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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. 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