American Red Cross Text-Book on Home Hygiene and Care of the Sick

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, | | | | | | | | toa