+
+CARE OF DISCHARGES FROM THE BOWELS AND BLADDER.--At the present time the
+following preparations are commonly used to disinfect stools and urine:
+5% solution of carbolic acid; chloride of lime solution, made freshly
+whenever needed by mixing thoroughly ½ pound of chloride of lime with
+one gallon of water; and unslaked lime to which is added _hot_ water.
+The amount of carbolic solution used should be about equal in bulk to
+the amount of material to be disinfected; the chloride of lime solution
+should be at least twice, and the unslaked lime at least one-eighth the
+bulk. Fecal masses should be broken up so that the disinfectant may
+reach every part; they may be stirred with tightly twisted toilet paper,
+which should be left in the bedpan and disinfected with the stools. If
+these substances are used, disinfection is considered complete at the
+end of an hour, and the contents of the bedpan may then be emptied into
+the toilet with safety. It may be necessary to provide two bedpans so
+that one may be available for use while the contents of the other is
+being disinfected. Bedpans and urinals should be boiled daily and kept
+thoroughly clean at all times.
+
+In places having no sewerage system, disinfected discharges may be
+emptied into a trench situated at a distance from the well, and then
+covered with earth. As an extra precaution, the disinfected discharges
+may be mixed with sawdust or kerosene and burned in the trench.
+Directions for installing a sanitary privy may be found in Bulletin 68
+of the United States Public Health Service.
+
+BATH WATER and water that has been used for cleansing the teeth and
+mouth may be disinfected in the same way as urine, or it may be emptied
+into a suitable receptacle and boiled ten minutes.
+
+CARE OF THE HANDS.--Disinfectants for the hands should be used in
+addition to scrubbing with soap and water, not as a substitute. The
+hands may be disinfected after scrubbing by soaking them for three
+minutes in one of the following solutions: alcohol 70%, carbolic acid
+solution 2½%, or a solution made by adding one teaspoonful of lysol or
+of creolin to a pint of water. These disinfectants are poisons if taken
+internally; the bottles must be carefully labeled and kept in a safe
+place. It is a good plan to wear rubber gloves when handling infective
+material; the gloves should afterward be boiled for ten minutes.
+
+CARE OF UTENSILS.--A sufficient number of dishes, spoons, tumblers,
+basins, etc. must be reserved for the patient's exclusive use; these
+utensils must be washed separately and dried with towels not used for
+other dishes. Mistakes frequently occur by which other persons use the
+patient's dishes, and in consequence his dishes should not be kept in
+the cupboard with other dishes; if no other safe place can be found,
+they had better stay in the patient's room covered with a clean cloth or
+napkin. The dishes should be scalded daily and at the termination of the
+illness they must be boiled briskly for ten minutes before they are
+returned to general use. Food left on the patient's tray should be
+burned; it should not be eaten by any one else, nor placed in the pantry
+or refrigerator with other food.
+
+CARE OF LINEN.--A satisfactory way to disinfect towels, night gowns, bed
+linen, etc. is to place the articles immediately in a wash boiler filled
+with cold water to which a little washing soda has been added, and then
+to boil them in the same water for twenty minutes; they can afterward
+go safely into the regular laundry. The boiling may be done once a day;
+articles soiled in the meantime may be left to soak in the cold water
+and soda.
+
+DISINFECTION OF THE PERSON.--"The cleansing and disinfection of the
+person includes washing the entire body and the hair with soap and
+water; thorough brushing of the teeth; rinsing the mouth; gargling the
+throat, and douching and spraying the nose with an antiseptic solution;
+and finally, a complete change of clothing (or a change of underwear)
+and a thorough shaking and brushing of the outer garments out-of-doors
+before these are put on again."--(New York State Department of Health.)
+
+TERMINATION OF QUARANTINE.--After the patient has recovered, he and the
+attendant should, if the doctor thinks it necessary, disinfect
+themselves as directed above before they mingle again with other people.
+The exact time when it is safe for a person to come out of quarantine
+and resume ordinary life varies in different diseases. Moreover, opinion
+differs in regard to quarantine periods for the same diseases, so that
+the regulations of Boards of Health in different cities show wide
+variations. It is of course impossible to say at just what moment every
+patient, or even the majority of patients, will stop expelling germs.
+Quarantine periods are intended to protect the community as completely
+as possible without causing unnecessary hardship to individuals. In any
+given case, the local regulations should be strictly observed but
+release from quarantine is not a guarantee that the patient is not still
+discharging germs, and extreme care should still be taken to prevent the
+spread of saliva and other discharges.
+
+TERMINAL DISINFECTION.--A room that has been occupied by a patient with
+a communicable disease should be thoroughly cleaned at the termination
+of the illness. Dishes, utensils, bed linen, etc. should be cared for in
+the ways already described. The floor, bedstead, and other furniture
+should be washed with hot water, soap, and washing soda. The walls,
+windows, etc., should be wiped with a cloth wrung out of hot water, soap
+suds, and soda. The mattress, unless badly soiled with discharges,
+should be scrubbed with the same solution and a stiff brush, and left
+out-of-doors in the sunshine for a day or two, or until dry. If badly
+soiled, it is best to destroy the mattress unless the Board of Health
+has facilities for steam sterilization. Ordinary washing is all that is
+generally required for blankets, but if badly soiled they should be
+sterilized by steam or burned. The room should then be thoroughly
+sunned and aired for a day or two, with the windows wide open both day
+and night. Sunning and airing are among the most important measures in
+disinfecting a room, and should not be slighted. If there has been gross
+pollution, as when a careless consumptive persists in spitting on the
+floor and walls, it may be necessary to remove the old paint and paper
+and have the room done over. The room may safely be occupied after all
+these measures have been taken.
+
+FUMIGATION.--Many Boards of Health have abandoned fumigation after
+communicable diseases, except after those which like typhus and yellow
+fever, are carried by vermin or insects. Dry formaldehyde gas, which was
+formerly used for fumigation, has a violent effect on mucous membranes,
+but its power to kill bacteria, even on surfaces, appears to be weak,
+while its penetrating power is not sufficient to disinfect bedding,
+carpets, upholstered furniture, and other fabrics. Since fumigation is
+costly, troublesome, and ineffectual there seems to be no good reason
+for using it. Moreover, its use gives a false sense of security, so that
+really effective measures like sunning, airing, and scrubbing are likely
+to be neglected.
+
+Theory and practice of disinfection, it is clear, have radically
+changed in recent years. Modern knowledge requires concurrent
+disinfection, or the destruction of germs from the moment when symptoms
+are first noticed; all the time, day and night, this disinfection must
+go on with unremitting care. Today wet sheets are not hung in doorways
+nor are chemicals left about in open dishes to disinfect quite harmless
+air, but scrupulous cleanliness at all stages of disease is recognized
+as one of the most important measures, if not the most important
+measure, in disinfection.
+
+
+EXERCISES
+
+1. Summarize the ways in which infectious diseases are spread.
+
+2. What is meant by the incubation period? State the length of the
+incubation period in measles; Liberty measles; whooping-cough; scarlet
+fever; chicken-pox; diphtheria; mumps; typhoid fever.
+
+3. Name some of the early symptoms common to most infectious diseases.
+If such symptoms appear, what should be done while waiting for the
+doctor to come?
+
+4. Discuss the importance, prevention, and treatment of common colds.
+
+5. What measures should be taken to isolate a patient who is suffering
+from a communicable disease?
+
+6. What special care should the attendant of a patient with a
+communicable disease give to her own clothing and person?
+
+7. Why are the children's diseases more serious in reality than they are
+commonly supposed to be?
+
+8. Describe the symptoms of each of the following: Measles, scarlet
+fever, chicken-pox, mumps, whooping-cough, and diphtheria.
+
+9. How should bowel and bladder discharges be disinfected?
+
+10. How should dishes and other utensils be disinfected?
+
+11. How should linen be disinfected?
+
+12. Describe measures necessary for concurrent disinfection.
+
+13. Describe measures necessary for terminal disinfection.
+
+
+FOR FURTHER READING
+
+Preventive Medicine and Hygiene--Rosenau.
+
+The New Public Health--Hill, Chapters VII-XVII.
+
+Essentials of Medicine--Emerson, Chapters XII-XV.
+
+Health and Disease--Roger I. Lee, Chapter X-XIV.
+
+Disease and Its Causes--Councilman, Chapters V-IX.
+
+Publications of the New York State Department of Health, Albany,
+entitled: The Teacher and Communicable Disease; A Method for the Control
+of Communicable Diseases in Schools; Regulations and Instructions for
+Cleansing and Disinfection; The Conduct of an Isolation Period for
+Communicable Disease in a Home; Tuberculosis; Typhoid Fever; Scarlet
+Fever; Measles; Whooping-cough; Diphtheria; Poliomyelitis, Acute
+Anterior (Infantile Paralysis); Smallpox; Septic Sore Throat; Venereal
+Diseases. (Any of the above pamphlets will be sent upon receipt of a
+three cent stamp.)
+
+
+
+
+CHAPTER XIII
+
+COMMON AILMENTS AND EMERGENCIES
+
+
+This chapter describes a few home treatments for the relief of slight
+ailments and injuries, together with some measures that may be employed
+in emergencies. For more extended instructions in these subjects the
+student should consult the Red Cross Text-book on First Aid.
+
+
+CONDITIONS IN WHICH THE NERVOUS SYSTEM IS INVOLVED
+
+HEADACHE.--Headache is not a disease in itself, but a symptom common to
+many different disorders. Among the abnormal conditions often causing
+headaches are fatigue, eyestrain, indigestion, constipation, neuralgia,
+rheumatism, anæmia, acute infections, and other disorders. Treatment
+should consist in finding the cause and removing it if possible; clearly
+no one remedy can cure so many different causes. A physician should be
+consulted if headaches are of frequent occurrence, but in many cases
+rest and attention to other hygienic requirements are all that is
+needed. During an attack of headache a hot foot bath may give relief, or
+a mustard paste or cold applications on the back of the neck, or an ice
+bag or cold compress on the forehead.
+
+SLEEPLESSNESS, like headache, has many possible causes, and effective
+treatment consists in finding and removing them. Pain or discomfort of
+any kind, fatigue, overwork, and worry are common causes. Sleeplessness
+easily becomes a habit that may persist after its cause has been
+removed; hence a person who has formed the habit of sleeplessness should
+patiently strive to break the old habit and to substitute a better. A
+careful hygienic régime is essential for the patient, exercise in the
+open air, and cultivation of a hopeful and tranquil spirit. The diet
+should be liberal, but light and unstimulating; tea and coffee should be
+omitted, certainly during the latter part of the day. The patient should
+spend rather a dull evening, avoiding excitement and mental exertion
+that is difficult, even though pleasurable. He should retire early. A
+hot tub or foot bath, and a hot drink at bed time may help to produce
+sleep. The bedroom should be dark, cool, and well ventilated, the bed
+comfortable and the covers light but warm. The patient should be told
+that rest is the most important thing for him, and that he should not
+try too hard to sleep nor worry if unsuccessful. The patient should try
+to banish from his mind, at bed time, thoughts that are distressing, and
+even those that are especially interesting. By using patience and
+persistence most persons can regain the power of sleeping even when
+habits of sleeplessness have been long established.
+
+FAINTING is a partial or total loss of consciousness due to a diminished
+supply of blood in the brain. It may follow bleeding, exhaustion from
+heat, fatigue from prolonged standing and the like, or strong emotional
+disturbance, like fear or surprise. Fainting is less common than it
+formerly was; it now occurs most frequently among persons suffering from
+anæmia, heart weakness, or special susceptibility.
+
+Symptoms of fainting are pale face, cold perspiration, rapid, feeble
+pulse, and shallow, sighing respiration. Treatment consists in removing
+the patient into cool, fresh air, applying cold water to the face and
+keeping the head low. For a person who feels faint but has not lost
+consciousness, this treatment will probably prove sufficient; if,
+however, he becomes unconscious, place him so that the head is lower
+than the body, loosen the clothing, especially the clothing about the
+neck, apply cold water to the face and chest, and see that fresh air is
+plentiful. When the patient is sufficiently conscious to swallow, give a
+teaspoonful of aromatic spirits of ammonia in half a glass of water and
+keep him quiet until he has entirely recovered.
+
+A person who is unconscious from any cause always requires immediate
+attention. In emergency work elevate the patient's head if his face is
+flushed, and keep it low if his face is pale. Do not try to arouse an
+unconscious patient by shaking him and calling to him, in the first
+place because it is useless to do so, and in the second, because
+consciousness will return spontaneously if his condition improves.
+
+CONVULSIONS.--In every case of convulsions a doctor is needed at the
+earliest possible moment. Convulsions in adults are very serious; in
+babies and small children although serious they are less alarming, since
+they may follow comparatively slight disturbances, particularly
+disturbances of digestion.
+
+Treatment for babies and children with convulsions consists first in
+keeping the child as quiet as possible, and next in measures to draw
+blood from the brain toward the surface of the body. The child should
+first be undressed, moving him as little as possible, and put to bed
+between warm blankets. Cold should be applied to his head by a compress
+or ice bag, and hot water bag should be placed near his feet. An enema
+should then be given. A warm tub bath is sometimes used to apply heat,
+if the convulsion has not subsided by the time the child is undressed.
+If the bath is given the temperature of the water should not be above
+106°, and should be tested by a thermometer. If no thermometer is
+available, the water should be tested with the elbow rather than the
+hand, and cold water should be added if it feels uncomfortably warm.
+There is great danger of scalding a child during the excitement
+inevitably caused by a convulsion.
+
+Although haste is needed when a child has convulsions, yet quiet is
+essential, since the slightest movement tends to increase the
+convulsions or to start them again. As soon as the convulsions are over
+the child should be removed from the bath and put to bed between warm
+blankets. Even after the symptoms have completely subsided, the greatest
+care should be taken to keep the child quiet. He should be handled and
+disturbed as little as possible. The bath should be repeated if
+convulsions begin again. The doctor, when he comes, will probably order
+a dose of castor oil; and therefore, if it is impossible to obtain a
+doctor at once, the dose should be given.
+
+SHOCK (in the medical sense of the word) or _collapse_, is a serious
+condition in which a patient's vitality and all his bodily processes are
+profoundly depressed. Generally shock occurs only after a severe injury
+or a long exhausting illness. Since, however, some persons are
+peculiarly susceptible to it, the possibility of shock must be kept in
+mind in treating even slight injuries. The probability of shock is
+somewhat increased if patients are allowed to see their own wounds.
+Injured persons should always sit or lie down while wounds, however
+slight, are dressed.
+
+Symptoms of shock are pallor, pinched, anxious expression, dilated
+pupils, cold clammy skin, feeble breathing, and rapid, weak pulse. The
+patient may be mentally normal, or irrational, or unconscious, but more
+frequently he appears stupid, and though conscious, he pays no attention
+to what is going on. Unfortunately this condition is sometimes mistaken
+for sleepiness, and he is left alone to sleep just when active measures
+are most needed.
+
+If a patient shows any symptom of shock the doctor should be summoned
+immediately, but no time should be lost in beginning treatment, since
+the condition may be critical. It should be remembered, however, that
+panic and confusion may alarm a patient who is conscious, and thus
+increase the shock. The patient should be covered warmly, and undressed
+under blankets, without exposure or avoidable moving. His head should be
+low, and as quickly as possible hot water bags should be placed near but
+not upon him. If the patient is conscious and able to swallow he should
+be given hot coffee or aromatic spirits of ammonia, one teaspoonful in
+half a glass of water. The legs and arms should be rubbed from the
+extremities toward the heart, but care should be taken to avoid touching
+or moving injured parts. The patient should stay in bed, warmly covered
+and closely watched for some time after he has apparently recovered.
+
+Helping a patient into bed is not necessarily the first thing to be done
+in every case of sudden illness. Great harm may be done by the
+injudicious moving of injured persons, and often it is safer to make a
+person comfortable with pillows and blankets where he happens to be,
+certainly until a sufficient number of people can be found to lift him
+properly. Clothing should be removed carefully, and one should not
+hesitate to cut it away if undressing is painful or necessitates much
+moving.
+
+STIMULANTS, in emergency work, are frequently misused. They should not
+be given when the head has been injured, when bleeding is profuse, or
+when the face is red and the pulse strong. Neither should attempts be
+made to give fluids of any kind to patients not sufficiently conscious
+to swallow. Safe stimulants to use are black coffee, tea, or aromatic
+spirits of ammonia. Alcoholic liquors should not be given unless
+prescribed by a physician.
+
+SUNSTROKE AND HEAT EXHAUSTION are both caused by excessive heat either
+indoors or out, but they differ both in symptoms and in treatment.
+
+Sunstroke or heat stroke, usually begins with acute pain in the head,
+followed almost immediately by loss of consciousness. The skin is dry
+and very hot, the face is red or purple, the pupils are dilated, the
+breathing is difficult, the pulse is slow, and the temperature high.
+
+Treatment consists in sending for the doctor, removing the patient to a
+cool place, undressing him and applying cold, especially to the head and
+spine, or still better, placing him in a very cold bath. The body should
+be rubbed constantly in the direction of the heart. Stimulants should
+not be given.
+
+Symptoms of heat exhaustion, on the other hand, resemble those of shock.
+The doctor should be summoned, and the patient should be removed to a
+cool and quiet place, where he should stay warmly covered in a reclining
+position. Stimulants should be given, hot water bags applied, and the
+other measures for treating shock should be employed.
+
+
+CONDITIONS IN WHICH THE DIGESTIVE TRACT IS AFFECTED
+
+NAUSEA AND VOMITING are frequently caused by injudicious eating,
+especially when a person is worried or fatigued. A doctor should be
+consulted if either one occurs often, or if vomiting is accompanied by
+pain, prostration, diarrhœa, fever, or other acute symptoms. A person
+who is nauseated should lie down in a cool, quiet place. Hot
+fomentations may be applied to the abdomen, or a mustard paste over the
+stomach. Soda mints or a teaspoonful of baking soda may be given
+dissolved in hot water, and unless diarrhœa is present a Seidlitz
+powder or other saline cathartic may be given. A large quantity of warm
+water may be given to wash out the stomach; it is more effectual if salt
+or mustard is added, in the proportion of one teaspoonful to a glass of
+water.
+
+HICCOUGH, which is usually caused by digestive disturbances, is not
+serious in healthy people, and can generally be stopped by holding the
+breath, or by drinking water. If these measures are not effectual, salt
+or mustard in water as already described or a teaspoonful of the syrup
+of ipecac, may be given to produce vomiting. If the hiccough still
+continues, medical advice should be obtained.
+
+DIARRHŒA is ordinarily caused by an infection, or by an offending
+substance in the intestines. The offending substance should be removed
+before attempts are made to check the diarrhœa. When a baby has diarrhœa
+four things should be done--all food should be withheld; boiled water
+should be given freely; bowel movements should be saved for the doctor
+to see; and unless a doctor can be found immediately, castor oil should
+be given, from one-half to one teaspoonful according to the age of the
+child. Similar treatment should be given to older children. Adults
+should take one tablespoonful of castor oil and drink boiled water
+freely, but they should take no food until the doctor comes.
+
+CONSTIPATION has been discussed on pages 193 and 52.
+
+COLIC is a sharp, intermittent pain in the abdominal region; it is
+caused in many instances by indigestion or chilling. The following
+remedies may relieve it: a hot water bag, an emetic, as salt or mustard
+in luke-warm water, a Seidlitz powder or other saline cathartic, soda
+mints, or a teaspoonful of syrup of ginger in hot water. Unless it feels
+sore or tender, the abdomen may be rubbed up, on the right side, across,
+just below the waist, and down, on the left side. Babies may be given a
+few teaspoonfuls of warm water, or an enema of salt and water.
+
+Colic may be serious. The doctor should be summoned at once if the
+patient seems exhausted, if the pain is severe, if pain is increased
+rather than relieved by pressure, if the abdomen feels sore, especially
+on the right side, or if sharp abdominal pain is accompanied by fever,
+vomiting, and stubborn constipation. If the above-mentioned symptoms are
+present, no food, drink, or medicine should be given until the doctor
+comes.
+
+
+CONDITIONS IN WHICH THE EYES OR EARS ARE AFFECTED
+
+STYES generally accompany eyestrain or poor general health. The cause
+should be found and treated; and especial attention should be given to
+correcting eyestrain, indigestion, and constipation. Hot applications
+may be used, but if pus gathers, the stye should be treated by a
+physician.
+
+FOREIGN BODIES IN THE EYE may sometimes be removed by blowing the nose
+violently, by yawning several times, or by drawing the upper lid down
+over the lower. The eye should not be rubbed. If it proves impossible to
+dislodge the object by these methods or by others similar, the patient's
+eyelid should be turned back in the following way: Let the patient sit
+with his head back in a low chair placed in a good light, and stand
+behind him holding his head between your side and upper arm. In this
+position the patient's head is held firmly while both of the operator's
+hands are free. Next draw down the lower lid, and remove the object, if
+visible, on the corner of a clean handkerchief. To turn back the upper
+lid, grasp the eyelashes firmly, draw the lid down, out, and then up
+over a match or pencil placed across the middle line of the lid and held
+in your other hand. Then wipe the object carefully away if it is
+visible.
+
+Irritation that persists after the foreign body has been removed may be
+relieved by a cold compress continued for an hour or more, or by a drop
+or two of castor oil placed under the lid. If attempts to remove the
+foreign body prove unsuccessful, if the injury is severe, or if
+irritation continues after several hours, apply a cold compress, bandage
+it firmly so that the eyeball is kept at rest, and seek the aid of a
+physician.
+
+DISORDERS AFFECTING THE EARS.--Permanent deafness may result from
+neglecting disorders of the ears. Ear-ache, discharge from the ear,
+swelling in or about it, pain or tenderness behind it, all require
+medical attention and no time should be lost in securing it. To relieve
+pain the patient may lie with the ear on an ice bag, but nothing
+whatever should be put into the ear before the doctor comes, except when
+an insect has entered the ear, and causes acute distress by the noise of
+its beating wings. If such an accident has occurred, the patient should
+lie on the unaffected side, and warm sweet oil should be dropped very
+gently into the affected ear by means of a medicine dropper. The insect
+generally drowns in the oil and floats to the opening of the ear canal.
+After it has been removed, the patient should lie on the affected side
+so that the oil may drain out of the ear.
+
+No attempts should be made to remove foreign bodies from the ear or
+nose, unless they can be reached easily with the fingers. Hair pins,
+crochet hooks and similar instruments should never be used for this
+purpose. It is best for a doctor to remove foreign objects because
+unskillful attempts are likely to move them further in.
+
+
+CONDITIONS IN WHICH THE SKIN IS AFFECTED
+
+PRICKLY-HEAT, which affects babies and children more often than adults,
+is an eruption caused by heat and moisture, and aggravated by flannel
+underwear. It may be prevented by keeping the skin dry and cool, and it
+may be relieved by bathing the skin with alcohol and water, about one
+part of alcohol to three of water, and by using after the bath a powder
+made of two parts of starch to one of boracic acid, or any good talcum
+powder.
+
+INSECT BITES AND STINGS.--The sting, if still in the wound, should first
+be removed, and then ammonia should be applied, since the poison is
+generally acid. Applications of cold water, alcohol and water, or wet
+salt may relieve the subsequent burning and itching, but ammonia is
+generally most effective.
+
+IVY POISONING may be treated by applying cloths wet in a strong solution
+of baking soda or of boracic acid, or by applications of carbolized
+vaseline or ichthyol. Severe cases should have medical attention.
+Scratching and rubbing seem to spread the inflammation, and special care
+should be taken not to rub the face or eyes with infected hands.
+Susceptible people should avoid the plant if possible.
+
+
+OTHER EMERGENCIES
+
+CHILLS may be the result of infection or of exposure to cold. An early
+diagnosis of the trouble is so desirable that it is well to send for a
+doctor even when symptoms are not severe. If a person has a chill his
+temperature should be taken at once; fever and chill together probably
+indicate invasion by bacteria. When chills follow exposure to cold the
+patient should go to bed between warm blankets, his body should be
+briskly rubbed, and hot water bags and a hot drink should be given. If
+he prefers, he may take a hot bath before going to bed.
+
+CROUP is caused by a spasmodic closure of the larynx so that breathing
+is impeded. The child who develops croup may have a slight cold, but
+frequently shows no symptoms until he wakes in the night with a hoarse
+ringing cough and difficult breathing. True croup, though often
+distressing, is seldom serious, even when the symptoms are so severe
+that the child appears to be partly suffocated. An emetic should be
+given at once, preferably syrup of ipecac, one teaspoonful followed by
+warm water, or ten drops every 15 minutes until the child vomits freely.
+Hot fomentations may be applied to the throat and chest in order to
+hasten relaxation of the muscular spasm, and water should be kept
+boiling near the bed in a teakettle or uncovered saucepan. The child
+should stay in a warm room during the following day.
+
+Whenever a child develops a croupy cough his throat should be examined.
+A physician should be summoned if the throat is red and especially if
+the redness is associated with rise in temperature. Cases of diphtheria
+have been overlooked by neglecting such symptoms.
+
+
+BLEEDING
+
+In the vast majority of cases, bleeding can be stopped by elevating the
+injured part and applying pressure over the wound. One should, however,
+remember that loss of blood is not the only danger presented by an open
+wound, for pus-producing germs, if they make their entrance, may cause
+an infection which may be as serious as the bleeding itself. Hence in
+dealing with open wounds of any sort one should always keep in mind the
+danger of infection as well as the danger from loss of blood.
+
+TREATMENT OF SLIGHT WOUNDS.--Loss of blood from slight wounds is seldom
+so serious as the danger of infection; therefore small cuts, pin pricks,
+scratches, etc. should be encouraged to bleed by pressure near the wound
+in order to expel the germs that may have entered. After the wound has
+bled a little, tincture of iodine should be applied by means of a cotton
+swab both to the wound itself and also to the surrounding skin.
+
+After the wound has thus been disinfected it should be covered with a
+sterile dressing; a sterile or aseptic dressing is material in which all
+bacterial life has been destroyed. Gauze from a First Aid dressing or
+from a packet of sterile gauze should be used for this compress, or
+gauze may be cut from a sterile bandage. The compress serves two
+purposes: it protects the wound from infection, and if applied with
+pressure it checks further bleeding.
+
+The compress should be securely bandaged in place, or its edges may be
+fastened with adhesive plaster or collodion. Neither of the two latter
+should cover the wound itself. The outside bandage may be changed when
+soiled, but the compress itself should not be disturbed until the wound
+has healed. It is a mistake to dress wounds oftener than necessary,
+since handling them always increases the chance of introducing germs.
+Most children, like Tom Sawyer, delight in wounds, but they should be
+prevented if possible both from inspecting and from exhibiting them.
+
+If heat, swelling, redness, or pain develop in a wound after a day or
+two, a doctor should be consulted; and not a minute should be lost if
+the patient has a chill or if red streaks appear extending from the
+wound in the general direction of the heart. Until the doctor comes the
+wounded part should be elevated and covered with cold applications wet
+in alcohol 25%, or in a solution of common salt, a teaspoonful to a pint
+of water.
+
+Several points should be remembered in dressing wounds. In the first
+place the mouth, which is full of germs, is not a good place for cut
+fingers. Moreover, wounds should not be touched by anything, especially
+the fingers, either washed or unwashed, nor should the scissors, fingers
+or other object be allowed to touch the surface of the dressing that is
+to be placed directly upon a wound. Unless they contain gross dirt
+wounds should not be washed with water, since washing introduces another
+chance of infection and accomplishes nothing except a tidy appearance,
+which is not essential. Furthermore, it should be remembered that
+exposure to the air will not infect a wound, and therefore time should
+be taken to find a suitable dressing. When a sterile dressing is quite
+impossible to obtain, the cleanest material available should be used;
+one of the best substitutes for a sterile dressing is the inner surface
+of a handkerchief or napkin that has not previously been unfolded since
+it was ironed. It is a common mistake to tie up a wound in the first
+article presented, which is usually a generous by-stander's soiled
+handkerchief. The same precautions in regard to cleanliness should be
+taken in dressing wounds that are known to be contaminated, since even
+into an infected wound it is possible to introduce more germs and more
+virulent ones.
+
+NOSEBLEED usually stops of itself, but if it is obstinate the patient
+should sit erect with the head back, and cold compresses should be
+placed on the nose and at the back of the neck. Pressure should be made
+on the upper lip by means of the fingers, or by a firm roll of paper or
+cotton placed under the upper lip. Salt or vinegar in water, a
+teaspoonful of either one to a cup of water, may be snuffed up the nose.
+The treatment should be continued for ten or fifteen minutes, or until
+bleeding stops; if the bleeding persists a doctor is needed.
+
+PROFUSE MENSTRUATION should be treated by keeping the patient quiet in
+bed with the head low and the feet slightly elevated. "Any marked
+increase, whether by amount, duration, or shortening of the interval
+between the periods ought to receive attention and be brought to the
+physician's notice" (Latimer). Painful menstruation may be relieved by
+rest in bed, mental as well as physical, by hot drinks and by the
+application of heat. Rest, and hygienic living persistently practised,
+will relieve most menstrual abnormalities. The common practice of using
+patent remedies and alcoholic liquors for disordered menstruation cannot
+be too strongly condemned.
+
+
+OTHER INJURIES
+
+SPRAINS.--A sprain is caused by twisting, stretching, or tearing the
+tissues about a joint. The first sharp pain comes from the injury to
+the tissues; subsequent pain is caused by the pressure of accumulated
+fluid. The other symptoms are those characteristic of inflammation.
+
+When a sprain is slight, the affected part should be elevated and kept
+at rest for the first twenty-four hours. Either heat or cold should be
+applied, or heat and cold alternately; a good treatment is to soak the
+part in hot water and afterward to allow cold water to run upon it from
+the tap. Gentle rubbing with a circular motion helps to reduce the
+swelling. If the joint must be used it should be bandaged tightly.
+
+Injuries to joints should never be neglected; and severe sprains always
+require medical attention, since in addition to the sprain a bone may be
+broken. A severely sprained joint should be elevated, treated with hot
+or cold applications, and kept at rest until it has been examined by a
+physician.
+
+BRUISES.--Bruises need no attention unless they are extensive or
+painful. The skin should be kept clean and if possible unbroken, since
+injured tissues are less resistant to infection than tissues in their
+normal state. Applications of cold water or of equal parts of cold water
+and alcohol may relieve the pain, but cold should not be used upon
+bruises that are extensive. A compress bandaged tightly in place may
+help to prevent swelling and discoloration.
+
+BURNS AND SCALDS.--Injuries from dry heat are called burns, and those
+from moist heat are called scalds. Both are painful, and both are
+dangerous if extensive or deep. Burns and scalds require medical
+attention if the injured area is extensive, if a large blister is
+formed, if the skin is destroyed or charred, and if symptoms of shock
+appear. Shock often follows burns or scalds even when the injury is
+comparatively slight.
+
+Treatment of slight burns, where the skin is reddened but not destroyed,
+has for its main object the exclusion of air. One of the following may
+be applied: dry baking soda, or baking soda made into a paste with
+water, picric acid gauze moistened in water, boracic acid ointment,
+vaseline, sweet oil, or castor oil; if none of these is obtainable,
+lard, cream, the white of an egg or unsalted butter may be used. Old
+muslin or linen bandaged lightly in place, should be used to cover the
+burn.
+
+The same treatment is used for sunburn, and also for small burns where
+blisters form. A blister, if it forms, should not be punctured; but if
+it is accidentally broken the skin of the blister should not be removed.
+It should be remembered that a broken blister is an open wound, and
+therefore liable to infection.
+
+BRUSH BURN is a name given to injuries where the surface of the skin
+has been removed. They include the scraped arms and legs which are
+common accidents in childhood. In order to dress a brush burn, particles
+of dirt should first be removed preferably by means of forceps that have
+been boiled, and the surrounding skin should then be cleansed with soap
+and water. The injured part should next be flushed with sterile salt
+solution, made by boiling water five minutes and adding to it salt in
+the proportion of one teaspoonful to a pint of water. If the dirt is
+difficult to remove a soap compress should be applied. To prepare the
+compress several thicknesses of gauze or muslin should be boiled in a
+strong solution of castile or green soap for ten minutes. The compress
+should remain in place several hours, and may be repeated if necessary.
+After the wound has been thoroughly cleansed, it should be dressed with
+old muslin that has been saturated in castor oil or spread with boracic
+ointment.
+
+
+EXERCISES
+
+1. Name some common causes of headache and of sleeplessness, and outline
+rational treatment for each of these disorders.
+
+2. Describe symptoms and treatment of shock; of fainting; of convulsions
+in children.
+
+3. Describe the treatment of all disturbances of the digestive tract
+mentioned in this book.
+
+4. What should be done if a foreign body has entered the eye? if one has
+entered the ear? What should be done for a person who has a stye? for a
+person with pain in or near the ear?
+
+5. How would you treat a sprain?
+
+6. Describe treatment for burns and scalds.
+
+7. Distinguish between heat stroke and heat prostration, and tell what
+treatment should be given in each case.
+
+8. What are the two principal dangers from slight wounds, and how should
+one guard against them? Show how you would dress a small cut.
+
+9. What should you do for a person with nose bleed?
+
+
+FOR FURTHER READING
+
+American National Red Cross Text Book on First Aid--Lynch.
+
+Immediate Care of the Injured--Morrow.
+
+Prompt Aid to the Injured--Doty.
+
+
+
+
+CHAPTER XIV
+
+SPECIAL POINTS IN THE CARE OF CHILDREN, CONVALESCENTS, CHRONICS, AND THE
+AGED
+
+
+In many cases of sickness institutional care has marked advantages. It
+may be the only solution when adequate provision for the sick is
+impossible at home; and it is often a necessity when a patient requires
+special equipment or apparatus, expert nursing, and medical attention
+within reach both day and night.
+
+On the other hand, it would not be desirable even if it were possible
+for all sick persons to be cared for in institutions. Care at home when
+it is adequate may be more successful than equally skillful care given
+elsewhere, since the sick quite as much as the well are injured by long
+separation from normal family life. Most children, because they need the
+attention of their own mothers, most convalescent and chronic patients,
+and most aged persons are cared for at home; and in the great majority
+of cases no better place for them could be found. Since patients of
+these four groups have needs peculiar to themselves, some special
+points in caring for them are considered in this chapter.
+
+
+CHILDREN
+
+Ability to observe quickly and accurately is seldom more needed than it
+is by a woman who cares for children. No one expects babies to explain
+their troubles, but people forget that small children are unable to
+describe their physical sensations with any degree of accuracy, although
+discomfort or sickness may show itself in all degrees of ill temper and
+bad conduct. For these exhibitions many a suffering child has been
+punished, where an older and more articulate person would have received
+considerate attention.
+
+Children, like babies, have a low resistance to disease. Moreover, they
+react quickly both to favorable and to unfavorable surroundings. Hence
+slight causes sometimes produce pronounced or even violent symptoms in
+children without giving cause for great anxiety, although the same
+symptoms if exhibited by adults, might indicate critical illness. On the
+other hand the recuperative power of children is high, and their
+recoveries are sometimes surprisingly rapid. It is a mistake, when a
+child has completely recovered from an acute but brief illness, to
+coddle him for weeks afterward merely because a grown person in similar
+circumstances would have failed to regain his strength.
+
+When a child is sick in bed, especial efforts should be made to insure
+adequate ventilation without chilling him. Children always lose heat
+rapidly because the body surface is proportionately large; when they are
+ill, therefore, it is especially necessary to keep them well covered, to
+see that their hands and feet are warm, and to avoid chilling them
+during their baths. But overheating must also be avoided, since all
+children, sick or well, who are too warmly dressed or who stay in rooms
+that are too warm, become weak and irritable and more susceptible than
+others to colds and other respiratory disorders. The child's skin should
+be kept clean and dry, but he should not be disturbed nor handled
+unnecessarily.
+
+Sick children require very simple food at short intervals. Variety is
+not so necessary for a child as for an adult, unless the child has been
+allowed to form bad habits of eating. Sick children should not be
+indulged unnecessarily, either in regard to their food or in other ways.
+However, attempts made during an illness to change the habits of a badly
+trained child are unwise because usually unsuccessful; parents who sow
+the wind by neglecting to train their children when they are in good
+health may as well make up their minds to reap a veritable whirlwind
+when the children are ill. Even when children are well trained it is
+difficult and sometimes impossible to prevent them from forming bad
+habits during sickness. Yet the labor of training a child reaps perhaps
+at no other time a richer reward than it does when the child is ill, and
+his recovery might be seriously impeded by unwillingness to accept
+necessary food, medicine, or treatment.
+
+PHYSICAL DEFECTS are faults in the structure of the body; adenoid
+growths, imperfect eyes, abnormally curved spines, and defective teeth
+are examples. Most physical defects can be cured in childhood by
+treatment or by slight operations. If untreated they frequently lead to
+sickness or to serious impairment of the body, and if neglected until
+adult life their injurious consequences are generally beyond remedy,
+even when the defects themselves can be repaired.
+
+Some indications of common physical defects are given below; they ought
+to be more generally known than they are. If a child exhibits one or
+more of the symptoms mentioned, he ought to be given a complete physical
+examination by a competent physician, and treatment, if needed, should
+begin without delay. The idea that children will outgrow these defects
+without treatment is erroneous. Better, however, than waiting until
+symptoms appear is the modern way of giving every child a physical
+examination at stated intervals, a practice already common in public
+schools where effective health work is carried on.
+
+EYESTRAIN frequently comes from imperfections in the shape of the eye;
+these imperfections can almost always be corrected by glasses. When a
+child is suffering from eyestrain, the eyes themselves may show
+indications of trouble; they may be blood-shot, the lids may itch or be
+crusted or inflamed, or styes may appear. In other cases the symptoms of
+eyestrain have no apparent connection with the eyes; such symptoms are
+headache, nausea, vomiting, indigestion, fatigue, irritability, poor
+scholarship, and nervous exhaustion. If a child shows any of these
+symptoms, or if he rubs his eyes, frowns, squints, wrinkles his
+forehead, sits bent over his book, or develops round shoulders, there is
+sufficient reason for having his eyes examined by an oculist.
+Examination by an optician should not be considered sufficient.
+
+ENLARGED TONSILS AND ADENOIDS.--The tonsils are masses of spongy tissue
+situated at the back of the mouth, on either side of the opening into
+the throat. If enlarged they may seriously interfere with breathing, and
+if diseased they frequently harbor the germs causing many acute
+infections, as well as germs of rheumatism and most of the heart
+disease originating in early life. Therefore the tonsils ought to be
+removed if they are diseased or greatly enlarged, but there is
+ordinarily no good reason for removing normal tonsils.
+
+Adenoids are situated at the back of the nose, and like the tonsils are
+composed of spongy tissue. Adenoids sometimes become so enlarged that
+they interfere with the passage of air through the nose, thus
+predisposing to catarrh, colds, and other respiratory diseases, to high
+palate with irregular teeth, to inflammation of the middle ear leading
+to deafness, to diminished mental activity, and to general poor health.
+
+If a child breathes through his mouth, if he snores at night, keeps his
+mouth open and has a dull, apathetic expression, his nose and throat
+should be examined, and if advisable his tonsils and adenoids should be
+removed.
+
+DEFECTIVE HEARING.--Permanent deafness among children in the great
+majority of cases comes from trouble in the throat or nose; hence the
+most effective measure to prevent deafness is to make sure that every
+child's nose, throat, and mouth are in a normal condition. Sensitive or
+timid children try to hide infirmities of any kind, but deaf children
+seem peculiarly unable to explain their difficulties. "No one," says
+Cornell, "has ever recorded that a small child complained of inability
+to hear." A child's ears should be examined if he breathes through his
+mouth, if he stoops habitually, if he is persistently inattentive, or if
+he is vague or stupid in carrying out directions. A child who appears
+normal at times and inattentive or stupid at other times should also be
+examined, since he may be deaf in one ear.
+
+Temporary deafness may come from accumulated wax in the ear. The wax
+should be removed by a doctor; inexpert attempts are likely to cause
+serious injury to the ear drum. Intermittent deafness may be caused by
+enlarged tonsils and adenoids. Children thus affected are not
+infrequently punished for seeming disobedience. Such children are
+especially liable to street accidents.
+
+DEFECTIVE TEETH have been considered on page 44.
+
+POSTURE.--In childhood the bones are soft and yield with comparative
+ease to continued strains; hence they often become deformed by bad
+positions assumed in sitting, standing, or in using the body in other
+ways. The postures habitually assumed by a child should be noticed and
+good postures should be insisted upon. But it is not enough to admonish
+him. The various causes tending to encourage bad positions should be
+corrected; among them are insufficient illumination of books and work,
+defective eyesight or hearing, obstructions in breathing, muscular
+weakness, and low general vitality. Children should have their chairs
+and tables suited to their size for their work both at home and in
+school.
+
+[Illustration: FIG. 28.--INCORRECT SITTING POSTURES. (_From Cornell,
+"Health and Medical Inspection of School Children." F. A. Davis Co.,
+Philadelphia._)]
+
+[Illustration: FIG. 29.--INCORRECT SITTING POSTURES. (_From Cornell,
+"Health and Medical Inspection of School Children." F. A. Davis Co.,
+Philadelphia._)]
+
+[Illustration: FIG. 30.--INCORRECT SITTING POSTURES. (_From Cornell,
+"Health and Medical Inspection of School Children." F. A. Davis Co.,
+Philadelphia._)]
+
+[Illustration: FIG. 31.--INCORRECT AND CORRECT STANDING POSTURES. (_From
+Cornell, "Health and Medical Inspection of School Children," F. A. Davis
+Co., Philadelphia._)]
+
+The adjustable chairs and desks now used in schools are a marked
+improvement upon the school furniture which has caused so many
+deformities in the past.
+
+[Illustration: FIG. 32.--ROUND SHOULDERS. (_Goldthwait, from Pyle's
+"Personal Hygiene."_)]
+
+One of the serious deformities caused by habitual faulty posture is
+curvature of the spine. A curvature not only injures a child's
+appearance and thus handicaps him in later life, but it brings strains
+and pressure upon the organs of the chest and abdomen which may
+seriously impair his health. As curvatures often pass unnoticed in their
+early stages, every child should be inspected occasionally when all his
+clothing has been removed, to see whether the weight is borne evenly on
+both feet, whether the development of the two sides is uniform, and
+whether the head and shoulders are properly carried. It should be
+noticed when the child stands, whether one shoulder is higher than the
+other, whether one shoulder blade projects more than the other, whether
+one hip is higher than the other, and whether one hand is lower than the
+other when the arms are hanging at the sides. The child should walk
+both toward and away from the observer, who should notice whether the
+child uses the two sides of his body in the same way, and whether he
+drags or shuffles his feet or has other abnormalities of gait.
+
+[Illustration: FIG. 33.--LATERAL CURVATURE. (_From Bancroft's "Posture
+of School Children." The Macmillan Co., New York._)]
+
+[Illustration: FIG. 34.--"WING SHOULDER BLADES IN FORWARD SHOULDERS.
+(_From Bancroft's "Posture of School Children." The Macmillan Co., New
+York._)]
+
+If abnormalities are found, a physician should be consulted. Often
+corrective exercises are all that is needed, and no one should put
+braces of any kind upon a child unless they have been prescribed by a
+physician. No attempt should be made to correct the common tendency of
+children to toe in or "walk pigeon-toed." Toeing-in is a natural manner
+of walking during the formative period and tends to strengthen the arch
+of the foot, while toeing-out tends to weaken the arch and to cause flat
+foot or broken arches.
+
+PREDISPOSITION TO NERVOUSNESS.--Heredity plays an important rôle in the
+predisposition to nervousness, so that children of nervous parents are
+particularly likely to show nervous instability. It is, however,
+difficult to say in a given case how much of his nervousness a child
+inherits and how much he acquires by imitating the irritability, the
+out-breaks of temper, and the other evidences of imperfect emotional
+control displayed by his nervously disposed parents. On the other hand,
+even children of nervous predisposition sometimes overcome their defects
+to some extent by imitating parents who have acquired self-control.
+
+Children predisposed to nervousness should be watched with special care,
+but they should not be allowed to realize that they are the objects of
+unusual solicitude. They need the most favorable surroundings that can
+be obtained, and their general health should be maintained at the
+highest possible level. Any condition that lowers vitality tends to
+increase their troubles; nervousness may be caused among children of
+good inheritance, and increased among others, by poor nutrition, lack of
+exercise and play out-of-doors, fatigue, loss of sleep, eyestrain,
+adenoid growths, and the poisons of infectious diseases.
+
+It is characteristic of many nervous children that they are too easily
+stimulated; they may be excitable, restless, unnaturally quick in
+moving, over-sensitive to pain and discomfort, easily fatigued,
+irritable in temper, and unable to control the emotions. They frequently
+make involuntary motions like grimacing and winking the eyes. Children
+of low nervous tone, however, are not necessarily excitable. A nervous
+child may be muscularly weak, awkward in gait, listless, dull, clumsy,
+forgetful, and inattentive. Such children often suffer from cold hands
+and feet and from profuse perspiration.
+
+Much can be done for these unfortunate children by removing the cause of
+their troubles if possible, by giving them simple and wholesome
+surroundings, by suiting their occupations to their strength, by
+eliminating mental strain, particularly during the adolescent period,
+and by training them to control their minds as well as their bodies.
+
+      "In addition to the hardening of the body, the education of
+      the child should include measures which increase the
+      resistance of the child against pain and discomforts of
+      various sorts. Every child, therefore, should undergo a
+      gradual process of 'psychic hardening' and be taught to
+      bear with equanimity the pain and discomfort to which
+      everyone sooner or later cannot help but be exposed. What I
+      have said about clothing, cold baths, walking in all
+      weather and at all temperatures, play and exercise in the
+      open air, has a bearing on this point, for a child who has
+      formed good habits in these various directions will have
+      learned many lessons in the steeling of his mind to bear
+      pain and to ignore small discomforts."--(Barker:
+      "Principles of Mental Hygiene Applied to the Management of
+      Children Predisposed to Nervousness.")
+
+
+CONVALESCENT PATIENTS
+
+After serious or prolonged illness the vitality is generally low and all
+bodily processes are likely to be depressed. During convalescence,
+therefore, the digestion is feeble, the muscles are weak so that fatigue
+follows slight exertion, and the sluggish condition of the circulation
+renders the patient especially sensitive to cold. Since the nervous
+system also becomes depressed and irritable, a convalescent patient is
+easily excited, easily discouraged, and quickly fatigued by mental
+effort. He finds the simplest decisions hard to make, and his emotions
+difficult to control; indeed, many a patient who has borne acute pain
+with unflinching courage becomes peevish at this stage, weeps easily,
+and expects more expression of sympathy than is good for him. Some
+persons naturally make quick recoveries, while others recuperate
+slowly. A long and tedious convalescence, it should be remembered, is
+the patient's misfortune rather than his fault.
+
+In restoring a convalescent patient to normal living it is imperative to
+proceed slowly. Food should be increased gradually both in variety and
+in amount; but the patient's appetite is not always a safe guide, and it
+may need to be encouraged or to be restrained. Both mental and physical
+exertion should begin only under careful supervision, and should
+increase by slow degrees. The patient should sleep as much as possible,
+should take long intervals of rest, and should continue no occupation to
+the point of fatigue. A patient who has been ill in a hospital or who
+has had at home the exclusive services of a nurse or an attendant, often
+finds the period following his return or following the nurse's departure
+an exceedingly difficult transition. The family should not expect or
+allow him to resume too many duties at a time when the mere acts of
+bathing and dressing may demand all the strength he has. Many
+convalescents are obliged, or think they are obliged, to take up regular
+work again before their strength is fully restored. There is generally
+no economy in so doing; indeed, time is saved in the end by waiting
+until recovery is complete before undertaking full work.
+
+Important as it is to build up the patient's physical strength, it is
+hardly less important to direct his thoughts away from himself and his
+sickness, and to help him renew his interest in normal living. During
+his illness he has of necessity relied upon the judgment and support of
+other persons, and his pain and discomfort have forced him to think
+constantly of himself and his many needs. The habit of sickness is
+readily broken by some persons, particularly by those whose nervous
+exhaustion has not been great and whose interests outside themselves are
+naturally keen. But the sick point of view has remarkable tenacity, and
+other patients, unless circumstances or deliberate efforts redirect
+their thoughts, will look upon themselves as invalids to the end of
+time.
+
+Hopefulness promotes health, while discouragement, apprehension, and
+unhappiness lower the tone of the whole system. Hence set backs,
+failures, delays, and relapses should not be dwelt upon, but signs of
+progress should be mentioned; judiciously however, since overdone
+attempts to cheer a patient seldom fail to have the opposite effect. If
+objects or situations that suggest undesirable thoughts are eliminated,
+the less often those thoughts tend to recur. Therefore, in order to
+break the habit of sickness, old thoughts must be gradually banished
+and new ones must be substituted. Sick-room appliances should be put out
+of sight as soon as they are no longer needed, and the patient may
+profit by moving into a different bed room. A few days spent away from
+home as soon as his strength permits often prove effective in breaking
+up sickness associations; the patient is generally encouraged when he
+finds that he can sleep in a different bed, endure some fatigue, and
+exist without daily visits from the doctor. Even a day spent at a
+different house in the same town sometimes directs the patient's
+thoughts into fresh channels. Gradually, but as quickly as safety
+allows, he should take his place in the normal family life and cease to
+be treated as an exception.
+
+Merely eliminating associations with sickness, however, is not enough;
+and exhorting a patient to forget himself and to become interested in
+something seldom accomplishes anything, especially if he is so depleted
+by illness that the thought of everyday activities suggests only
+weariness and pain. A person so weak that he is thoroughly fatigued by
+dressing himself should not be expected to view with enthusiasm the
+prospect of a full day's work. Much, however, may be accomplished by
+providing something that the patient really likes to do, and deliberate
+efforts must be made to stimulate his interest in some occupation,
+however simple it may be.
+
+Occupations for invalids are more than a means to pass away the time;
+they are also of distinct curative value. The patient's interest is not
+always easy to arouse, and some ingenuity may be needed in the
+beginning; sometimes interest is best aroused by working at some
+handicraft in his presence, and finally offering, as a favor, to teach
+him to do it also. His interest in any occupation is invariably
+increased if a well person not only directs but shares in the work.
+
+Care should be taken to select occupations suited to the patient's
+physical condition, to his age, tastes, and mental development. Two or
+three occupations are better than one, so that he may change from one to
+another before any one becomes tedious. Work requiring fine motions,
+close attention, or concentrated thought should be used for short
+periods, only, and no work should be continued to the point of fatigue.
+The patient should not be allowed to feel that he must finish a certain
+amount in a certain time. Even poor work is better than none, and a
+patient should always be encouraged by judicious praise.
+
+Games and puzzles are useful to some extent, but an aimless occupation
+is not so beneficial as one which has a tangible product, particularly
+a product that is useful as well as beautiful. Occupations frequently
+possible for invalids and convalescents include knitting, crocheting,
+many kinds of needle work, clay modeling, basketry, stenciling, weaving,
+book-binding, metal work, and photography. Manuals are now available
+giving directions for these and many other handicrafts. Sick children
+often enjoy collecting stamps, post marks, and other objects, making
+scrap books, sewing, weaving, knitting, paper folding, and various other
+kindergarten occupations.
+
+
+CHRONIC PATIENTS
+
+The whole field of caring for the sick offers nowhere greater
+opportunity for fine and finished work than it offers in the case of
+chronic invalids. It is an achievement of which an artist might be proud
+to make a chronic patient comfortable in body, happy in mind, and
+agreeable to others. Moreover, since success can never be attained by
+one who wearies in well doing, the care given to a chronic invalid tests
+not only the attendant's skill but also her moral and spiritual quality.
+
+Care of a chronic patient has for its aims maintaining the patient's
+health, rendering him as happy and comfortable in mind and body as it is
+possible for him to be, and providing whatever special treatment and
+attention his case requires. In order to maintain his health constant
+attention must be given to diet, to hygiene of the sick room, and indeed
+to all his surroundings. In many chronic illnesses, such as rheumatism
+and kidney disease, the diet is prescribed by the doctor; in every case
+care should be taken that the patient is not overfed or underfed, that
+the food is suited to his digestive powers, that foods causing
+flatulence are eliminated, particularly if the patient's trouble is
+heart disease, and not the least important requirement, that he derive
+as much pleasure from his food as possible.
+
+The regular daily care of the patient and of his room, already described
+in this book, should be scrupulously carried out, and no less
+scrupulously during the tenth year than it was during the tenth day.
+Cleanliness in every detail is absolutely essential to the patient's
+welfare; no one is more unpleasant either to himself or to others than a
+chronic patient who is neglected. Patients who are constantly in bed, it
+should be remembered, and paralyzed patients in particular, are
+peculiarly susceptible to pressure sores. If a patient is able, it is
+extremely important for him to sit up in a chair part of the day.
+Sitting up should never be omitted because it involves the expenditure
+of time and trouble for the attendant.
+
+It is often said that for most people some personal experience of
+sickness is beneficial; it can safely be said, however, that no one
+benefits from spending any considerable portion of his life in a state
+of helplessness and suffering. Behavior and character itself are
+determined by influences constantly coming into the mind from daily
+surroundings and associations with other people: one who recalls this
+fact needs only a moment's reflection to realize how ill adapted to
+healthy development of mind and character are the limited lives of the
+sick. Especially unfortunate is the situation of chronic invalids, shut
+off as they are from the objective interests and activities of normal
+life, deprived of all practice in making the salutary small adjustments
+and sacrifices required in every day living with other people, and
+self-centered as they necessarily tend to become from the inevitable
+focusing of attention upon their own discomforts and pain.
+
+On the whole, a surprisingly large number of invalids successfully
+resist the disintegrating effects of sickness upon character. But it is
+nevertheless true, as Dr. Weir Mitchell says, that "Sickness ennobles a
+few but debases many." A selfish invalid has more than once destroyed
+the happiness of an entire family, or spoiled the life of one member of
+it by monopolizing her whole time and attention. Families should
+remember that their injudicious sacrifices seldom bring enduring
+happiness or contentment to the patient himself; indeed, in the long run
+such sacrifices generally injure him even more than they injure his
+victims. Clearly much must and should be sacrificed by members of a
+family to the needs of an invalid; but in general it may be said that a
+sacrifice is injudicious if it relieves the patient of activity or
+responsibility that he can support without injury, if it makes him more
+dependent in mind or body, if it results in restricting his attention to
+himself and his affairs, or if it increases his tendency to make demands
+on others.
+
+Purposeful activity of some sort and the necessity for contributing to
+the welfare of others are essential parts of a wholesome life. If these
+essentials are entirely eliminated from the life of an invalid, the
+patient's greatest needs are probably left unsatisfied, even though the
+physical care he receives may be perfect in every detail. All that was
+said in regard to occupations for invalids applies with particular force
+to occupations for chronic patients, since however valuable manual
+occupations may be as a means to bring about recovery, they are still
+more valuable in furnishing interest and purpose in a life whose only
+prospect is a succession of weary, useless years. Handicapped patients
+sometimes learn occupations that yield a financial return, and ability
+to earn even a little stimulates self respect and mental health, whether
+the money is needed or not. The important point, however, is that the
+finished product should have a recognized use.
+
+In addition to enabling the patient to make things with his hands, a way
+should be found if possible by which he may contribute to the group of
+people with whom he lives. If a way can be discovered for him to do so,
+the opportunity should not be denied him nor should his service fail to
+be noted and appreciated, even if it is nothing more than telling a
+story to a restless child.
+
+
+CARE OF THE AGED
+
+At the end of life, as at its beginning, every individual especially
+needs the interest and protection of his own family. In ordinary
+circumstances neither a baby nor an aged person can be cared for so
+fittingly or so successfully in any other place as he can be in his own
+home.
+
+With advancing years is to be expected a general slowing down of all the
+powers. In old age both body and mind show characteristic changes, and
+particularly changes causing lowered resistance and diminished vigor. If
+the manner of living is adapted to these changes, both happiness and
+usefulness may be prolonged. But so gradually do the changes often come
+that they may escape notice for a long time, and the younger generation
+in looking back sometimes realizes with regret how much earlier measures
+might have been taken to prolong the usefulness and to mitigate the
+discomforts of aged parents and friends.
+
+Old people are keenly sensitive to cold, since the circulation gradually
+becomes less vigorous and they take little exercise. Keeping them warm
+both in bed and out adds more perhaps to their comfort than any other
+one measure. They should have warm underclothing and soft shawls and
+other extra wraps. A real service will be rendered by the person who
+invents a suitable and dignified wrap for old or feeble men, who dislike
+the informality of sweaters and feel disgraced by shawls. Old persons
+should and can be kept warm in bed, by providing them with hot water
+bags, with warm night clothes including stockings, by using woollen or
+outing flannel sheets if necessary, and by providing a sufficient number
+of light but warm bed covers. It is not always understood that many
+covers do not remedy the deficiencies of a thin mattress. If a thick
+mattress or two thin mattresses cannot be provided, a thick comforter or
+even many layers of newspaper should be placed between the mattress and
+the springs, and another thick comforter should be placed between the
+mattress and the lower sheet. Rubbing the body with warm olive oil often
+affords great comfort, by improving the circulation and thus increasing
+the sensation of warmth, and also by relieving the tendency of the skin
+to become dry and cracked. Poor circulation at night may cause cramps in
+the muscles of the legs; the cramps can usually be relieved by warmth
+and gentle rubbing.
+
+Old people frequently wish their rooms to be very hot, both by day and
+by night, even as hot as 80° or 85°, but if it is possible to keep them
+warm in any other way the temperature of the room should be kept at 70°.
+Well ventilated rooms are highly important for old people as for all
+others of low resistance, and it is entirely possible for their rooms to
+be warm and yet well ventilated. Aged persons should be carefully
+guarded from chill, exposure, crowds, and infected persons. Like little
+children they are peculiarly susceptible to the respiratory diseases,
+which cause many of the deaths commonly attributed to old age.
+
+Digestion usually becomes weaker than in earlier years, and less food is
+needed. It should be simple, hot, and divided into four or five meals
+rather than three. Old people often wake at an early hour, and hot
+nourishment will prevent them from growing weak and faint while waiting
+for the family breakfast. Both constipation and looseness of the bowels
+are common ailments in old age. So far as possible the bowels should be
+regulated by means of diet; but muscular weakness resulting in inability
+to control the bowels should not be mistaken for and treated as
+diarrhœa.
+
+It is unwise for old people to undertake unaccustomed or sudden muscular
+exertion, since the muscular system including the heart muscle grows
+weak and is generally unable to endure great strain. The bones,
+moreover, grow brittle and heal with difficulty if broken, so that
+persons of advanced years no matter how active should avoid walking on
+icy pavements, climbing on chairs to reach high shelves, and placing
+themselves in other insecure positions. Assistance must be tactfully
+given, however, as active old people are inclined to resent it. On the
+other hand, old people should be encouraged to continue moderate and
+safe activities, and to take regular exercises suited to their strength.
+Although increasing muscular weakness tends to make most old people
+indolent, it is far better for them both in mind and in body to remain
+as active as they can without danger of too great fatigue. At all
+events, they should be prevented if possible from becoming bedridden.
+
+Since in old age sight, hearing, and other special senses become less
+acute, one should remember that an old person may not notice the odor of
+escaping gas, the light of a smouldering match, or the sound of an
+approaching motor car, and that he must be specially guarded from such
+dangers of every day life. On account of their dulled perceptions old
+people are sometimes unjustly considered to be less intelligent than
+they really are. Young people moreover should be told, if an aged person
+is untidy and careless in personal habits, that the apparent negligence
+is caused by dulled perceptions and diminished muscular control for
+which old people are no more responsible than they are for failing
+eyesight or for inability to hear.
+
+Families should also realize that changes in mind and character are
+beyond an aged person's control and that they should not be made the
+cause for remonstrance or arguing. Just as the arteries harden with
+advancing years, as the bones become brittle and as other tissues become
+less flexible, so changes are likely to occur in the nervous system. It
+is not surprising when the brain substance like other tissues is
+becoming less flexible, that the powers of attention should weaken,
+that memory for recent events should diminish, or that other mental
+powers should fail. Changes in disposition are not uncommon: previously
+controlled persons sometimes become querulous and exacting, while
+excitable and irritable persons become more placid. With most old people
+emotions become less intense; feeble old people hardly realize great joy
+or great sorrow, and seldom look forward to death with apprehension.
+
+Among the most important changes that occur in the nervous system is its
+gradual loss in power to respond to new demands. New habits are
+difficult or impossible to form, and old habits are hard to break.
+Attempts to break the habits of a life time are therefore dangerous, and
+radical changes in old people's ways of living are attended by risk as
+well as by unhappiness. Such loss of adaptability in the nervous system
+makes it increasingly difficult for old people to assimilate new ideas
+and to understand new points of view. The feeling that the world is
+strange and that the next generation has gone on without them accounts
+for the tragic loneliness of many old people. Clearly it is for those
+who are younger and more flexible to bridge the gulf between the
+generations by their understanding and their sympathy.
+
+Physical care to whatever extent it is needed should be given to all old
+people as soon as they are unable to care for themselves, and thought
+should be given to adapting their surroundings and ways of living to
+their strength and needs, just as they should be adapted to the strength
+and needs of chronic patients. But a warning should be given against
+managing old people too much. It is hard for people who have managed
+their own lives successfully for many years to be managed, even for
+their own good. Indeed, it is questionable kindness to deprive old
+people of all freedom of action, even if following their own
+inclinations occasionally has disastrous results. Few persons would wish
+to prolong their lives if long life involved being thwarted in every
+desire, and sometimes real kindness consists in allowing old people to
+do certain things that are not good for them. Keeping them warm and
+letting them do as they please will go far to make old people happy.
+
+Many of the changes in old age reverse the developing process of
+childhood. In youth and age extremes meet, and the care of the aged
+presents certain marked similarities to the care of little children.
+Both require simple food, occupations suited to their strength, and
+protection from infections, from fatigue, and from nervous strain; both
+are dependent, more or less helpless, and for their happiness both need
+the affectionate care of their own families. But in one respect their
+needs are fundamentally different. In childhood formation of proper
+habits is all important, and in caring for children the future effect of
+every word and act must be taken into consideration. Old people, on the
+other hand, since they live largely in the past and their habits are
+irrevocably formed, may be indulged without harm in ways that would
+demoralize a child; with a clear conscience one may make them happy in
+ways both great and small. This difference makes possible one of the
+greatest pleasures that come to one who cares for the helpless and the
+sick, for of all enduring satisfactions few are greater than the power
+to fill with comfort and happiness the closing days of life.
+
+
+EXERCISES
+
+1. What is meant by a physical defect? Name some of the most common
+defects.
+
+2. Name some permanent injuries to the body caused by defective teeth;
+by diseased or enlarged tonsils and adenoids; by faulty posture.
+
+3. Describe some common symptoms of eye strain in children; of enlarged
+tonsils and adenoids; of deafness.
+
+4. Name several possible causes of round shoulders, and explain why
+urging a round-shouldered child to hold himself erect is seldom enough
+to make him correct his posture.
+
+5. What measures should be taken to overcome nervousness in children?
+
+6. Describe in detail the health work carried on in the public schools
+of your city or town. Considering the important part played by
+uncorrected physical defects in causing permanent physical disability
+among adults, do you think in the long run it is cheaper or more
+expensive for a community to spend money in protecting the health of
+school children?
+
+7. Discuss the particular needs of convalescent and of chronic patients.
+
+8. Explain the effect of activity upon recovery, and explain why it is
+desirable for invalids to have occupation.
+
+9. What special needs should be provided for in caring for old people?
+
+
+FOR FURTHER READING
+
+Invalid Occupations--Tracy.
+
+Occupation Therapy--Dunton.
+
+Handicrafts for the Handicapped--Hall and Buck.
+
+When Mother Lets Us Make Toys--Rich.
+
+Amusements for Convalescent Children--New York State Department of
+Health, Albany.
+
+Essentials of Medicine--Emerson, Chapter IX.
+
+Civics and Health--Allen.
+
+How to Live--Fisher and Fisk, Chapter III, Section II; and Supplementary
+Notes, Section III.
+
+Health Work in the Schools--Hoag and Terman.
+
+Medical Inspection of Schools--Gulick and Ayres.
+
+The Hygiene of the Child--Terman.
+
+Posture of School Children--Bancroft.
+
+
+
+
+CHAPTER XV
+
+QUESTIONS FOR REVIEW
+
+
+I. Show how you would:
+
+    1. Make an unoccupied bed. (Notice the number of minutes it takes
+       you to do it well.)
+
+    2. Remove all the covers from an unoccupied bed and leave the bed to
+       air.
+
+    3. Open a bed to receive a patient.
+
+II. Show how you would:
+
+    1. Change all the linen and remake an occupied bed. (How long did
+       it take you?)
+
+    2. Turn a patient from his back to his side, and the reverse.
+
+    3. Remove, shake, and readjust a patient's pillows.
+
+    4. Move a patient from one bed to another.
+
+    5. Prepare a weak patient to sit up in a chair, and assist him from
+       the bed to the chair.
+
+    6. Assist a weak patient from the chair to the bed.
+
+    7. Arrange pillows and back rest for a patient to sit up in bed; and
+       also how you would remove the pillows and back rest.
+
+III. Show how you would:
+
+    1. Lift a patient who has slipped down toward the foot of the bed,
+       and show what you would do to prevent him from slipping down.
+
+    2. Prevent bed covers from resting upon a sensitive foot, leg,
+       abdomen, or arm.
+
+    3. Describe and demonstrate every device you would use and every
+       thing you would do to prevent pressure sores.
+
+    4. Arrange pillows to support the arms of a person sitting up in
+       bed.
+
+    5. Arrange a table or a substitute for a table to support the book
+       or work of a patient sitting up in bed.
+
+    6. Arrange the light for a patient who is allowed to read in bed.
+
+IV.
+
+    1. Assemble all the articles you would use in giving a bed bath.
+       (How long did it take you?)
+
+    2. Show how to give a complete bed bath. (How long did it take you?
+       Did you have to stop the bath to fetch anything you had
+       forgotten?)
+
+    3. What special care would you give to the mouth and teeth? to the
+       finger and toe nails? to the hair? to badly tangled hair? How
+       would you cleanse the mouth of a helpless patient?
+
+    4. Show how to shampoo the hair of a bed patient.
+
+    5. Show how you would give a bath to a baby.
+
+    6. Show everything that you would do to prepare a patient for the
+       night.
+
+V.
+
+    1. Show how to take the temperature, pulse, and respiration.
+
+    2. Show how to cleanse a clinical thermometer.
+
+    3. Show how to give a foot bath (_a_) to a patient out of bed, (_b_)
+       to a patient in bed.
+
+    4. Show how you would give a cool sponge bath to a feverish patient.
+
+    5. Show how to give, remove, and cleanse a bed-pan.
+
+    6. Show how to fill and apply a hot water bag; an ice bag.
+
+    7. Show how to prepare and apply a mustard paste; a mustard leaf; a
+       flaxseed poultice; hot fomentations; cold compresses.
+
+    8. Show how to measure and administer a fluid medicine; pills or
+       tablets.
+
+    9. Show how to prepare and administer a salt and water enema to a
+       grown person; to a baby.
+
+   10. Show how to prepare steam inhalations.
+
+   11. Show how to apply an ointment; a liniment.
+
+VI.
+
+    1. Show how you would feed a helpless patient who is lying down.
+
+    2. Show how you would feed a patient who is able to sit up but
+       unable to use his hands.
+
+    3. Prepare a liquid nourishment tray.
+
+    4. Set a tray for light diet; for full diet.
+
+    5. Show how to place a tray for a patient unable to sit up but able
+       to feed himself; for a patient sitting up in bed.
+
+    6. What personal care should be given a patient just before meals?
+       just after meals?
+
+    7. How would you modify the diet of a patient inclined to
+       constipation? to diarrhœa?
+
+VII.
+
+    1. Describe effective household methods for removing dust.
+
+    2. Demonstrate the cleaning of a refrigerator.
+
+    3. Show how to ventilate a sick room while protecting the patient
+       from direct draughts.
+
+    4. Show how to clean a sick room with a minimum of disturbance to
+       the patient.
+
+    5. Explain how a patient with communicable disease should be
+       isolated.
+
+    6. Demonstrate the daily care of a room occupied by a patient with
+       communicable disease.
+
+    7. Explain methods of concurrent disinfection.
+
+    8. Explain methods of terminal disinfection.
+
+    9. Tell how the following should be disinfected: discharges from the
+       nose, throat, eyes, ears, bowels, bladder, wounds, and sores; bed
+       and personal linen; blankets; mattresses; dishes; utensils,
+       especially bedpans and urinals; clothing and person of the
+       attendant, especially the hands; furniture, rugs, and woodwork.
+
+VIII.
+
+    1. Name some of the most obvious symptoms of sickness.
+
+    2. Name some symptoms that would lead you to take a patient to a
+       doctor; to send for a doctor; to send for a doctor in haste.
+
+    3. Name some symptoms that are dangerous to neglect even though the
+       patient feels fairly well.
+
+    4. What are some of the symptoms of physical defects in children?
+       Name some conditions that are frequently caused by unremedied
+       defects.
+
+    5. Name some diseases commonly ushered in by symptoms resembling
+       those of a cold in the head.
+
+    6. What symptoms would lead you to isolate a patient?
+
+    7. Give as many illustrations as you can of the part played by good
+       and bad habits in determining health and sickness.
+
+IX.
+
+    1. How would you dress a cut? a burn? a sprain?
+
+    2. What would you do for a person suffering from colic? nausea?
+       diarrhœa? chill?
+
+    3. What are the symptoms of shock? heat stroke? heat prostration?
+       What treatment would you give in each case?
+
+    4. What would you do for a fainting person? for a person suffering
+       from nose bleed? from earache? from a cinder in the eye?
+
+    5. What course of action would you advise for a person troubled with
+       sleeplessness? frequent headaches? excessive irritability?
+       unusual depression of spirits? unfounded suspicions of other
+       persons' motives? a tendency to have the feelings hurt easily?
+       inability to control the emotions?
+
+X.
+
+    1. Why is it better to prevent sickness than to cure it?
+
+    2. Name the essentials of good hygienic conditions for babies, for
+       children, for grown people, for the aged.
+
+    3. How much of the sickness in the United States is preventable?
+
+    4. If part of the sickness is preventable, why is it not prevented?
+
+    5. What constitutes adequate care of the sick?
+
+    6. What proportion of the young men in your community who were
+       drafted have been rejected for physical disability? How many were
+       rejected for disabilities that might have been prevented?
+
+XI. (Answers to the following questions can generally be obtained from
+local health officers.)
+
+    1. What are the duties and powers of your local board of health?
+
+    2. How much did your city or town spend per person last year on
+       health protection? How does this amount compare with the amount
+       spent per person for police protection? for fire protection?
+
+    3. Who inspects the water supply in your town? the milk supply? the
+       food supply?
+
+    4. In your city, what was the number of deaths per 100,000 of the
+       population from tuberculosis each year for the last five years?
+       from typhoid fever?
+
+    5. Is there a tuberculosis sanitarium in your city or county? Are
+       nurses employed to supervise tuberculosis patients who remain at
+       home?
+
+    6. What provision does your community make for patients suffering
+       from other communicable diseases?
+
+    7. What measures are taken in your community to instruct school
+       children in matters of health? to instruct grown persons?
+
+    8. How does your community provide medical and nursing care for
+       persons unable to pay part or all of the cost of such service?
+
+XII. Explain why the following common beliefs are erroneous or
+unfounded:
+
+    1. That a damp cellar causes diphtheria.
+
+    2. That night air is harmful.
+
+    3. That one should "stuff a cold" and "starve a fever."
+
+    4. That almost everyone needs a tonic in the spring.
+
+    5. That the health of one's family would be endangered if a
+       tuberculosis hospital were placed on the next block.
+
+    6. That clearing up the back yard will protect the children of a
+       family from infantile paralysis.
+
+    7. That odorless and tasteless water is necessarily free from
+       harmful germs.
+
+    8. That all children should have the children's diseases, and have
+       them as early as possible.
+
+    9. That boils are a benefit to the system by removing impurities
+       from the blood.
+
+   10. That tomatoes cause cancer.
+
+   11. That consumption is inherited.
+
+   12. That dirt breeds disease.
+
+   13. That diseases come up drains.
+
+   14. That if a teaspoonful of medicine does you good, a tablespoonful
+       will do you more good.
+
+   15. That instinct teaches a mother how to care for her baby.
+
+   16. That low heeled shoes, though suitable for boys and men, cause
+       broken arches in women and girls.
+
+   17. That in one's own case, the rule that everyone needs regular
+       meals, regular hours of sleep, and daily exercise out of doors,
+       may be safely violated.
+
+
+
+
+APPENDIX
+
+
+The New York City Department of Health has kindly permitted us to
+include the following circulars of information issued by the Division of
+Child Hygiene.
+
+
+DEPARTMENT OF HEALTH THE CITY OF NEW YORK
+
+INSTRUCTIONS TO PARENTS REGARDING THE CARE OF THE MOUTH AND TEETH.
+
+The physical examination of school children shows that in many instances
+the teeth are in a decayed and unhealthy condition.
+
+Decayed teeth cause an unclean mouth. Toothache and disease of the gums
+may result.
+
+Neglect of the first teeth is a frequent cause of decay of the second
+teeth.
+
+If a child has decayed teeth, it cannot properly chew its food.
+Improperly chewed food and an unclean mouth cause bad digestion, and
+consequently poor general health.
+
+If a child is not in good health, it cannot keep up with its studies in
+school. It is more likely to contract any contagious disease, and it has
+not the proper chance to grow into a robust, healthy adult.
+
+If the child's teeth are decayed, it should be taken to a dentist at
+once.
+
+The teeth should be brushed after each meal, using a tooth brush and
+tooth powder.
+
+The following tooth powder is recommended:
+
+  2 oz. powdered precipitated chalk.
+  ½ oz. powdered Castile soap,
+  1 dram powdered orris root.
+  Thoroughly mix.
+
+This prescription can be filled by any druggist at a cost not to exceed
+fifteen cents.
+
+
+DEPARTMENT OF HEALTH CITY OF NEW YORK
+
+Instructions to Parents Regarding the Care of the Nose
+
+The physical examination of school children shows that in many instances
+they breathe through the mouth because they cannot breathe properly or
+sufficiently through the nose.
+
+This may be due to bad habits in regard to keeping the nose clean, or,
+in a majority of instances, to a growth which is known as "adenoids" and
+which stops up the back of the nose. In either case, the air is not
+breathed through the nose, and the child becomes what is known as a
+"mouth breather."
+
+Constant breathing through the mouth causes the child to become pale,
+restless in its sleep and dull in its actions. The child often speaks as
+though it had a cold in the head. Frequently there is an almost constant
+discharge from the nose.
+
+Mouth breathing renders a child especially liable to contract
+tuberculosis and other infectious diseases; in fact, the child has very
+little resistance to disease of any kind.
+
+Every child should be given a handkerchief, and be taught to thoroughly
+blow the nose several times each day. If, after doing this regularly,
+the child is still unable to breathe properly through the nose, it is
+probable that an adenoid growth is present. Such children should be
+taken to the family physician or to a dispensary for further advice and
+treatment.
+
+Do not wait too long in the hope that the child will outgrow the
+condition, for the effect of adenoid growths persisting throughout
+childhood may injure the person for life.
+
+Have your child's throat and nose examined one month after measles,
+scarlet fever, or diphtheria.
+
+
+DEPARTMENT OF HEALTH CITY OF NEW YORK
+
+Instructions to Parents on the Care of Children's Hair and Scalp
+
+Children affected with vermin of the head are excluded from school. The
+following directions will cure the condition:
+
+Mix one-half pint of sweet oil and one-half pint of kerosene oil. Shake
+the mixture well and saturate the hair with the mixture. Then wrap the
+head in a large bath towel or rubber cap so that the head is entirely
+covered; the head must remain covered from six to eight hours.
+
+(Tincture of larkspur may be used instead of oil mixture. The directions
+for use are the same.)
+
+After removing the towel, the head should be shampooed as follows:
+
+To two quarts of warm water add one teaspoonful of sodium carbonate
+(washing soda). Wet the hair with this solution and then apply Castile
+soap and rub the head thoroughly about ten minutes. Wash the soap out of
+the hair with repeated washings of clear warm water. Dry the hair
+thoroughly.
+
+Nits: If the head is shampooed regularly each week as above described,
+it will cure and prevent the condition of "nits."
+
+
+DEPARTMENT OF HEALTH CITY OF NEW YORK
+
+DIET FOR CHILD FROM 12TH TO 18TH MONTH
+
+FIRST MEAL--ON RISING.
+
+(1) 1 to 2 ounces juice of a sweet orange
+
+or
+
+Pulp of 6 stewed prunes
+
+or
+
+1 ounce pineapple juice.
+
+(2) 8 ounces milk with either zwieback, or toasted biscuits or stale
+toasted bread.
+
+Note: Fruit must be given either ½ hour before or ½ hour after milk.
+
+SECOND MEAL--DURING FORENOON.
+
+Milk alone or with zwieback.
+
+NOON MEAL.
+
+(1) 6 ounces soup
+
+or
+
+3 ounces beef juice.
+
+Note: Soup may be made of chicken, beef or mutton.
+
+(2) Stale bread may be added to the above.
+
+FOURTH MEAL--AFTERNOON.
+
+Milk or toasted bread and milk.
+
+EVENING MEAL.
+
+(1) 4 ounces thick gruel mixed with 4 ounces top half milk.
+
+Taken with zwieback.
+
+Note: Gruel may be made of oatmeal, farina, barley, hominy, wheatena, or
+rice.
+
+(2) Apple sauce
+
+or
+
+Prune jelly.
+
+Total milk in 24 hours, 1 to 1¼ quarts.
+
+Note: 8 ounces is equal to a half pint.
+
+
+DEPARTMENT OF HEALTH CITY OF NEW YORK
+
+DIET FOR CHILD FROM 18TH TO 24TH MONTH
+
+BREAKFAST.
+
+(1) Juice of one sweet orange
+
+or
+
+Pulp of six stewed prunes
+
+or
+
+Pineapple juice (fresh or bottled) 1 ounce.
+
+(2) A cereal such as cream of wheat, oatmeal, farina, or hominy
+preparations with top milk (top 16 ounces) sweetened or salted. A glass
+of milk, bread and butter.
+
+Note: If constipated give the fruit ½ hour before breakfast with water;
+if not, they may be given during the forenoon.
+
+Raw fruit juice must be given either ½ hour before or ½ hour after milk.
+
+FORENOON.
+
+A glass of milk with two toasted biscuits or zwieback or graham
+crackers.
+
+DINNER.
+
+(1) Broth or soup made of beef, mutton, or chicken, and thickened with
+peas, farina, sago or rice
+
+or
+
+Beef juice with stale bread crumbs; or clear vegetable soup with yolk of
+egg
+
+or
+
+Egg soft boiled, with bread crumbs, or the egg poached, with a glass of
+milk.
+
+(2) Dessert: apple sauce, prune pulp, with stale lady-fingers or graham
+wafers
+
+or
+
+Plain puddings: rice, bread, tapioca, blanc-mange, junket or baked
+custard.
+
+SUPPER.
+
+Glass of milk, warm or cold; zwieback and custard or stewed fruit.
+
+Total milk in 24 hours, 1½ quarts.
+
+
+DEPARTMENT OF HEALTH
+
+CITY OF NEW YORK
+
+DIET FOR CHILD FROM TWO TO THREE YEARS
+
+BREAKFAST.
+
+(1) Juice of 1 sweet orange
+
+or
+
+Pulp of 6 stewed prunes
+
+or
+
+1 ounce pineapple juice (fresh or bottled)
+
+or
+
+Apple sauce.
+
+(2) A cereal such as oatmeal, farina, cream of wheat, hominy or rice,
+slightly sweetened or salted as preferred, with the addition of top milk
+(top 16 ounces)
+
+or
+
+A soft boiled or poached egg with stale bread or toast.
+
+(3) A glass of milk.
+
+Note: If constipated give the fruit ½ hour before breakfast with water;
+if not, they may be given during the forenoon.
+
+Milk and raw fruit juice must not be given at same meal.
+
+DINNER.
+
+(1) Broth or soup made of chicken, mutton or beef, thickened with
+arrowroot, split peas, rice, or with addition of the yolk of an egg or
+toast squares.
+
+(2) Scraped beef or white meat of chicken, or broiled fish (small
+amount)
+
+or
+
+Mashed or baked potatoes with fresh peas or spinach or carrots.
+
+(3) Dessert: apple sauce, baked apple, rice pudding, junket or custard.
+
+SUPPER.
+
+(1) A cereal or egg (if egg is not taken with breakfast) with stale
+bread or toast
+
+or
+
+Bread and milk or bread and cocoa or bread and custard.
+
+(2) Stewed fruit.
+
+
+DEPARTMENT OF HEALTH
+
+CITY OF NEW YORK
+
+DIET FOR CHILD FROM THREE TO SIX YEARS
+
+BREAKFAST.
+
+(1) Fruits: an orange, apple, pear or stewed prunes.
+
+(2) Cereal: oatmeal, hominy, rice or wheat preparations, well cooked and
+salted, with thin cream and sugar
+
+or
+
+Egg: soft boiled, poached, omelet or scrambled.
+
+(3) Milk or cocoa.
+
+DINNER.
+
+(1) Soup: beef, chicken or mutton.
+
+(2) Meat: chicken or beefsteak or roast beef or lamb chops or fish.
+
+(3) Vegetables: spinach or carrots or string beans, peas, cauliflower
+tops, mashed or baked potatoes, beets or lettuce (without vinegar)
+
+Macaroni, spaghetti.
+
+Bread and butter--not fresh bread or rolls.
+
+(4) Dessert: custard, rice or bread or tapioca pudding, ice cream (once
+a week) cornstarch pudding (chocolate or other flavor) stewed prunes or
+baked apple.
+
+SUPPER.
+
+(1) Milk toast or graham crackers and milk
+
+or
+
+A thick soup, as pea, or cream of celery with bread and butter
+
+or
+
+A cereal and thin cream with bread and butter.
+
+(2) Stewed fruit; custard or plain pudding; jam or jelly.
+
+
+
+
+GLOSSARY
+
+(For complete definitions of the following words the student is referred
+to general and scientific dictionaries)
+
+
+A
+
+ANTISEPTIC.--A substance which prevents or hinders the growth of
+micro-organisms.
+
+ANTITOXIN.--A substance that neutralizes the action of a toxin.
+
+ASEPTIC.--Free from living germs.
+
+AXILLA.--The armpit.
+
+
+B
+
+BACILLUS (pl. bacilli).--A rod-shaped or elongated bacterium.
+
+BACTERIAL.--Relating to bacteria.
+
+BACTERICIDE.--An agent having the power to destroy bacteria.
+
+BACTERIOLOGICAL.--Relating to bacteriology.
+
+BACTERIOLOGY.--The science dealing with microorganisms.
+
+BACTERIUM (pl. bacteria).--A unicellular vegetable micro-organism.
+
+
+C
+
+CARRIER.--An apparently healthy person who harbors pathogenic germs in
+his body.
+
+COCCUS (pl. cocci).--A bacterium of spherical or nearly spherical shape.
+
+COUNTER-IRRITANT.--A substance or agent which if applied to the skin
+causes irritation and thereby relieves an abnormal condition in another
+part of the body.
+
+
+D
+
+DEGENERATION.--A deterioration in cells or tissues of the body so that
+they become less able to perform their proper functions.
+
+DEGENERATIVE.--Pertaining to degeneration.
+
+DEODORANT.--An agent that destroys odors.
+
+DIGESTIVE TRACT.--The entire alimentary canal, including the mouth,
+œsophagus, stomach, and the small and large intestines.
+
+DIPLOCOCCUS.--A form of coccus in which two individuals remain attached
+after cell division has taken place.
+
+DISINFECT.--To destroy the germs of disease.
+
+DISINFECTANT.--An agent that destroys the germs of disease.
+
+DISINFECTION.--The process of destroying the germs of disease.
+
+
+E
+
+EMETIC.--A substance used to induce vomiting.
+
+ENEMA.--An injection of fluid into the rectum.
+
+
+F
+
+FECAL.--Pertaining to feces.
+
+FECES.--Matter discharged from the bowels; bowel movement.
+
+FERMENTATION.--Decomposition produced in an organic substance by the
+action of certain living agents.
+
+FISSION.--The process by which a cell divides into two parts.
+
+FLAGELLUM (pl. flagella).--A long hair-like appendage, by the action of
+which certain micro-organisms are enabled to move.
+
+FLEX.--To bend at a joint.
+
+FOMENTATION.--See _Stupe_.
+
+
+G
+
+GASTRIC JUICE.--The fluid secreted by the glands of the stomach.
+
+GERM.--A minute unicellular organism, either animal or vegetable; a
+micro-organism; a microbe.
+
+GERMICIDE.--An agent having the power to kill germs.
+
+
+H
+
+HOST.--An animal or plant in or upon which another organism lives.
+
+
+I
+
+IMMUNE.--Not susceptible to a particular disease; also, a person who is
+not susceptible to a particular disease.
+
+IMMUNITY.--The state in which an individual is not susceptible to a
+particular disease.
+
+IMMUNIZE.--To render immune.
+
+INCUBATION.--The interval between exposure to an infectious disease and
+the first appearance of symptoms.
+
+INFECT.--To communicate disease germs.
+
+INFECTION.--An agent by which disease may be communicated from one
+individual to another; also, an infectious disease.
+
+INOCULATE.--To introduce any biological product directly into the
+tissues of the body.
+
+INOCULATION.--The process of inoculating.
+
+INTESTINAL TRACT.--The small and large intestines.
+
+
+M
+
+MICROBE.--See _Germ_.
+
+MICRO-ORGANISM.--See _Germ_.
+
+MUCUS.--The substance secreted by mucous membranes.
+
+MUCOUS MEMBRANES.--The membranes lining certain cavities of the body,
+especially the digestive and respiratory tracts.
+
+
+N
+
+NUTRIENT.--One of several chemical groups to which the essential
+constituents of food belong.
+
+
+O
+
+ORGANIC.--Derived from or relating to an organism.
+
+ORGANISM.--An individual that is or has been alive.
+
+
+P
+
+PARASITE.--An individual that lives in or upon another individual.
+
+PASTEURIZATION.--The process of pasteurizing.
+
+PASTEURIZE.--To subject milk to a temperature of 142°-145° Fahrenheit
+for thirty minutes.
+
+PATHOGENIC.--Disease-producing.
+
+PERTUSSIS.--Whooping-cough.
+
+PROTEID.--One of the complex nitrogenous substances constituting the
+essential parts of animal and vegetable tissues.
+
+PROTOZOÖN (pl. protozoa).--An animal organism composed of a single cell.
+
+PUS.--The fluid product of inflammation; matter.
+
+PUTREFACTION.--Decomposition of nitrogenous organic matter brought about
+by micro-organisms and accompanied by a foul odor.
+
+
+R
+
+RESISTANCE.--See _Immunity_.
+
+RESPIRATORY TRACT.--The air passages, including the nose, mouth, larynx,
+trachea, bronchial tubes, and lungs.
+
+
+S
+
+SAPROPHYTE.--A vegetable organism that lives on decaying organic matter.
+
+SARCINA.--Literally, a bundle. Applied to bacteria grouped in bundles or
+packets.
+
+SEPTIC.--Putrefying or decomposing; infected by pus-producing bacteria.
+
+SEQUELA.--A disease or unhealthy condition following another disease or
+unhealthy condition.
+
+SERUM.--The fluid which separates from the clot after blood has
+coagulated; especially, that containing an antitoxin.
+
+SEWAGE.--Any substance containing urine or fecal matter; also, the
+substance which passes through sewers.
+
+SPIRILLUM (pl. spirilla).--A variety of bacteria having spirally twisted
+cells.
+
+SPORE.--A resting stage, characterized by great resistance, into which
+certain germs enter when conditions become unfavorable for their growth.
+
+SPUTUM.--Spit; expectoration.
+
+STAPHYLOCOCCUS.--A variety of bacteria that group themselves in masses
+resembling bunches of grapes.
+
+STERILE.--Free from living germs; aseptic.
+
+STERILIZATION.--The process of rendering sterile.
+
+STERILIZE.--To render sterile.
+
+STREPTOCOCCUS.--A variety of bacteria that arrange themselves in chains.
+
+STUPE.--A cloth wrung out of hot water and applied to the surface of the
+body.
+
+SUSCEPTIBLE.--Lacking resistance to a disease.
+
+SUSCEPTIBILITY.--The condition in which resistance to a disease is low.
+
+
+T
+
+TETRAD.--A variety of bacteria that arrange themselves in groups of
+four.
+
+TISSUE.--A collection of cells having the same function.
+
+TOXIN.--A poison produced by the action of micro-organisms.
+
+
+U
+
+UNICELLULAR.--Composed of a single cell.
+
+UTERUS.--The womb.
+
+
+V
+
+VACCINATE.--To inoculate with a poison in order to bring about immunity
+to a disease.
+
+VACCINE.--Any substance which if introduced into the body causes the
+formation of protective substances.
+
+VOMITUS.--Vomited substances.
+
+
+
+
+INDEX
+
+
+A
+
+  Abdomen, 68
+
+  Abdominal binder, 68
+
+  Action of drugs, 200
+
+  Adenoids, 284
+
+  Aged, care of, 303
+
+  Ailments and emergencies, 257
+
+  Air, 72
+
+  Alcohol, 160
+
+  Appliances,
+    bed cradles, 173
+    bedpans, 176
+    rubber utensils, 138
+
+  Applications, local, 220
+    cold, dry, 231
+    cold, moist, 235
+    hot, dry, 225
+      bricks, 226
+      flannel, 226
+      salt or sand, 226
+      water bags, 225
+    hot, moist, 227
+      fomentations, 229
+      poultices, 227
+      stupes, 229
+
+  Attendant, 127
+
+
+B
+
+  Bacteria, 1, 4, 5
+    bacilli, 5
+    coccus, 4
+    effects produced by, 3
+    entrance into the body, 9
+    food of, 2
+    immunity, 13
+    in food, 19
+    in water, 19
+    methods of study, 1
+    motion, 5
+    origin of communicable diseases, 3
+    parasites, 3, 8
+    saprophytes, 2
+    shape, 4
+    spirillum, 4
+    spores, 7
+    structure and development, 4
+    where found, 8
+
+  Bacteriology, 1
+
+  Baths, 42, 154
+    bed, 156
+    cleansing, 171
+    cold tub, 97, 171
+    daily, 24
+    foot, 165
+      mustard, 165
+    hot, 97
+    infant's, 78
+    sitz, 176
+    tub, 154
+
+  Bed cradles, 173
+
+  Bedmaking, 132
+
+  Bedpan, 176
+
+  Bed-rooms, care of, 84
+
+  Beds, 132
+    care of, 134
+    dimensions, 133
+    rubber pillow cases, 138
+    rubber sheets, 138
+    selection of, 132
+    wooden, 132
+
+  Bed sores, 169
+
+  Birth registration, 63
+
+  Blankets, 140
+
+  Bleeding, 272
+
+  Blindness, 33
+
+  Breast feeding, 73
+
+  Bruises, 276
+
+  Brush burn, 278
+
+  Burns, 277, 278
+
+
+C
+
+  Cancer, 111
+
+  Carriers, 17
+
+  Charts, 10, 246
+
+  Chickenpox, 236
+
+  Childhood, see Infancy, 60
+
+  Children, care of, 280
+    with adenoids, 284
+    with defective hearing, 285
+    with defective teeth, 286
+    with enlarged tonsils, 284
+    with eyestrain, 284
+    with incorrect posture, 286
+    with physical defects, 283
+    with predisposition to nervousness, 292
+
+  Chills, 270
+
+  Chronic patients, care of, 299
+
+  Circulars of information, 318
+    Department of Health, City of New York, 318
+      care of hair and scalp, 321
+      care of mouth and teeth, 318
+      care of nose, 320
+      diet of child twelfth to eighteenth month, 322
+      diet of child eighteenth to twenty-fourth month, 323
+      diet of child two to three years, 324
+      diet of child three to six years, 325
+
+  Cleaning room, 126
+
+  Cleanliness, personal, 41
+
+  Clothing, 47
+    disinfection of, 95
+    of infants, 68
+
+  Coccus, 4
+
+  Cold applications, 220
+
+  Cold, prevention of common, 241
+
+  Colic, 266
+
+  Compresses, cold, 232
+
+  Constipation, 52, 193, 266
+
+  Convalescents, care of, 294
+
+  Convulsions, 260
+
+  Counter irritants, 233
+
+  Croup, 271
+
+
+D
+
+  Degenerative diseases, 20, 24
+
+  Development of child, 64
+
+  Diaper, 69
+
+  Diarrhœa, 266
+
+  Diphtheria, 245
+
+  Disinfectants, 251
+
+  Disinfection, 248
+
+  Drainage, 40
+
+  Draughts, 32
+
+  Dust, effect upon health, 36
+
+
+E
+
+  Ear, disorders affecting, 268
+
+  Emergencies, 257
+
+  Enemata, 210
+    directions for giving, 210
+    for baby, 212
+
+  Environment, 29
+
+  Eruptive diseases, 236
+
+  Excreta, disinfection of, 249
+
+  Excretions, 52
+
+  Expectoration, 249
+
+  Eye, ailments, 267
+    compresses for, 232
+    foreign bodies in, 267
+
+  Eyestrain, 284
+
+
+F
+
+  Fainting, 259
+
+  Fatigue, 53, 106, 181
+
+  Feeding of infants, 73
+
+  Filtration of water, 50
+
+  Flies, as carriers of disease germs, 38
+
+  Floors, 120
+
+  Fomentations, 229
+
+  Food, 35, 48, 188
+    classification of, 48
+    for children, 78
+    for infants, 72
+
+  Foot bath, 165
+
+  Fumigation, 254
+
+  Furniture, 120
+
+
+G
+
+  Garbage, 37
+
+  Glossary, 326-330
+
+  Growth of child, 64
+
+
+H
+
+  Habits, 82
+
+  Hair, care of, 163
+
+  Handkerchiefs, 239
+
+  Hands, 11, 12, 43, 250
+
+  Headache, 257
+
+  Heat, application of, 220
+    exhaustion, 264
+
+  Heating, 54
+
+  Heredity, 27
+
+  Hiccough, 265
+
+  House, cleanliness of, 33
+
+  Humidity, 31
+
+  Hygiene, oral, 44
+    personal, 19, 28
+
+
+I
+
+  Immunity, 13
+
+  Infancy (and childhood), hygiene of, 60
+    air, fresh, 72
+    baths, 78
+    care of eyes, 80
+      of mouth, 81
+      of nostrils, 81
+      of genital organs, 81
+    clothing, 68
+    cry, significance of, 82
+    diet, 74
+    mother's milk, danger of substitutes, 72
+      water, 75
+      weaning, 75
+    excretions, 67
+    exercise, 83
+    growth and development, 64, 65
+      length at birth, 64
+        increase, 65
+      muscular development, 64
+      special senses, 66
+      speech, 66
+      teeth, 66
+      weight at birth, 64
+        increase, 65
+    habits, 82
+    mortality, 61
+    nursing bottles, 75
+      nipples, 75
+    play, 84
+    pulse, 96
+    respiration, 99
+    sleep, 70
+    toys, 85
+
+  Infection, 1, 43
+
+  Inflammation, 220
+
+  Inhalation, 213
+
+  Insects, 38, 270
+
+  Insect bites and stings, 270
+
+  Inunction, 214
+
+  Isolation, duration of, 247
+
+  Ivy poisoning, 270
+
+
+K
+
+  Kitchens, 34
+
+
+L
+
+  Light, 33, 124
+
+  Linen, 251
+
+  Lysol, 251
+
+
+M
+
+  Malaise, 106
+
+  Mattress, 135
+    care of, 136
+
+  Measles, 246
+
+  Medicines and remedies, 200
+    action of drugs, 200
+    amateur dosing, 202
+    enemata, 210
+    inhalation, 213
+    inunction, 214
+    patent remedies, 205
+    sprays and gargles, 213
+    suppositories, 209
+
+  Medicines, administration of, 206
+
+  Menstruation, profuse, 275
+
+  Mental condition, 104-112
+
+  Microorganisms, 9
+
+  Milk, 51
+    pasteurization, 51
+
+  Mouth, care of, 160
+    wash, 182
+
+  Mustard paste, 233
+    leaves, 233
+
+
+N
+
+  Nausea, 265
+
+  Nipple, bottle, 77
+    care of, 77
+
+  Non-communicable diseases, 20
+
+  Nosebleed, 274
+
+
+P
+
+  Pain, 105
+
+  Parasites, 3, 4, 8
+
+  Patent remedies, 205
+
+  Patient, care of,
+      with communicable disease, 236
+      with colds and slight infections, 238
+      with more serious infections, 242
+    changing sheet, 147
+    changing, 146
+    lifting, 146
+    mouth, 160
+    moving, 152
+
+  Personal hygiene, 19
+
+  Pillows, 137
+    covers, 138, 140
+
+  Poisonous drugs, 215
+
+  Posture, 286
+
+  Poultices, 227, 228
+
+  Prenatal care, 62
+
+  Prickly heat, 269
+
+  Protozoa, 8
+
+  Public agencies, 107
+
+  Public sanitation, 19
+
+  Pulse, 96
+
+  Purification of water, 50
+
+
+Q
+
+  Quarantine, termination of, 252
+
+
+R
+
+  Records, 107
+
+  Recreation, 55
+
+  Rectum, 93
+
+  Respiration, 99
+
+  Rest, 53
+
+  Rooms, 27
+
+
+S
+
+  Saprophytes, 2
+
+  Scalds, 277
+
+  Scarlet fever, 246
+
+  Sewage, 39
+
+  Sheets, 137, 138, 142
+
+  Shock, 261
+
+  Sick-room, model, 118
+
+  Sleep, 55, 70
+
+  Sleeplessness, 258
+
+  Small-pox, 246
+
+  Special senses in sickness, 101
+
+  Spores, 7
+
+  Sprains, 275
+
+  Sprays and gargles, 213
+
+  Stimulants, in emergency work, 263
+
+  Stupes, 229
+
+  Styes, 267
+
+  Sunstroke, 264
+
+  Suppositories, 209
+
+  Symptoms, 88
+
+
+T
+
+  Teeth, 45, 160
+    defective, 286
+    treatment, 46
+
+  Temperature, 92
+    method of taking, 92
+    normal, 95
+
+  Temperature of baths, 79, 155
+    of house, 30, 124
+    sponging for, 177
+    variations, 114, 206
+
+  Thermometer, clinical, care of, 92
+
+  Tonsils, enlarged, 284
+
+  Tuberculosis, 27-107
+
+
+U
+
+  Urine, 103
+
+
+V
+
+  Vaccination, 13, 25
+
+  Ventilation, 29, 123
+
+  Vomiting, 265
+
+
+W
+
+  Water, 49
+    filtration, 50
+
+  Weaning, 75
+
+  Weight, 65
+    loss of, 64
+
+  Whooping cough, 246
+
+  Wounds, 272
+
+
+
+
+[Transcriber's Note:
+
+
+Punctuation errors (e.g. missing period at end of sentence, missing
+quotation marks, etc.) and letters printed upside down have been
+corrected without note. Except where noted, inconsistencies in
+hyphenation, capitalization, and spelling (e.g. travelling and
+traveling) have not been changed. The original index had numerous
+errors, such as references to terms that do not appear in the text.
+Except where noted below, it has been left as printed.
+
+The following corrections were made:
+
+p. viii: Records, 105. to Records, 107. (under Chapter IV)
+
+p. ix: Care of the Patients with Communicable Diseases to Care of
+Patients with Communicable Diseases (under Chapter XII)
+
+p. ix: Care of liver, 251. to Care of linen, 251. (under Chapter XII)
+
+p. 15: innoculation to inoculation (Vaccination and inoculation have
+saved thousands of lives.)
+
+p. 16: principle to principal (principal causes which diminish
+resistance), to match cited text
+
+p. 37: gerns to germs (through which disease germs)
+
+p. 40: From "_The Human Mechanism_." to _From "The Human Mechanism."_
+(to match format of other captions)
+
+p. 41: perferably to preferably (preferably, chloride of lime.)
+
+p. 77: runnnig to running (thoroughly cleansed under running water)
+
+p. 82: symptons to symptoms (other symptoms of distress)
+
+p. 96: thay to they (taken together they are)
+
+p. 108: 8:30 to 8:30 a.m.
+
+p. 111: develope to develop (may develop into cancer)
+
+p. 115: missing degree symbol added (At noon his temperature was 101°)
+
+p. 132: illnes to illness (unless his illness is slight)
+
+p. 136: servicable to serviceable (makes a serviceable cover)
+
+p. 150: paitent to patient (ready for the patient.)
+
+p. 150-151: removed duplication of text in captions for Fig. 14 and Fig.
+15 (CHANGING THE DRAW SHEET, and CHANGING A PATIENT FROM ONE BED TO
+ANOTHER)
+
+p. 161: erroneous italics removed from "patient" and "her" (even a
+patient unable to sit up can brush her teeth)
+
+p. 167: added missing "bath" (to give a cool sponge bath)
+
+p. 175: ahould to should (the protection of the abdomen should)
+
+p. 177: expecially to especially (if it is especially difficult or
+undesirable)
+
+p. 177: patients' to patient's (between the patient's back and the pan;)
+
+p. 178: deoderant to deodorant (a properly kept pan needs no deodorant)
+
+p. 183: invarably to invariably (casual visitors almost invariably
+offend)
+
+p. 189: nurtients to nutrients (pancreatic juice acts upon all three
+nutrients)
+
+p. 195: solied to soiled (is always superior to soiled linen.)
+
+p. 205: appy to apply (apply even more strongly to using patent
+medicines.)
+
+p. 211: 166 to 176 (the directions on page 176.)
+
+p. 216: selzer to seltzer (seltzer aperient)
+
+p. 226: slighest to slightest (there is the slightest possibility of
+scalding)
+
+p. 227: accidently to accidentally (see that the switch is not
+accidentally)
+
+p. 228: cohers to coheres (when the mixture coheres)
+
+p. 229: annoint to anoint (anoint it with vaseline)
+
+p. 233: dicharge to discharge (If there is discharge from the eye,)
+
+p. 242: chould to should (visitors should be rigidly)
+
+p. 245: himelf to himself (safeguard the patient himself.)
+
+Table between pp. 246-247: diappearance to disappearance (Two weeks
+after onset and one week after disappearance)
+
+Table between pp. 246-247: pa-patient to patient (after child last saw
+patient.)
+
+p. 250: If to It (It may be necessary to provide two bedpans)
+
+p. 266: 216 to 193 (discussed on pages 193 and 52.)
+
+p. 280: etter to better (no better place)
+
+p. 300: attenom, to attention (constant attention must be given)
+
+p. 300: rotion to room, (hygiene of the sick room,)
+
+p. 301: salutory to salutary (making the salutary small adjustments)
+
+p. 308: querelous to querulous (sometimes become querulous)
+
+p. 329: Putrifying to Putrefying (Putrefying or decomposing)
+
+p. 331: bed-cradles to bed cradles (Index sub-entry, under "Appliances")
+
+p. 331: Bed-cradles to Bed cradles (Index entry)
+
+p. 331: Bed-sores to Bed sores (Index entry)
+
+p. 331: Brushburn to Brush burn (Index entry)
+
+p. 332: Foot-bath to Foot bath (Index entry)
+
+p. 333: Microörganisms to Microorganisms (Index entry)
+
+p. 333: Pre-natal to Prenatal (Index entry)
+
+p. 334: oss to loss (Index entry for "Weight, loss of")
+
+A fold-out table was facing p. 247 in the original book. For the plain
+text versions, it has been split into several smaller tables, with the
+"DISEASE" column repeated in each section. In the third section,
+"POLIOMYELITIS" has been hyphenated (POLIO-MYELITIS) to save space.
+
+The footnote pertaining to the table is immediately after it, not at the
+end of the chapter as usual.]
+
+
+
+
+*** END OF THE PROJECT GUTENBERG EBOOK AMERICAN RED CROSS TEXT-BOOK ***
+
+***** This file should be named 32250-0.txt or 32250-0.zip *****
+This and all associated files of various formats will be found in:
+    https://www.gutenberg.org/3/2/2/5/32250/
+
+Updated editions will replace the previous one--the old editions will
+be renamed.
+
+Creating the works from print editions not protected by U.S. copyright
+law means that no one owns a United States copyright in these works,
+so the Foundation (and you!) can copy and distribute it in the
+United States without permission and without paying copyright
+royalties. Special rules, set forth in the General Terms of Use part
+of this license, apply to copying and distributing Project
+Gutenberg-tm electronic works to protect the PROJECT GUTENBERG-tm
+concept and trademark. Project Gutenberg is a registered trademark,
+and may not be used if you charge for an eBook, except by following
+the terms of the trademark license, including paying royalties for use
+of the Project Gutenberg trademark. If you do not charge anything for
+copies of this eBook, complying with the trademark license is very
+easy. You may use this eBook for nearly any purpose such as creation
+of derivative works, reports, performances and research. Project
+Gutenberg eBooks may be modified and printed and given away--you may
+do practically ANYTHING in the United States with eBooks not protected
+by U.S. copyright law. Redistribution is subject to the trademark
+license, especially commercial redistribution.
+
+START: FULL LICENSE
+
+THE FULL PROJECT GUTENBERG LICENSE
+PLEASE READ THIS BEFORE YOU DISTRIBUTE OR USE THIS WORK
+
+To protect the Project Gutenberg-tm mission of promoting the free
+distribution of electronic works, by using or distributing this work
+(or any other work associated in any way with the phrase "Project
+Gutenberg"), you agree to comply with all the terms of the Full
+Project Gutenberg-tm License available with this file or online at
+www.gutenberg.org/license.
+
+Section 1. General Terms of Use and Redistributing Project
+Gutenberg-tm electronic works
+
+1.A. By reading or using any part of this Project Gutenberg-tm
+electronic work, you indicate that you have read, understand, agree to
+and accept all the terms of this license and intellectual property
+(trademark/copyright) agreement. If you do not agree to abide by all
+the terms of this agreement, you must cease using and return or
+destroy all copies of Project Gutenberg-tm electronic works in your
+possession. If you paid a fee for obtaining a copy of or access to a
+Project Gutenberg-tm electronic work and you do not agree to be bound
+by the terms of this agreement, you may obtain a refund from the
+person or entity to whom you paid the fee as set forth in paragraph
+1.E.8.
+
+1.B. "Project Gutenberg" is a registered trademark. It may only be
+used on or associated in any way with an electronic work by people who
+agree to be bound by the terms of this agreement. There are a few
+things that you can do with most Project Gutenberg-tm electronic works
+even without complying with the full terms of this agreement. See
+paragraph 1.C below. There are a lot of things you can do with Project
+Gutenberg-tm electronic works if you follow the terms of this
+agreement and help preserve free future access to Project Gutenberg-tm
+electronic works. See paragraph 1.E below.
+
+1.C. The Project Gutenberg Literary Archive Foundation ("the
+Foundation" or PGLAF), owns a compilation copyright in the collection
+of Project Gutenberg-tm electronic works. Nearly all the individual
+works in the collection are in the public domain in the United
+States. If an individual work is unprotected by copyright law in the
+United States and you are located in the United States, we do not
+claim a right to prevent you from copying, distributing, performing,
+displaying or creating derivative works based on the work as long as
+all references to Project Gutenberg are removed. Of course, we hope
+that you will support the Project Gutenberg-tm mission of promoting
+free access to electronic works by freely sharing Project Gutenberg-tm
+works in compliance with the terms of this agreement for keeping the
+Project Gutenberg-tm name associated with the work. You can easily
+comply with the terms of this agreement by keeping this work in the
+same format with its attached full Project Gutenberg-tm License when
+you share it without charge with others.
+
+1.D. The copyright laws of the place where you are located also govern
+what you can do with this work. Copyright laws in most countries are
+in a constant state of change. If you are outside the United States,
+check the laws of your country in addition to the terms of this
+agreement before downloading, copying, displaying, performing,
+distributing or creating derivative works based on this work or any
+other Project Gutenberg-tm work. The Foundation makes no
+representations concerning the copyright status of any work in any
+country other than the United States.
+
+1.E. Unless you have removed all references to Project Gutenberg:
+
+1.E.1. The following sentence, with active links to, or other
+immediate access to, the full Project Gutenberg-tm License must appear
+prominently whenever any copy of a Project Gutenberg-tm work (any work
+on which the phrase "Project Gutenberg" appears, or with which the
+phrase "Project Gutenberg" is associated) is accessed, displayed,
+performed, viewed, copied or distributed:
+
+  This eBook is for the use of anyone anywhere in the United States and
+  most other parts of the world at no cost and with almost no
+  restrictions whatsoever. You may copy it, give it away or re-use it
+  under the terms of the Project Gutenberg License included with this
+  eBook or online at www.gutenberg.org. If you are not located in the
+  United States, you will have to check the laws of the country where
+  you are located before using this eBook.
+
+1.E.2. If an individual Project Gutenberg-tm electronic work is
+derived from texts not protected by U.S. copyright law (does not
+contain a notice indicating that it is posted with permission of the
+copyright holder), the work can be copied and distributed to anyone in
+the United States without paying any fees or charges. If you are
+redistributing or providing access to a work with the phrase "Project
+Gutenberg" associated with or appearing on the work, you must comply
+either with the requirements of paragraphs 1.E.1 through 1.E.7 or
+obtain permission for the use of the work and the Project Gutenberg-tm
+trademark as set forth in paragraphs 1.E.8 or 1.E.9.
+
+1.E.3. If an individual Project Gutenberg-tm electronic work is posted
+with the permission of the copyright holder, your use and distribution
+must comply with both paragraphs 1.E.1 through 1.E.7 and any
+additional terms imposed by the copyright holder. Additional terms
+will be linked to the Project Gutenberg-tm License for all works
+posted with the permission of the copyright holder found at the
+beginning of this work.
+
+1.E.4. Do not unlink or detach or remove the full Project Gutenberg-tm
+License terms from this work, or any files containing a part of this
+work or any other work associated with Project Gutenberg-tm.
+
+1.E.5. Do not copy, display, perform, distribute or redistribute this
+electronic work, or any part of this electronic work, without
+prominently displaying the sentence set forth in paragraph 1.E.1 with
+active links or immediate access to the full terms of the Project
+Gutenberg-tm License.
+
+1.E.6. You may convert to and distribute this work in any binary,
+compressed, marked up, nonproprietary or proprietary form, including
+any word processing or hypertext form. However, if you provide access
+to or distribute copies of a Project Gutenberg-tm work in a format
+other than "Plain Vanilla ASCII" or other format used in the official
+version posted on the official Project Gutenberg-tm website
+(www.gutenberg.org), you must, at no additional cost, fee or expense
+to the user, provide a copy, a means of exporting a copy, or a means
+of obtaining a copy upon request, of the work in its original "Plain
+Vanilla ASCII" or other form. Any alternate format must include the
+full Project Gutenberg-tm License as specified in paragraph 1.E.1.
+
+1.E.7. Do not charge a fee for access to, viewing, displaying,
+performing, copying or distributing any Project Gutenberg-tm works
+unless you comply with paragraph 1.E.8 or 1.E.9.
+
+1.E.8. You may charge a reasonable fee for copies of or providing
+access to or distributing Project Gutenberg-tm electronic works
+provided that:
+
+* You pay a royalty fee of 20% of the gross profits you derive from
+  the use of Project Gutenberg-tm works calculated using the method
+  you already use to calculate your applicable taxes. The fee is owed
+  to the owner of the Project Gutenberg-tm trademark, but he has
+  agreed to donate royalties under this paragraph to the Project
+  Gutenberg Literary Archive Foundation. Royalty payments must be paid
+  within 60 days following each date on which you prepare (or are
+  legally required to prepare) your periodic tax returns. Royalty
+  payments should be clearly marked as such and sent to the Project
+  Gutenberg Literary Archive Foundation at the address specified in
+  Section 4, "Information about donations to the Project Gutenberg
+  Literary Archive Foundation."
+
+* You provide a full refund of any money paid by a user who notifies
+  you in writing (or by e-mail) within 30 days of receipt that s/he
+  does not agree to the terms of the full Project Gutenberg-tm
+  License. You must require such a user to return or destroy all
+  copies of the works possessed in a physical medium and discontinue
+  all use of and all access to other copies of Project Gutenberg-tm
+  works.
+
+* You provide, in accordance with paragraph 1.F.3, a full refund of
+  any money paid for a work or a replacement copy, if a defect in the
+  electronic work is discovered and reported to you within 90 days of
+  receipt of the work.
+
+* You comply with all other terms of this agreement for free
+  distribution of Project Gutenberg-tm works.
+
+1.E.9. If you wish to charge a fee or distribute a Project
+Gutenberg-tm electronic work or group of works on different terms than
+are set forth in this agreement, you must obtain permission in writing
+from the Project Gutenberg Literary Archive Foundation, the manager of
+the Project Gutenberg-tm trademark. Contact the Foundation as set
+forth in Section 3 below.
+
+1.F.
+
+1.F.1. Project Gutenberg volunteers and employees expend considerable
+effort to identify, do copyright research on, transcribe and proofread
+works not protected by U.S. copyright law in creating the Project
+Gutenberg-tm collection. Despite these efforts, Project Gutenberg-tm
+electronic works, and the medium on which they may be stored, may
+contain "Defects," such as, but not limited to, incomplete, inaccurate
+or corrupt data, transcription errors, a copyright or other
+intellectual property infringement, a defective or damaged disk or
+other medium, a computer virus, or computer codes that damage or
+cannot be read by your equipment.
+
+1.F.2. LIMITED WARRANTY, DISCLAIMER OF DAMAGES - Except for the "Right
+of Replacement or Refund" described in paragraph 1.F.3, the Project
+Gutenberg Literary Archive Foundation, the owner of the Project
+Gutenberg-tm trademark, and any other party distributing a Project
+Gutenberg-tm electronic work under this agreement, disclaim all
+liability to you for damages, costs and expenses, including legal
+fees. YOU AGREE THAT YOU HAVE NO REMEDIES FOR NEGLIGENCE, STRICT
+LIABILITY, BREACH OF WARRANTY OR BREACH OF CONTRACT EXCEPT THOSE
+PROVIDED IN PARAGRAPH 1.F.3. YOU AGREE THAT THE FOUNDATION, THE
+TRADEMARK OWNER, AND ANY DISTRIBUTOR UNDER THIS AGREEMENT WILL NOT BE
+LIABLE TO YOU FOR ACTUAL, DIRECT, INDIRECT, CONSEQUENTIAL, PUNITIVE OR
+INCIDENTAL DAMAGES EVEN IF YOU GIVE NOTICE OF THE POSSIBILITY OF SUCH
+DAMAGE.
+
+1.F.3. LIMITED RIGHT OF REPLACEMENT OR REFUND - If you discover a
+defect in this electronic work within 90 days of receiving it, you can
+receive a refund of the money (if any) you paid for it by sending a
+written explanation to the person you received the work from. If you
+received the work on a physical medium, you must return the medium
+with your written explanation. The person or entity that provided you
+with the defective work may elect to provide a replacement copy in
+lieu of a refund. If you received the work electronically, the person
+or entity providing it to you may choose to give you a second
+opportunity to receive the work electronically in lieu of a refund. If
+the second copy is also defective, you may demand a refund in writing
+without further opportunities to fix the problem.
+
+1.F.4. Except for the limited right of replacement or refund set forth
+in paragraph 1.F.3, this work is provided to you 'AS-IS', WITH NO
+OTHER WARRANTIES OF ANY KIND, EXPRESS OR IMPLIED, INCLUDING BUT NOT
+LIMITED TO WARRANTIES OF MERCHANTABILITY OR FITNESS FOR ANY PURPOSE.
+
+1.F.5. Some states do not allow disclaimers of certain implied
+warranties or the exclusion or limitation of certain types of
+damages. If any disclaimer or limitation set forth in this agreement
+violates the law of the state applicable to this agreement, the
+agreement shall be interpreted to make the maximum disclaimer or
+limitation permitted by the applicable state law. The invalidity or
+unenforceability of any provision of this agreement shall not void the
+remaining provisions.
+
+1.F.6. INDEMNITY - You agree to indemnify and hold the Foundation, the
+trademark owner, any agent or employee of the Foundation, anyone
+providing copies of Project Gutenberg-tm electronic works in
+accordance with this agreement, and any volunteers associated with the
+production, promotion and distribution of Project Gutenberg-tm
+electronic works, harmless from all liability, costs and expenses,
+including legal fees, that arise directly or indirectly from any of
+the following which you do or cause to occur: (a) distribution of this
+or any Project Gutenberg-tm work, (b) alteration, modification, or
+additions or deletions to any Project Gutenberg-tm work, and (c) any
+Defect you cause.
+
+Section 2. Information about the Mission of Project Gutenberg-tm
+
+Project Gutenberg-tm is synonymous with the free distribution of
+electronic works in formats readable by the widest variety of
+computers including obsolete, old, middle-aged and new computers. It
+exists because of the efforts of hundreds of volunteers and donations
+from people in all walks of life.
+
+Volunteers and financial support to provide volunteers with the
+assistance they need are critical to reaching Project Gutenberg-tm's
+goals and ensuring that the Project Gutenberg-tm collection will
+remain freely available for generations to come. In 2001, the Project
+Gutenberg Literary Archive Foundation was created to provide a secure
+and permanent future for Project Gutenberg-tm and future
+generations. To learn more about the Project Gutenberg Literary
+Archive Foundation and how your efforts and donations can help, see
+Sections 3 and 4 and the Foundation information page at
+www.gutenberg.org
+
+Section 3. Information about the Project Gutenberg Literary
+Archive Foundation
+
+The Project Gutenberg Literary Archive Foundation is a non-profit
+501(c)(3) educational corporation organized under the laws of the
+state of Mississippi and granted tax exempt status by the Internal
+Revenue Service. The Foundation's EIN or federal tax identification
+number is 64-6221541. Contributions to the Project Gutenberg Literary
+Archive Foundation are tax deductible to the full extent permitted by
+U.S. federal laws and your state's laws.
+
+The Foundation's business office is located at 809 North 1500 West,
+Salt Lake City, UT 84116, (801) 596-1887. Email contact links and up
+to date contact information can be found at the Foundation's website
+and official page at www.gutenberg.org/contact
+
+Section 4. Information about Donations to the Project Gutenberg
+Literary Archive Foundation
+
+Project Gutenberg-tm depends upon and cannot survive without
+widespread public support and donations to carry out its mission of
+increasing the number of public domain and licensed works that can be
+freely distributed in machine-readable form accessible by the widest
+array of equipment including outdated equipment. Many small donations
+($1 to $5,000) are particularly important to maintaining tax exempt
+status with the IRS.
+
+The Foundation is committed to complying with the laws regulating
+charities and charitable donations in all 50 states of the United
+States. Compliance requirements are not uniform and it takes a
+considerable effort, much paperwork and many fees to meet and keep up
+with these requirements. We do not solicit donations in locations
+where we have not received written confirmation of compliance. To SEND
+DONATIONS or determine the status of compliance for any particular
+state visit www.gutenberg.org/donate
+
+While we cannot and do not solicit contributions from states where we
+have not met the solicitation requirements, we know of no prohibition
+against accepting unsolicited donations from donors in such states who
+approach us with offers to donate.
+
+International donations are gratefully accepted, but we cannot make
+any statements concerning tax treatment of donations received from
+outside the United States. U.S. laws alone swamp our small staff.
+
+Please check the Project Gutenberg web pages for current donation
+methods and addresses. Donations are accepted in a number of other
+ways including checks, online payments and credit card donations. To
+donate, please visit: www.gutenberg.org/donate
+
+Section 5. General Information About Project Gutenberg-tm electronic works
+
+Professor Michael S. Hart was the originator of the Project
+Gutenberg-tm concept of a library of electronic works that could be
+freely shared with anyone. For forty years, he produced and
+distributed Project Gutenberg-tm eBooks with only a loose network of
+volunteer support.
+
+Project Gutenberg-tm eBooks are often created from several printed
+editions, all of which are confirmed as not protected by copyright in
+the U.S. unless a copyright notice is included. Thus, we do not
+necessarily keep eBooks in compliance with any particular paper
+edition.
+
+Most people start at our website which has the main PG search
+facility: www.gutenberg.org
+
+This website includes information about Project Gutenberg-tm,
+including how to make donations to the Project Gutenberg Literary
+Archive Foundation, how to help produce our new eBooks, and how to
+subscribe to our email newsletter to hear about new eBooks.
+
+