The causes of disease are spoken of by authors as predisposing, and exciting. By proximate cause of disease is meant the cause of the symptoms present; this cannot appropriately be dwelt upon here.
By exciting cause is meant the immediate cause of a disease, and the distinction from predisposing cause arises from the fact that when two persons are exposed to something injurious to the health, they may not be equally affected.
It has been said that if twenty persons undergo hardship and exposure from shipwreck, the effect of the wet and cold may be in one to cause catarrh, in another rheumatism, in a third pleurisy, in a fourth opthalmia, in another inflammation of the bowels, and fifteen may escape without any illness at all. A predisposing cause is defined to be anything whatever, which has had such an influence on the body as to have rendered it unusually susceptible to the exciting cause of the particular disease. In most cases the distinction is obvious, but it is sometimes difficult to say of a given cause whether it ought to be ranked among the predisposing or the exciting causes.
Disease is often warded off notwithstanding the presence of the exciting cause, when we ascertain and prevent the predisposing cause of it, and it may sometimes be averted in despite of strong predisposition, if we know and can guard against the agencies by which it is capable of being excited.
When we enumerate causes of disease we see among them many that under ordinary circumstances minister to life, health, and enjoyment; and I can hardly refer at all to the varying circumstances under which they become the medium of pain, disease and death. These circumstances are so various, so many of them are apt to be put in operation at the same time, and so little power have we of excluding them one after the other, so as to ascertain the exact efficiency of each, that our observation respecting their actual effects are open to much fallacy.
We cannot for instance in a given case estimate accurately the effect of impurities in the atmosphere such as organic and inorganic dust, nor the effect of differences in degree of its natural qualities such as extremes of heat and cold, sudden variations of temperature, excessive moisture or dryness, different electric conditions, differences of pressure, a deficiency of light, and the amount of ozone, &c.
The range of temperature compatible with human life is very great; men live in the hottest and the coldest climates, where the earth produces any sustenance for them. It requires more care to preserve life under intense cold than under intense heat. Tropical climates are thickly peopled where the thermometer ranges from 80° to 100° for a long time together. In arctic countries on the other hand where the thermometer sinks to 40° or 50° below zero, we still find inhabitants, but they are few and thinly scattered. It is probable that at a degree of temperature a little greater than that of the equator or a little less than that of the poles men would perish.
Man is capable of existing under certain circumstances for a short time, and enduring a much higher degree of heat than the general atmosphere attains in the hottest portions of the earth, but there are generally some deleterious effects from hot climates or continued hot weather.
The effect of HEAT is to stimulate the organic functions of the body, but when considerable heat is applied for some time together its effect is to cause languor and lassitude, want of energy, a disinclination for exertion both bodily and mental; it has a depressing effect generally upon the animal functions or the nervous system, and there are some forms of disease that are distinctly traceable to heat as a cause.
We all know the effect of hot weather in causing perspiration, and when the operation of high temperature is continued for some time it has a marked influence upon the liver, increasing the quantity of bile that is secreted, and altering its sensible qualities; this is sometimes followed by inflammation of the liver.
In this country those attacks of vomiting and diarrhœa which are so common towards the latter end of summer or in autumn are the effects of a succession of hot days. In tropical climates the morbific effects of external heat are still more conspicuous, tending to violent disorders of the stomach and intestines, and also to acute inflammation of the liver and to acute abscesses in that organ.
In these cases the heated atmosphere unduly stimulating the secreting function of the liver creates the predisposition to the disease, while the exciting cause of the inflammation may be exposure to cold.
There may be deleterious effects from exposure to cold where the climate is quite hot. For instance a man may after the heat occasioned by the employments of the day, undress and lie opposite a window, his shirt wet with perspiration, to enjoy the sea breeze at night, and though the thermometer may be as high as 80° he may have a sensation of cold. If there is real chilliness it may be deleterious.
Heat sometimes acts as an exciting cause of disease—it produces sunstroke, or it may produce an eruptive disease such as prickly heat, &c.
The effect of extreme COLD (I use the term cold in the popular acceptation), when its application is continued, is that of a sedative upon the organic functions. Though at first causing pain in the extremities, if continued it causes sleep or overpowering drowsiness. Before this complete stupor comes on there may be a blunting of the sensations and confusing of the intellect, giving to the person exposed to it, the appearance of one intoxicated. When persons in this state are suffered to sleep, and the operation of the cold continues, they become less and less sensible to external impressions until death closes the scene.
But the effect of cold upon the body within certain limits of intensity and duration is that of a tonic. When its refrigerating and sedative properties can be sufficiently counteracted by exercise and warm clothing, cold is stimulating, refreshing, and invigorating to mind and body, it clears and sharpens the faculties, bestows alacrity and cheerfulness of spirits, and may become a curative agent.
Yet exposure to cold is one of the most common causes of various complaints. As a rule it is true that there is danger from sudden vicissitudes of temperature, although the proposition requires limitation. No peril need attend a change from a hot to a cold temperature if the power to evolve heat inherent in the system be entire and active and persistent, not lessened by any of those circumstances which have the effect of weakening it, such as local disease, and fatigue. Cold is dangerous, not especially when the body is hot, but when it is cooling after being heated. At such times taking a large draught of cold water, or cooling the body suddenly some other way might cause death immediately; if not, an inflammation of some internal part of the body might arise.
Every thing that has the effect of weakening the system and so diminishing the power of evolving heat, favors the morbific effect of cold, and is a predisposing cause of disease. The most common of these debilitating circumstances are fasting, evacuations, fatigue, a last night’s debauch, excess in venery, long watching, much study, and rest or inaction immediately after it, or after great exercise.
The faculty of evolving heat is weak in old persons and in the newly born, and these are often the victims of the power of cold.
The bad effects of cold depend very much upon the duration of the sensation. Even slight feelings of chilliness, if long protracted, are apt to terminate in some form of disease.
Cold is more likely to prove injurious when it is applied by a wind or currant of air, and the injurious operation of cold is augmented when it is accompanied with moisture—wetness is the worst way in which cold can be applied. The contact of wet or damp clothes with the skin, both increase and prolong the sensation of cold. A foggy atmosphere is more prejudicial than a clear one of the same temperature. While we are asleep, also, our power of resisting the effects of cold is diminished.
The power of habit enables a person to resist the effect of cold, and we may sometimes turn our knowledge of it to good account in gradually fortifying the system against the influence of cold that cannot be avoided. But we must not, while we fear to render our children effeminate by over care and much clothing, run into the opposite extreme and endanger their health by exposure. The process of hardening is doubly dangerous when it is attempted with children who were originally delicate, and should never be tried on any child or any person who is unsound, who shows any signs of present or approaching disease, or any marked predisposition to future, and especially to scrofulous disease.
An abiding sense of chilliness must never be permitted even when we are endeavoring to accustom a child to cold. If they can be kept in the cold air, and at the same time be kept feeling warm either by exercise, diversion of the mind, or by clothing, the result as regards the health is good.
The cold bath, and especially the shower bath, is a good means of fortifying the body against cold air. When we take a cold bath in the morning, if the sense of cold does not remain long, and is followed by a glow of warmth, the bath is sure to do good. If, however, after the bath we suffer headache, and continue to be chilly and languid or uncomfortable, it should at once be given up as useless and dangerous.
In this country, generally, catarrh and coughs and pectoral complaints of all kinds, are most apt to prevail in the winter and spring months, while bowel complaints are more numerous and distressing in the summer. The mucous membranes of the air passages sympathize with the skin under the agency of external cold; those of the stomach and intestines under that of heat.
The thoracic disorders which commence or grow worse in the winter are often fatal, and there are various other maladies that are aggravated by cold, so that the mortality of winter is greater than that of summer. Bowel complaints are more prevalent at the latter part of summer or early fall, when moderately cold days succeed a long period of hot weather, the high diurnal temperature being the predisposing cause, and the cold exciting or bringing on the disease.
I shall not refer to other causes of disease except to say that if two persons marry each other who have a hereditary predisposition to disease, their children, if they have any, will probably not be healthy.
Symptoms are the signs by which we know that disease is present. Every circumstance happening in the body of the sick person capable of being perceived by himself or others, which can be made to assist our judgment concerning the seat or nature of the disease, its probable course and termination or its proper treatment, is a sign or symptom.
These phenomena are the evidence upon which the whole art of the physician proceeds. It is important that the nurse should know how to note the symptoms, not only that she may know how and report to the doctor changes that occur in his absence, but that she may be able also to minister to those who are suddenly attacked with sickness, and to judge whether in cases of slight indisposition it is necessary to send for a physician.
By arranging and comparing symptoms, and by noting the circumstances under which they occur, the physician can distinguish the disease, and learn what are the indications of treatment—this belongs especially to him. But it is very important that a nurse should know how to note all changes as they occur, and sometimes it is best she should keep a written record of them. An important point in a trained or skillful nurse is that of her ability to observe accurately and describe intelligently what comes under notice in the absence of the physician. She should cultivate the habit of strict observation, and simple and truthful statement—neither deficient, exaggerated, or perverted, stating facts and not opinions.
Symptoms or phenomena which accompany disease may be subjective, those which are evident only to the patient, or objective which are observable by others. Both sorts of symptoms shed mutual light on each other, and as the statements of the patient are not always trustworthy, the nurse should be careful not to let anything pass unseen that can by vigilance be noted.
The following directions will help the nurse to cultivate the habit of observing symptoms:
Try to learn all you can of the previous history of the case; you will sometimes get information which the patient would not be likely to communicate to the doctor in person.
Note the patient’s apparent age with any indications of disguised age, signs of weakness—whether corpulent or bloated; note any deformities, swellings or wounds, and notice the attitudes and expression of the countenance.
A sufferer instinctively takes THE POSITION most conducive to ease. When one lung is affected the patient lies on that side, that the healthy one may have the greater freedom of motion. When there is peritonitis (inflammation of the bowels), he lies on his back with his knees drawn up to relax the abdominal muscles. If there is colic alone he may lie on the abdomen, as pressure may relieve his pain. When a patient has been persistently on his back, if he turns onto his side it is a sign of improvement.
Inability to breathe termed ORTHOPNŒA, occurs in affections of the heart, and also in asthma. Lying quietly in bed is usually a favorable sign. Restlessness and slipping to the foot of the bed, in low stages of fever, are bad signs.
Of the uneasy, morbid symptoms, pain is the most important, and most common. Pain occurs in nearly all inflammations, and it may occur where there is no inflammation at all.
Bones, muscles, tendons, ligaments, the bladder, the kidneys, the uterus, all modify in a manner that is peculiar to themselves the pain that is produced by injury or disease. Such terms as the following are used to express a peculiar character of pain: It is said to be sharp, shooting, growing, burning, dull, heavy, tearing, and so on.
If pain is felt in any part when pressure is made upon it the heightened sensibility is called TENDERNESS, the part is said to be tender. A part may be both painful and tender, as it usually is if the pain continue for a time; it may be tender without being painful as it is usually, if pain continued for a time and then ceased.
Itching is an uneasy sensation allied to pain. It often affects the natural outlets of the body. It occurs about the rectum from the motions of little worms that nestle there, and other causes; and this itching of the rectum, and likewise of the pudendum, are distressing complaints, harassing the patient continually, preventing sleep and requiring medical treatment (F. 195). The tingling and pricking often felt in the windpipe, and provoking coughing, has some analogy to itching.
Nausea is sometimes a direct symptom of gastric disorder, at other times it is a very important indirect result of disease at some distance from the stomach. The nausea which is so troublesome to pregnant women, is an instance of a morbid sensation, sympathetic of irritation in a distant organ.
Dizziness or vertigo results sometimes from disease within the head, and sometimes it is the indirect result of disease of the stomach or of mere debility.
A sensation of sinking, sensations of weight and lightness, of drowsiness, tenesmus, strangury, heartburn, and various conditions of the special senses are mostly SUBJECTIVE SYMPTOMS.
One of the first symptoms of diabetis is a preternatural keenness of appetite, but in most diseases the appetite is lost or impaired or perverted.
Thirst is generally great in diabetis, and there is commonly considerable thirst in inflammatory complaints.
The above named symptoms are mostly subjective, but are accompanied by others that are objective, that show that the functions of certain parts are disturbed or suspended; and it is of especial importance to notice the PULSE, as this is a valuable guide in treating disease.
Each contraction of the heart sends out a wave which distends the blood vessels, and they by their contractility or elasticity carry it on through the entire arterial system. This periodical distention is the pulse.
The PULSE BEATS can be felt wherever an artery approaches the surface; it is usually taken and counted at the wrist; in children it can be best taken at the temporal artery during sleep.
To take the pulse accurately place two or three fingers on the artery making moderate pressure, and note particularly its frequency, its regularity, its forces and its fullness.
The RATE varies with varying circumstances. The average number of pulsations in a healthy adult is from 70 to 75, but there are some persons who, when they are quite well have a pulse of 80 or 90 to the minute, and there are others in whom it seldom rises above 60. It is usually more rapid in women than in men, is much more frequent in early life than in old age, and the average rate in a healthy child is 120.
In disease, the pulse may acquire a great degree of frequency. It may reach 150 or even 200, but in such cases it is generally feeble and can hardly be counted. Besides observing the frequency of the pulse, its character in other respects must be noted.
Irregularity of the pulse generally indicates disease, and there are two varieties of it. In most instances of irregular pulse, succeeding beats differ in length, force and character; in the other variety a pulsation is from time to time left out; the pulse is said to intermit.
In the DICROTIC PULSE a secondary wave or undulation can be felt. It is often met in typhoid fever, and an inexperienced person might be led to count double the number of beats.
Another important quality of the pulse is its hardness or compressibility. The hard pulse ordinarily, though not always, indicates inflammation. This hard pulse may be known by pressing pretty hard with one finger, while we observe with the others whether we arrest or abolish the pulse.
A pulse is said to be full or large if it is felt to strike a large portion of the finger; other departures from the normal standard are spoken of as soft, quick, or sharp, throbbing, bounding, thready, wiry, flickering, &c.
The normal standard of the temperature of a healthy person is 98.4°. There is some variation, and indeed a daily cycle of variations, so that in the morning it is 99 or at least 98½ and in the evening 97½, but the range is small, and if the variation is more than that, it is indicative of disease. There is only a deviation of about 15° within which life can be sustained; a temperature of more than 107° or less than 93° will almost certainly prove fatal.
Every mother who can, as well as every nurse, ought to own a clinical thermometer, as thereby she may detect the beginning of a disorder before there are other marked signs of indisposition. She should use it upon the first suspicion of a departure from health and frequently afterwards, until she knows that the temperature is normal. An increase, especially if beginning each day a little earlier, is a bad indication; a decrease from a high temperature each day is a sign of improvement. In pneumonia and generally in such disorders as are initiated with a chill, the rise is sudden and rapid.
In typhoid and some other fevers, the elevation is slight at first and gradually rises. The exacerbations and remissions or other deviations can only be recognized by taking the temperature frequently, and it should be taken at the same hour each day to exhibit the cycle of changes.
An irregularity of temperature in the course of a disease that has a regular type may indicate a complication, or it may depend upon local causes, such as constipation, bad air, &c. The decline of fever and of temperature may be gradual, or it may drop to a steady normal within a few hours.
Before using the thermometer the index must be thrown down to a point below the normal. Hold it with the bulb down and shake till it falls sufficiently.
The part (the axilla) should not have been exposed for washing for at least half an hour before taking the temperature, and it is a good precaution to keep the axilla (or mouth) closed for ten minutes before putting the bulb of the thermometer into it, and a little time may be saved by slightly warming the bulb in the hand before its introduction. If we are careful and see that the axilla is first dried from perspiration, and that the clothing is not in the way, and that the thermometer is held firmly in position a sufficient time, we may get a correct axillary temperature, unless in a very emaciated person. If taken in the mouth the lips must be closed during the process.
The rectum gives the most reliable temperature, and this method is employed for infants. The thermometer should be oiled and introduced for about two inches. Unless the presence of feces prevent, the thermometer will be half a degree higher than if taken in the axilla. It will sometimes take ten minutes or more to obtain the temperature, but some thermometers will do the work in less than five minutes.
That respiration and circulation are intimately connected, and that whatever modifies the pulse usually effects the breathing is a fact generally known. That the proper performance of the function of every organ in the body depends somewhat upon proper respiration, is a fact not so generally known and recognized, and as this is an important topic we may properly here enlarge upon it.
By the muscular action of the diaphragm and intercostal muscles, and the consequent contractions and expansion of the lungs, the alternate inspirations and expirations are produced which we call breathing. The lungs are not completely filled and emptied by each respiration, and a certain amount of air remains stationary in them. Were this air which remains stationary constantly in a particular portion of the lungs, the same without change, we would derive no benefit from that portion of the lungs. Practically, however, it is believed that the additional supply breathed in and out is diffused through and alters the character of the whole.
A healthy adult ordinarily breathes about eighteen times per minute, taking in each time about twenty inches of air. It is said that it takes at this rate sixteen respirations to completely renovate the air. This is probably true of our ordinary breathing, but the renovation of the air depends upon our manner of breathing. It is possible for us to breath so that at one expiration we almost displace the air from every portion of our lungs, and then by a full, deep, prolonged inspiration, (throwing forward the chest, throwing back the shoulder, and keeping the body erect,) fill the lungs fully with air and thus not only change the air in our lungs, but change in some degree the character of our blood so as to increase its purity.
In order to test this let me ask anyone who is suffering from any slight indisposition, if it be headache, nausea, pains in different parts of the body, or any sickness, to try to breathe in this manner for half an hour, and observe if they do not feel better, being careful at the same time that the air breathed is good and pure. This point is of so much importance that I will refer to it again hereafter.
The character of the respiration is an important diagnostic symptom and should always be noted. The rate of respiration varies as does that of the pulse, but the former is partly under the control of the will. The respirations are more rapid in women than in men, in children than in adults; it is modified also by position, exertion, excitement, and other conditions. We may count the respirations by observing the rise and fall of the chest, but it is well to put our hand on the stomach where the motions may be felt.
Breathing is in man mostly abdominal, in woman mostly thoracic, but inflammation in the chest or abdomen will affect its character.
Dyspnœa, difficulty of breathing, arises when from any cause the amount of air entering the lungs does not correspond to the amount of blood sent by the heart for purification. The air may be unfit for its work, or disease in the lungs, or air passages may shut it out. Asphyxia results if the supply of air is in any way cut off.
In this connection I will say to the nurse, give the patient pure air. Learn how indispensable this is to life, or health, or comfort; how indispensable to any person, and especially to the sick; how liable the air in the room is to be contaminated by the air breathed or expired by those in the room; by lights burning in the room; by exhalations from the bodies of the sick; by excreta left for a time in the room; by the inevitable floating dust from the floors and walls; from clothing, bedding, and furniture; and from the presence of organic matter in increased quantity, and of most deleterious quality in and around the sick.
A thousand feet of air space where the air is constantly renewed, is necessary for a healthy adult; a sick person should have two or three times as much, because with them there is increased susceptibility to draughts. Be very careful that the sick are not placed so that a direct current of air can blow on any part of the body, but either by the use of fans or in some other way the air must be renewed around their bed.
The problem to be solved is, how can fresh, pure air be best supplied? The inequalities of temperature within and without the room produces some natural ventilation, as this sets the air in motion and effects an exchange of air, if there are some apertures around the doors and windows.
This, however, is seldom sufficient, and artificial ventilation is often necessary. An open fire is a good apparatus for this purpose. The draught which it creates carries the air from the room up the chimney, while a fresh supply is drawn in to take its place. This supply should be from the outward air, or from an adjoining room in which the air is not contaminated.
The inlets and outlets for air should be of equal capacity, on opposite sides of the room, and of different heights to secure thorough ventilation. They should be as far as possible from the patient and from each other. In cold and damp weather great care is necessary to keep the air fresh and wholesome and at the same time to avoid chilling the patient. But even in cold weather the doors and windows may be thrown open for a minute at a time, if the patient is at the time protected by additional clothing.
However, during the night and in cold and wet weather, the principal supply of air will be from an adjoining room, air that is warmed, but it should be as pure as possible. When the weather is cold, and especially the latter part of the night, have more heat in the room and not less fresh air; if needed give your patient additional clothing and foot warmers.
The windows may be thrown open once or twice a day in cold weather, if the patient is protected by putting additional clothing on the bed, and using some sort of a screen, (an umbrella may be used for a screen), as a protection from the cold and direct draughts. But as the contamination of the air continues, the purification of it should be equally so, and some fresh air must constantly be admitted—some device used for the purpose. The window may be raised two or three inches and the aperture closed with a board, then the air will find admittance through the opening between the two sash; or when the window is raised three inches, a board six inches wide may be placed on the window sill a little inside of it; thus there will be an aperture both at the top and bottom of the lower sash. Or the upper sash may be lowered a little. The current of air which comes in (this is usually the lower one) should be directed upwards.
In the summer a lamp may be kept burning in the fireplace or grate; flues must in some way be kept heated or they will not draw. Stoves assist ventilation to some extent, but furnaces and radiators do not assist at all to ventilate, and the air is thereby especially dry. A pan of water may be kept boiling in the room, or perhaps merely setting on the stove, or a towel or two may be hung near a radiator and kept constantly wet; these will dampen the air by evaporation, and this is often necessary when the rooms are kept warm by artificial heat. About 66° is a proper temperature for a sick room in most cases, but 60° to 65° is suitable for fever cases; feeble and emaciated persons require a temperature of 70° to 75°.
Be careful to have the room warm when the patient is out of bed.
The ordinary symptoms which characterize inflammation may be known if we observe what takes place when an external part is injured. Let us suppose that a healthy man has a piece of glass stuck in his arm. He soon has pain, then redness in that part of his arm, then swelling, which is hard near the injury, and increases so that some swelling may be observed, though not so hard at a little distance, and the part is quite tender and hot.
These are the ordinary symptoms of inflammation: pain, redness, heat, and swelling, with tenderness that is manifested when the part is pressed.
If the inflammation increases there are signs of disorder in other parts of the body; the patient may be first chilly and feeble, then the skin may become hot and dry all over the body, the pulse fall hard and frequent, lassitude comes on with headache, perhaps pain in different parts of the body; he has also other symptoms of fever; is restless, sleeps ill, loses his appetite, his tongue becomes white, his mouth is dry, he is thirsty, the secretions of the body are diminished, has what is called inflammatory fever, or sympathetic fever, or pyrexia, the last term being now most generally used.
These phenomena, this inflammation, ends in two or three different ways. If measures have been taken for subduing the inflammation—in the supposed case of the arm—if the glass has been removed, it will probably happen that the symptoms above named will disappear. This is to end in what is called RESOLUTION.
When the inflammation goes on until pus is formed it is said to end in SUPPURATION. The symptoms grow more severe for several days, the swelling at length assumes a more pointed form, the skin in its centre begins to look white, and the swelling there gets softer; there is throbbing pain, perhaps the patient has chills or rigors; then when the swelling is cut open or the cuticle breaks a yellow creamlike fluid is poured out which is pus, and there is generally an abatement of the symptoms. If, however, the suppuration or discharge of pus continues for some time, other symptoms are manifested such as frequent shiverings, followed by flashes of heat which end in perspiration; this is HECTIC FEVER.
When the inflammation is still more intense it sometimes ends in MORTIFICATION, the part dies by the violence of the disease, the red color changing to a livid or purplish, or greenish black hue, the flesh losing its sensation and having an offensive odor.
Of course inflammation may be in an organ or structure that is internal, and we determine the seat of the disease, partly by the character of the pain. Sometimes the pain is sharp and piercing; this is its character generally in serous membranes such as the pleura or peritoneum (membranes covering the lungs and intestines.) There is less pain when the inflammation is in the mucous membrane, or in the parenchymatous structure of organs, such as the lungs, liver, and spleen.
There is generally an aggravation of pain upon pressing a part that is inflamed. Pain caused by air distending the bowels and stretching the nerves may be relieved by pressure. Spasmodic contractions of the muscles will cause pain without much tenderness.
The temperature of an inflamed part exceeds that which belongs to it in health. In inflammation as in fever, it has been known to rise to 107°. The increase of heat depends upon an influx of arterial blood, and therefore of oxygen into the part. There is probably always some increase of heat, though it may not always be noticed in every case of inflammation.
There is more REDNESS than is natural in a part that is inflamed. There is more blood than usual in the vessels that carry red blood, and the red blood enters into the small vessels where the red particles cannot commonly be seen. All the minute vessels seem to be enlarged. The redness often remains sometime after the inflammation has ceased.
The degree of SWELLING in different cases depends partly on the nature and structure of the part affected and partly on the intensity of the inflammation; in some instances there is so little that it is not appreciable.
Almost all the swelling results from the presence of matters thrown into the inflamed part. In the central hard portion the hardness is to be ascribed to an effusion into the areolar tissue of it, of a fluid which is transparent at first, afterwards becoming opaque, called coagulable lymph. Serum is effused into the areolar tissue of the softer swelling at the circumference.
Even under moderate inflammation some amount of effusion takes place into the texture or from the surface of a part. This effusive serous fluid called also serosity, resembles and probably is the scrum of the blood. When this passes into the areolar structure of a part it is called œdema, (though this is not always by inflammation) and if the serosity passes out extensively over the body, the disease is called anasarca or general dropsy.
If a considerable amount of this serous fluid is poured out in a short time from the peritoneum, it is a form of ascites or abdominal dropsy. If it is thus poured into the pleura it causes apnœa, or difficulty of breathing, and requires aspirating.
It is not often that a correct diagnosis can be made of a disease by a single symptom, but there are marked and characteristic symptoms which indicate some diseases in children with considerable certainty.
A strongly marked nasal or palate sound in the child’s cry indicates an abscess behind the pharynx. When this nasal tone is heard we should palpate with the finger on the throat to ascertain the degree of soreness.
A long drawn, ten times lengthened, loud sounding expiration with normal inspiration, and no dyspnœa is sufficient for the diagnosis of CHOREA MAJOR (St. Vitus dance.)
A high thoracic continually sighing inspiration, the upper part of the thorax doing the work of breathing, and with a sighing or groaning sound, shows the commencement of HEART WEAKNESS, CARDIAC PARALYSIS OR FATTY DEGENERATION OF THE HEART, and will probably be followed by such symptoms as cyanosis, coldness of the extremities, &c.
Strongly marked diaphragmatic expiration accompanied by a fine, high whistling sound, points to BRONCHIAL ASTHMA. This sound, however, resembles that made in croup. If there is a pause between the end of expiration and the beginning of inspiration, croup may be excluded.
Sleepiness, lasting twenty-four to thirty-six hours, occurring without fever or other disturbance to account for it, is an initial symptom of MENINGITIS, though it might be caused by narcotics or uremia.
A prominent, firm fontanelle means increase in quantity of the contents of the cranium-exudation of some sort. It cannot be caused by fullness of the vessels alone if it is firm and resisting. We know that we have cerebral disease with DROPSY or exudation (Hydrocephalus).
When the fontanelle is deeply sunken, it points to loss of blood or other nutritive juices, as in cholera, &c.
A sharp, shrill cry, accompanied by an expression of fright or great anxiety, and occurring about an hour after the child has fallen asleep, is the only symptom of the “Alp”—night terrors, sudden awaking from bad dreams.
Periodical crying, lasting from five to ten minutes, should always make us think of spasm of the bladder or PAINFUL URINATIONS.
Violent crying at stool with fear of the act, and general avoidance of it, points to FISSURE OF THE ANUS, and is usually accompanied with constipation.
A violent cry full of pain and almost continuous, with the throwing about of the head on the pillow and grasping it with the hands, means OTITIS or EARACHE.
Weakness or immobility of the child, after a comparatively slight or short illness, points to SPINAL PARALYSIS.
Delayed ossification of the cranial bones is an early sign of RICKETS, as is crying continued for weeks (increased on touch of the extremities), accompanied with fever and incessant sweating.
Vomiting of all kinds of food continued for weeks in children of closed cranium but with large cranial measurements, when there is no fever, pain, idiopathic disease, or a cerebral tumor, indicates chronic HYDROCEPHALUS with an acute onset.
Congestion of the cheeks in children, excepting in cases of cachexia and chronic disease, indicates an INFLAMMATION or a febrile condition.
Congestion of the face, ears and forehead of short duration, strabismus with febrile reaction, oscillation of the iris, irregularity of the pupil with falling of the upper lids, indicates a brain affection.
Enlargement of the spongy portions of the bones indicates RICKETS.
A thick and purulent secretion between the eyelids may indicate great PROSTRATION of the general powers.
Passive congestion of the conjunctival vessels indicates approaching DEATH.
Long continued lividity, as well as lividity produced by excitement or exercise, the respirations continuing normal, are indices of FAULT IN THE FORMATION OF THE HEART, or great blood vessels.
A temporary lividity indicates the existence of a grave acute disease, especially of the respiratory organs.
Irregular muscular movements, which are partly under the control of the will, indicates the existence of CHOREA (St. Vitus dance).
The contraction of the eyebrows, together with a turning of the head and eyes to avert the light, is a sign of cephalalgia (headache).
When the child holds its hand upon its head, or strives to rest the head upon the bosom of the mother or nurse, it may be suffering from ear disease.
When the fingers are carried to the mouth, and there is besides great agitation apparent, and when it turns its head from one side to another, there is probably some obstruction or some abnormal condition of the larynx.
A feeble and plaintive cry indicates a trouble in the abdominal regions.
If the respiration is intermittent but accelerated, there is capillary bronchitis. In bronchitis the cough is clear and distinct.
A hoarse and rough cough is indicative of true CROUP. When the cough is suppressed and painful, there is PNEUMONIA or PLEURISY.
In diseases of the stomach, liver or bowels we have usually a coated tongue; a white tongue indicates FEBRILE disturbance or some THROAT trouble; a brown moist tongue, INDIGESTION; a brown dry tongue, DEPRESSION, BLOOD POISONING or TYPHOID FEVER; a red moist tongue, INFLAMMATORY FEVER; a broad, pale flabby tongue accompanies a DROPSICAL CONDITION of the system; a tremulous, moist and flabby tongue indicates FEEBLENESS, NERVOUSNESS; a pale flabby tongue which shows the pressure of the teeth, a generally relaxed condition of the system; the irritable or strawberry tongue with its red papilla, points to an irritated stomach, and is met with in SCARLET FEVER; a furred and dry tongue is indicative of VIOLENT LOCAL INFLAMMATION; if afterwards clean, red and dry, protracted INFLAMMATORY FEVER.
Wheezing cough and wheezing breathing indicates ASTHMA; dull, heavy aching pain at the base of the chest, ACUTE BRONCHITIS; urgent desire to go to stool, DYSENTERY; diminished secretion of urine, INFLAMMATORY and FEBRILE DISORDERS; cold hands and feet, NERVOUS DISEASES and low states of the blood.
In general, the diagnosis of diseases of children is easy if we simply compare the objective symptoms with those which should obtain in a healthy child of the same age. But we must remember that with children symptoms which appear very grave are often evanescent, and on the other hand the indications of very serious disease may be disregarded on account of their natural vivacity and recuperative powers. In each case each child should be studied by itself considering its antecedents, its peculiarities, its surroundings, and its relations to them.
The mother has the best chance to know these; she sees the child when awake and asleep, when dressed and undressed; she knows its history, what has been its diet, what her own health has been, her own habits, her surroundings and occupations, and whether there may or may not have been anything to cause sickness of the child in her own toils or trials. The nurse and the mother should note all the facts, for their own guidance and for the guidance of the physician if he is called.
Very few of the symptoms heretofore mentioned can be neglected with impunity. While some cases of sickness may be left to the powers of nature to restore health, others require judicious early treatment, and a physician should be called. We should generally enjoin rest, but we should act by our medicines to meet every positive indication.
We are the assistants of nature; we must act by removing the causes where they can be reached; we must relieve pain, but we must not by officious kindness do too much and interfere with the natural return to health. Remember that drugs are not all powerful, that time, rest, diet and numberless little things are the means by which we aid in the fight against disease.
It is an excellent plan not to continue medicine too long. Place the child on the road to health and see if it will not with a little supervision improve—still, however, using proper rest, diet, &c.
But as the apparently trifling symptoms of to-day may become the full fledged attack of to-morrow, we must pay attention to every untoward symptom. Parents are liable to be unnecessarily scared, and afterwards go to the other extreme and neglect calling a physician until serious injury has occurred.
I will here give you a few aphorism and general rules: Treatment of the sick should be according to the patient as well as according to the disease. Adult males are not so sensitive as females; young children, whether male or female, are sensitive, tender and excitable, and alive to every irritation. But young children differ in their constitution, and some have peculiarities or idiosyncracies so that medicines of ordinary activity act very powerfully or even violently.
Small children are always sensitive to the action of medicine, and small doses only are required for them. And in consequence of the activity of the vital powers, and the quickness and force of the circulation, there is a remarkable susceptibility to inflammatory action, disease sometimes running on rapidly to organic and incurable mischief.
In treating children employ the mildest remedies at first, and aid their action by regimen. When an emergency demands, use those articles which experience has shown to have power to meet such an emergency. Exhibit such medicine in the minimum dose and increase or repeat until the desired effect is produced. Be very careful not to fill the child with nostrums for some imaginary ill, lest you thereby make it ill. Always remember that the first step in treatment is to change the conditions which produced the disease—remove the cause and assist nature to repair the injury.
Usually the nurse or the mother does not treat disease, or administer medicine except under the direction of a physician, and it is not always necessary for her to know the principles that guide in their administration, or why particular medicines are given. But it is sometimes necessary for the nurse or mother to decide what shall be done, and to act before the doctor can be consulted. Accidents and emergencies occur, distress and sickness may suddenly attack some member of a family at any time, and little ailments are complained of every day by some of them; the question arises, what shall be done?
It is not necessary every time to send for the physician, and he cannot at a moment’s notice be obtained. For many ailments the mother prescribes, and many times the early and judicious use of medicines or regimen not only relieves present suffering, but also prevents the developement of serious, and protracted and dangerous maladies. This is especially true in regard to incipient inflammation, and I shall here speak particularly of its treatment.
What has heretofore been said about inflammation gives us some guide to enable us to know whether the case calling for our care is one of an inflammatory character. If the pulse is full and hard and a little more frequent than usual, and there is restlessness and some pain we may conclude that there is IRRITATION that precedes inflammation at least, before such symptoms as depression, chilliness followed by heat, headache, a furred tongue, loss of appetite, and apparent weakness come on. But if any of these symptoms are present we should search for the cause. Perhaps if the inflammation is external we shall be able to ascertain what produces the trouble. In every case we ought to know the cause if possible, as we thus have more clear indications for treatment.
But we may use the sedative treatment in all cases where these symptoms come on in a person who has previously been healthy. Of course you will not bleed—that, if done at all, should be done by the doctor. But all sources of irritation ought to be removed, so that the patient may enjoy perfect quiet; the sick room should be ventilated, and kept at the temperature of about 60°; let the diet be light; allow ice and cold water freely, and if there is much febrile excitement use sedatives and saline refrigerants. The best sedative is veratrum viride, and the following is a convenient way of administering it: Drop 30 drops of the fluid extract of veratrum in 30 teaspoonfuls of water and give 1 teaspoonful every two hours. To adult subjects if there is considerable fever two drops of the extract, or two teaspoonfuls of the diluted preparation may be given at first and the dose may be repeated in an hour, but it will not be best to continue such large doses. Aperients may be given if there are fecal accumulations in the bowels. Although quinine is a tonic, six to ten grains of it are sometimes given with good effect in a case of inflammation.
Opium is a good remedy judiciously given; one dose (1 grain for an adult) is good in a case of catarrh or cold; successive doses are necessary in a case of peritonitis or enteritis, but this should be given on a physician’s advice. It acts probably by quieting the nerves—by sustaining the faltering action of the heart, and by keeping the inflamed part at rest. Sometimes cold, and sometimes hot applications are made to inflamed parts, and it is said that the sensations of the patient are the best criterion of their usefulness. Except, however, in cases of inflammation of the brain, and perhaps even then, I think that hot applications are the best. When we wish to promote suppuration hot fomentations should be applied.
Counter irritants relieve inflammation of the deeper parts by drawing the circulating fluid and the nervous energy to the surface. The milder kinds called rubefacients, produce merely local warmth and redness; these may often be used advantageously. Mustard applied so as to redden the skin is generally useful.
Vesicants, epispastics, or blistering agents are safe appliances but they are distressing, and their use may be deferred until a physician advises them.
I have said that the diet should be light while the pulse is hard and full. Afterwards when the pulse is natural, or if it becomes irregular or small, good broths or other nutrients are to be given, milk, cream, and even raw eggs may be administered. In general food should not be pressed upon a patient.
I have mentioned counter irritants and I think it best at this time to advert to all the various topical applications, irritating, soothing and protective, and to give such instructions as I can in regard to them.
Counter irritants are frequently applied over or near the seat of the disease, and often also at a remote part to obtain what is called revulsive action. In both instances, however, their action may be revulsive. If applied to the thorax or chest, for example in a case of pneumonia, the cuticle to which it is applied is almost as remote from the lung by the way of the circulation, as is the cuticle of the wrist or ankle. But practically a sinapism may be very useful applied at either place—possibly more useful if applied over the seat of the inflammation, because there is a sympathy between the parts—they may be used very beneficially in domestic medication.
In a few succeeding pages I give some directions to the nurse who acts under the doctor’s orders.
Ammoniacal liniments, and other washes and embrocations that are sufficiently irritating to produce redness when rubbed on the skin, should be rubbed on briskly so as to produce considerably increased circulation in the capillaries, &c. One of the most commonly used rubefacients is mustard. To make a mustard plaster, or sinapism, take one part of powdered mustard, and about three times the quantity of flour and mix into a paste with tepid water, and spread it evenly between two pieces of thin muslin. As hot water or vinegar weakens the active principle of mustard, tepid water is best, even if it seems cold when applied to the patient. Good sinapisms are conveniently made also by doubling brown paper several thicknesses, wetting it and sprinkling on the mustard alone.
The mustard must not be left on long enough to vesicate; usually it should be taken off within half an hour (or moved,) except when applied to the soles of the feet, when they may commonly be left on for several hours. Their action must be carefully watched upon an insensible or delirious patient, or a little child. In mixing the plaster for children glycerine may be used, and then the plaster may remain on longer. Confine in place by a bandage. If the patient complain of the burning or smarting after the plaster is removed, dust the part with starch or fine flour, or dress with vaseline to exclude the air.
You may make a cayenne pepper plaster in the same way that a mustard plaster is made, or you may sprinkle pepper upon a thin slice of pork. This makes good draughts for children and may be useful sometimes for sore throat if applied to the neck. But capsicum plasters, &c., can be bought at the drug store. In the country it is generally convenient to obtain and apply horse radish leaves; these are good rubefacients. In order to produce immediate VESICATION I have known a doctor to heat an iron spoon until it was sufficiently hot, and then rub it over a small space of skin; and a small blister may be quickly made by saturating a bit of cotton with hartshorn, putting it in a top thimble and applying it to the skin to remain seven or eight minutes. But the agent most commonly used to produce vesication is the CANTHARIDEAL PLASTER. If you are to produce a blister with this, the part should first be washed and dried, shaved if there is any hair upon it, then if you wish the blister to rise soon wet the plaster and also the skin with vinegar; apply, and secure the plaster in place by a bandage. Most commonly it will rise in from four to eight hours, but without waiting for it to rise fully you may remove the plaster and apply a poultice which will produce the desired effect. Do not tear the skin in taking the plaster off. When the blister is well raised make a slight incision or two for the escape of serum, and dress with vaseline or tallow. This is the usual way, but in some cases the physician may direct differently, perhaps may leave the blister undisturbed and allow the fluid to be reabsorbed.
Strangury and congestion of the kidneys sometimes follow the prolonged use of cantharides; to prevent this, it is sometimes recommended that tissue paper be well oiled and interposed between the plaster and skin. And as camphor corrects the action of cantharides upon the bladder, it is recommended that in case of a child particularly, a solution of camphor in ether be sprinkled upon the plaster. If a blister is applied to a young child, it should be carefully watched and not allowed to remain too long. In two or three hours the skin will be well reddened, and the plaster may be removed and a poultice applied.
Tincture of iodine is sometimes applied as a counter irritant, but several coats and repeated applications are necessary to produce a blister.
Local stimulation can be obtained from bits of cantharideal plaster kept on for an hour or two, and removed or changed before the point of vesication is reached. The same effect follows the rapid passage of a hot flat iron over a piece of brown paper or flannel laid upon the skin. It is generally best that the flannel should be wet first; and should an emergency arise when from hemorrhage or some other cause there is danger of immediate collapse, the application of heat in this way may rouse the sufferer and prevent immediate death. This or the actual cautery is sometimes used to relieve lumbago, or rheumatism. If you have thereby a slight burn, you may dress it in a solution of bicarbonate of soda and cover from air with rubber tissue.
If a SETON is inserted in the skin, the silk should be moved daily and the matter well cleared out.
Wet cups are applied to relieve congestion and to abstract blood, the skin being first scarified.
Dry cupping is most practiced for the relief of pain and to draw the blood away from an inflamed organ. Small tumblers may be used in the absence of cupping glasses, if the edges are smooth. When you apply the cups have at hand also a lamp, a saucer of alcohol, a bit of sponge or a wad of lint fastened to the end of a stick. Have the cups perfectly dry, dip the sponge in the alcohol which you will ignite from the lamp, (they being near the patient), and let it burn for an instant in the inverted glass, then withdraw and extinguish it, and rapidly place the cup over the intended spot. As the heated air in the glass condenses in cooling, the skin will be forcibly sucked up, and the blood drawn towards the surface. Each cup will remain on from three to five minutes. Do not attempt to apply them to a bony and irregular surface, and be very careful not to burn the patient by getting the edges of the glass too hot. To remove the cup press with the finger close to the cup so that air will be admitted.
Wet cupping will be attended to by the physician, who will provide the scarificator, and adhesive straps. See that plenty of soft towels are provided.
There are two varieties of LEECHES used in this country, the American and the foreign. The latter differs from the former in having five or six stripes down its back instead of three, and it will draw from five to six times its own weight of blood as it is larger and more voracious than the American variety.
The domestic variety is sometimes preferred for children, as it will draw a sufficient amount of blood usually. Leeches should not be applied over any large vessel, and preferably should be over a bony surface where pressure can be made to stop the blood if it continues to run. The leech should not be handled, it may be washed and dried in the folds of a towel.
To induce them to bite, the part to which they are to be applied must be perfectly clean, and it may be best to pick or scratch the skin so that the leech has first a taste of blood; or you may put the leech in a wine glass, test tube, leech glass, or small bottle filled with water; cover with a cord and invert over the place; hold it close and slip out the paper. The leech will then probably take hold and the glass can be taken off, and the water absorbed by a towel. If one is to be applied inside the mouth or nostril, put a thread through its tail to prevent its being swallowed. If such an accident should occur have the patient drink freely of salt and water, and induce vomiting.
If the leech seems sluggish when applied stroke it gently with a dry towel. When full it will drop off. If you wish to take them off sooner, do not remove by force, but put a little salt on their heads. If the bleeding from the orifice continues too long it may be checked by a compress of lint, an application of ice, or by touching with nitrate of silver, or carbolic acid. Leeches not used may be kept in a jar of water with sand in the bottom, and a perforated cover, or it may be covered with a linen cloth. The water in which they are kept should be changed twice a week in winter and oftener in summer. Salt will make a leech disgorge the blood with which it is filled, but if kept afterwards it is liable to be diseased, and to cause disease in those that are with it.
By FOMENTATIONS or stupes is commonly meant the application of flannels or towels wet with hot water or some medicinal decoction. If hot water only is used, they are a convenient means of applying warmth and moisture, but they require constant attention, needing to be changed every ten or fifteen minutes. They are chiefly of use in relieving pain and inflammation, and in promoting suppuration when that is desirable.
Two pieces of flannel should be at hand each doubled to the desired size; they are to be saturated with boiling water and wrung out dry as possible. To wring it out without scalding one’s fingers, put it inside a towel, and this may be made with a hem at the end so that a stick can be thrust through it. Wring the flannel so dry that it will not make the bed or bed clothing wet. Cover with oiled muslin a little larger than the fomentation, and over that lay some dry flannel or cotton. If the stupe is put on hot, and frequently changed, it derives or draws blood towards the skin, and is often useful in relieving spasm and pain; and the continued use of them prevents suppuration. Medicaments are sometimes added to make them more irritant or sedative; then they are not changed so often, but they must not be allowed to get cold. After the fomentations are discontinued, carefully wipe the parts dry to which they have been applied, and cover with a warm, dry flannel.
I subjoin a few useful fomentations in which decoctions or medicines are used.
1. Add one ounce muriate of ammonia and two ounces spirits of camphor to 1 quart of boiling water just before dipping the flannel into it.
2. For a fomentation to the bowels, chest, &c., of a child, take 1 oz. paragoric, 1 oz. Jamaica ginger, and 4 ozs. hot water.
3. Twenty drops spirits turpentine may be sprinkled over each stupe, but be careful about blistering the skin or making a sore.
4. A decoction of chamomile flowers, hops, or conium, may be used for the fomentation instead of water.
5. Twenty drops or more of laudanum may be dropped over each stupe. This might soothe pain without causing stupor.
Poultices, like stupes, are means of applying warmth and moisture. If applied early, it is believed they may prevent the formation of pus, as they bring about a resolution of the inflammation. When suppuration has commenced they facilitate the passage of matter to the surface, and lessen the extent of the disease. When applied to an inflamed part or swelling they should extend over considerable surrounding surface, but for a suppurating wound they should be but little larger than the opening.
Avoid putting them on very hot in a case of paralysis and also upon children, though they should be applied quite hot usually.
To make BREAD POULTICES pour boiling water on slices of bread without crust, simmer a few minutes, then beat up the bread quickly and spread it upon a piece of muslin previously cut of the desired size, leaving about two inches of margin upon each side. Then put on the poultice some lard or oil or vaseline to keep it from getting dry and hard, and to make it less likely to stick. It will be well to put on it a cover of thin muslin or mosquito netting, or tulle, or illusion, and then fold over like a broad hem the edges of both the covers. The poultice should be evenly spread about a quarter of inch in thickness and may be carried to the patient on a small tray or board, and if you are changing the poultice you should also have a small basin to carry away the old ones. After applying the poultice cover with some impervious material (oiled muslin or rubber cloth) to keep in the heat. Such a poultice as this will keep warm for five or six hours, but it should not be allowed to become cold and hard. Milk should not be used in making poultices as it quickly sours.
Poultices are made of various materials. Flax seed meal, starch, powdered slippery elm, Indian meal, and oat meal are used. They should all be made of such a consistence that they will be tenacious as possible, and should have at least a little oil on them to prevent their getting dry.
For PUTRID SORES some disinfectant solution may be used instead of water in making the poultice, such as a weak solution of chlorinated soda.
Yeast poultices are used to hasten the separation of gangrenous sloughs. Mix six ounces of yeast with the same quantity of water at blood heat. Stir in fourteen ounces of wheat flour and let it stand near the fire until it rises. Apply while fermenting, or, “Take of wheat flour a pound, yeast half a pint, mix, and expose the mixture to a gentle heat until it begins to rise.”
The following are old officinal forms for poultices:
Alum cataplasm. Take the whites of two eggs, of alum a drachm, shake them together so as to form a coagulum. (A common mode of preparing the alum poultices is to rub the whites of two eggs briskly in a saucer with a lump of alum till the liquid coagulates.) The curd produced by coagulated milk with alum is sometimes used as a substitute. The alum cataplasm is sometimes employed in incipient or chronic opthalmia as an astringent application. It is placed over the eye enveloped in folds of cambric or soft linen.
Cataplasm Carbonis ligni. Take a sufficient quantity of wood charcoal red hot from the fire, and having extinguished it by sprinkling dry sand over it, reduce it to very fine powder and incorporate in the simple cataplasm in a tepid state. Charcoal recently prepared has the property of absorbing those principles upon which the offensive odor of putrefying, animal substance depends. In the form of poultice it is an excellent application to foul and gangrenous ulcers, correcting their fetor and improving the condition of the sore. It should be frequently renewed.
Conium Cataplasm. Take of extract of poison hemlock (conium) two ounces, water a pint. Mix and add of bruised flax seed sufficient to produce a proper consistence. This cataplasm may be advantageously employed as an anodyne in cancerous, scrofulous, and other painful ulcers, but its liability to produce narcotic effects in consequence of the absorption of the active principle of the hemlock must not be overlooked.
Sometimes a bag is made to contain a poultice, and such a bag should be used if we desire to apply a large poultice to the chest or abdomen. One can be made for the breast and for the back at the same time, and two straps over the shoulder may unite them. A hop poultice is a thin bag loosely filled with hops and wrung out of hot water.
Dry fomentations are sometimes employed. Thin bags filled with heated sand, ashes, salt, bran, or hops are used, to keep the heat applied to the skin; and to warm the feet and quicken the circulation in the extremities, hot bricks, bottles filled with water, &c., are applied. These should be rolled in hot flannel or at least enveloped in something.
Cold applications are sometimes used to subdue inflammation in the early stages. They are not good when matter is forming, or during sloughing. When they are used they ought to be continuously applied so as to keep up a constant cooling effect. Sometimes either water or some lotion is used with the design of cooling by evaporation. If a part is wet with water, alcohol, vinegar, a solution of muriate of ammonia, or other fluid, and left uncovered, the effect will be to cool it. When you design to cool by evaporation do not lay on more than one thickness of muslin or lint, and this must be wet so often that it does not get nearly dry. But a part may be cooled by several folds of muslin wet in ice water, and changed for fresh ones before they get warm. It is important that they do not become warm, and hence they should be frequently changed; alternate cooling and reaction is hurtful rather than beneficial. A steady cold stream of water is one means of cooling, and another device is to carry across a part a long strip of muslin or lamp wicking, having one end in a vessel of cold water higher than the bed, and the other leading to a basin below it. Protect the bed well with India rubber cloth so that both the patient’s clothing and the bed are kept dry.