Part 15

The peculiarities of the fetal circulation, leaving details aside, are: the direct communication between the two auricles of the heart, through an opening called the foramen ovale; the communication between the pulmonary artery and descending portion of the arch of the aorta, by means of a tube called the ductus arteriosus; and the communication between the placenta and the fetus, by means of the umbilical cord.

The arterial blood for the nutrition of the fetus is carried from the placenta along the umbilical cord by the umbilical vein. Entering the fetus at the umbilicus, the blood passes upward to the liver and is conveyed into the inferior vena cava in two different ways. The larger quantity first enters the liver, and, alone or in conjunction with the blood from the portal vein, ramifies through the liver before entering the inferior vena cava, by means of the hepatic veins. The smaller quantity of blood passes directly from the umbilical vein into the inferior vena cava, by a tube called the ductus venosus.

In the inferior vena cava the blood from the placenta becomes mixed with the blood returning from the lower extremities of the fetus. It enters the right auricle and, guided by a valve—the Eustachian valve, passes through the foramen ovale into the left auricle. In the left auricle it unites with a small quantity of blood returned from the lungs by the pulmonary veins. From the left auricle the blood passes into the left ventricle and is distributed by the aorta almost entirely to the upper extremities by the superior vena cava, the blood enters the right auricle, and, passing over the Eustachian valve, descends into the right ventricle, and from the right ventricle into the pulmonary artery. As the lungs in the fetus are solid, they require very little blood, and the greater part of the blood passes through the ductus arteriosus into the descending aorta, where, mixing with the blood delivered to the aorta by the left ventricle, it descends to supply the lower extremities of the fetus, the chief portions of this blood, however, being carried back to the placenta by the two umbilical arteries.

From this description of the fetal circulation it will be seen:

1. That the placenta serves the double purpose of a respiratory and nutritive organ, receiving the venous blood from the fetus, and returning it again charged with oxygen and additional nutritive material.

2. That the greater part of the blood traverses the liver before entering the inferior vena cava; hence the large size of this organ at birth.

3. That the blood from the placenta passes almost directly into the arch of the aorta and is distributed by its branches to the head and upper extremities; hence the large size and perfect development of those parts at birth.

4. That the blood in the descending aorta is chiefly derived from that which has already circulated in the upper extremities and, mixed with only a small quantity from the left ventricle, is distributed to the lower extremities; hence the small size and imperfect development of these parts at birth.

NURSING IN DISEASES OF CHILDREN.

=Spasmodic Croup.=—Spasmodic croup is due to a sudden closure of the glottis.

_Causes._—Exposure to a cold, damp atmosphere, indigestion, or irritation of the throat. There may be some hoarseness a few hours preceding the attack and the child awakens suddenly in the paroxysm of the sharp croup cough, experiences difficulty in breathing and has the cyanotic appearance so terrifying to the mother, but which need give no cause for serious alarm.

_Treatment._—Apply hot compresses about the throat. If the attack is severe give an emetic—one dram of salt or mustard in one-half cup of warm water, and repeat in twenty minutes if necessary; an enema of warm water should be given and steam inhalation resorted to. Keep the child in an even temperature, restrict diet for a few days, and keep bowels active.

=Parotitis (Mumps).=—An infectious disease characterized by inflammation of the parotid glands. Incubation is from two to three weeks.

_Symptoms._—The disease comes on with a mild chill, pain below the ear and swelling of the glands. There is great discomfort and the tension is very disagreeable.

_Treatment._—Keep patient in bed during the height of the disease. Give liquid and soft diet. Bowels should be opened freely. No medicine is required unless fever is high. Apply cold compresses to the affected part, though, if preferred, hot ones may be used. A pad of cotton with oiled silk is the best application. In cases of extreme redness or tenderness of the glands, leeches may be applied. In cases of delirium use the ice-cap. For orchitis, lubricate the parts with camphorated oil and support with a soft cotton pad.

Duration of disease, from seven to ten days.

=Whooping-Cough.=—An infectious disease, beginning with catarrh of the air-passages, like an ordinary cold. The short expiratory coughs following each other in rapid succession and the period of drawing a long breath give rise to the whoop characterizing pertussis.

_Incubation._—A week to ten days.

_Treatment._—Isolate patient and if attack is severe put him in bed. Fresh air is the most essential element. If the cough is distressing, ipecacuanha wine and paregoric may be given. During convalescence the child should be watched carefully, as at this period bronchopneumonia and tuberculosis are apt to develop. Change of air is advisable. Tonics and cod-liver oil should be employed. The diet should be easily digestible, nourishing food. After each paroxysm and after the child has recovered from the exhaustion it produces give nourishment. There will be a partial if not complete absorption of the food before another attack. Duration of the disease from six to twelve weeks.

=Colic.=—_Causes._—Constipation, indigestible foods, flatus, overfeeding, improper foods and exposure to cold.

_Symptoms._—Child cries out very suddenly and sharply. There is a convulsive movement of the extremities, the hands are tightly closed, abdomen is tense.

_Treatment._—Gentle pressure and massage with warm oil over the abdomen and a few doses of hot or peppermint water will expel the gas. Burnt brandy is good. The simple warm enema is a common remedy. Wrap warm flannels around the lower parts of the body and keep the hands warm.

=Diarrhea.=—Frequent loose evacuations without tenesmus.

_Causes._—Impure water or food; irritating secretions poured into the bowels; bottled milk.

Diet should be restricted to cereal and albumin water. Flush the bowels very gently with warm water.

=Dysentery.=—_Symptoms._—Fever, tenesmus and frequent small mucous, bloody stools. Treat as diarrhea. Keep child warm, especially about the abdomen.

=Cholera Infantum (Summer Complaint).=—_Symptoms._—Fever, intense thirst, continuous vomiting, and purging of the bowels. Stools soon become watery and pale-green in color, and the child has all appearances of complete prostration.

_Treatment._—Stomach washing and intestinal irrigation carefully given. Restrict diet to barley water containing a few drops of brandy and give hourly for a few days.

=Rickets.=—A disease of infants, characterized by impaired nutrition of the entire body and alteration of growing bones.

_Causes._—Not positively known. Heredity may be a predisposing factor. Another theory given is want of sunlight, impure air, prolonged lactation, and suckling. As it is a constitutional disease it is almost certain to be due to a disturbance of nutrition. _It is much less found in the breast-fed than in the artificially fed and more common when the artificial feeding is bad than when it is properly given._

=Scurvy= is a constitutional disease of metabolism _due to a faulty diet_. Probably the absence of some constituents in the nature of vitamins. _Scurvy and rickets are two distinct diseases_, and yet both may be due to _impure, improper infant feedings_.

_Three General Symptoms of Great Importance._—First, a diffuse soreness of the body, so that the child cries when an attempt is made to move it; second, slight fever; third, profuse sweating. Deformities may often be prevented if, in the early stages, constant care is taken that the child is properly held.

=Thrush.=—_Aphthæ._—Small white, furry mouth ulcers developing during the first and second year of infancy.

_Cause._—Lack of cleanliness in the care of the mouth, especially after feeding with bottled milk. The patches are tenacious, grow larger, until sometimes they involve the entire gastro-intestinal tract, resulting in acute indigestion and bowel disorders.

The first symptom is usually some evidence of painful distress in the infant’s efforts to nurse; fever, diarrhea and vomiting occur and the trouble may become acute.

_Treatment._—Absolute sterile cleanliness in the preparation and administering of the patient’s food. The mouth must be cleansed with warm boric acid solution after every feeding. The patches should be touched gently with the same solution, and the lips anointed with a soothing lotion.

=Convulsions.=—The principal predisposing causes are infancy conditions affecting the nutrition of the brain and hereditary influences. The brain grows more during the first year than in later life, and this rapidity of growth is in itself an important predisposing cause of functional derangement. After infancy attacks of convulsions are much less frequent, and after seven years they are relatively rare. Death may take place from a single attack in very young infants, especially those who are rachitic.

Convulsions may be thought to indicate the onset of some acute disease when they occur in a child over two years old, and when they come on suddenly or with only slight premonition in a child previously well; but the most important point is that they are accompanied by a high temperature—104°-106° F. Acute meningitis is the only other condition likely to produce these symptoms. Whether the convulsions mark the onset of lobar pneumonia, scarlet fever, malaria, or some other disease can be determined only by carefully watching the patient’s symptoms for 24 or 36 hours.

In convulsions depending upon some disorder of the alimentary tract, we may get a history of chronic constipation or improper feeding, and in nursing infants, sometimes of passion or intoxication in the wet-nurse. Convulsions are so frequently due to digestive derangement that the condition of these organs should be one of the first things to be looked into. Examination of the urine should never be omitted in any case of convulsions of doubtful origin, even where no dropsy is present. This, both in infants and older children, is too often overlooked. In all cases of convulsions of doubtful or obscure origin occurring in infants, rickets should be suspected as the underlying cause, and the child carefully examined for other evidences of that disease.

_Treatment._—Cold should be applied to the head, best by means of an ice-cap or cold cloths, and dry heat and counterirritation to the surface of the body and extremities.

_The Mustard Pack._—The child is stripped and laid upon a blanket, and the trunk is surrounded by a large towel or sheet saturated with mustard water. This is made as follows: 1 tablespoonful of mustard, 1 quart of water. In this the towel is dipped and, while dripping, wound around the entire body. The patient should then be rolled in the blanket. This pack may be continued for 10 or 15 minutes; at the end of which time there will usually be a very decided redness of the whole body. It may be repeated, according to indications. Where it is desired to produce general counterirritation, the mustard pack is not quite as efficient as the mustard bath, but it has the advantage in causing much less disturbance to the patient. The mustard pack is useful in the conditions of collapse, or of great prostration from any cause whatever, in convulsions, and in cerebral or pulmonary congestion. The degree to which the counterirritant of the skin should be carried will depend upon the condition of the pulse and the cyanosis. The feet may be placed in mustard water while the child lies in its crib (Holt).

A FEW NOTES ON MEDICAL DISEASES.

RHEUMATISM.

A constitutional disease, characterized by fever, inflammation in and around the joints, occurring in succession, and a great tendency to induce the condition of endocarditis or pericarditis.

=Cause.=—Usually exposure to cold—chilling of the body—damp atmosphere.

=Treatment.=—Rest in bed is important. The bedding should be yielding, and the patient wear loose flannel night-clothes. Sleeping between blankets promotes perspiration, increases the activity of the skin, prevents exposure to cold and may reduce the liability to heart trouble. Change bed-clothing frequently.

_Diet._—Should be easily digested food. Milk is the most suitable. Dilute with alkaline or mineral water. Barley- or oatmeal-water and lemonade may be given. Broths and soups may be substituted for milk at times. Regular feedings every two hours until patient convalesces.

GOUT.

Gout is characterized by sudden attacks of severe pain in the smaller joints, especially that of the big toe. There is a gradual deposit of urate of sodium in and about the joints, and presence of uric acid in the blood.

=Causes.=—Intemperate living, excess in drinking wines and liquors, overindulgence in rich foods, change of climate.

=Treatment.=—Proper elimination. Free use of all kinds of mineral waters, abstention from alcoholic drinks and moderation in eating. Exercise by walking and living in the open air may counteract any hereditary tendency to the disease. Cold baths, followed by massage, may be given to the sthenic patient, while the warm and tepid bath should be substituted for the asthenic type. Protect the body from exposure to cold. Flannel underwear should be worn.

_Diet._—Milk for liquid—no coffee or tea. Vegetables and fruit, excepting bananas, strawberries, tomatoes, oranges, lemons; fish, oysters and soup in small quantities; no fresh meat should be allowed for a time. Avoid hot breads, pastry of all kinds, spices and eggs.

DIABETES MELLITUS.

A disorder of nutrition, characterized by an accumulation of sugar in the blood, and excreted in the urine. The amount of urine is greatly increased, accompanied by progressive loss of flesh and strength.

=Treatment.=—Regulate diet, exercise and mode of living. A warm bath every other day and a Turkish bath every two weeks are very beneficial.

_Diet._—Avoid sugar, starch and all liquors. Patient may eat soups without vegetables and flour; fish of all kinds; meats and fats cooked in any way except with flour; gluten bread. Of vegetables—lettuce, cucumbers, spinach, tomatoes, onions, celery, radishes, cauliflower, cabbage, egg-plant. Of desserts—custard, nuts, acid fruits, ice cream without sugar. Of drinks—coffee, tea and buttermilk, lemonade, beef-tea, chicken broth, and egg-nog.

Fluid diet must be moderate, and sugar and flour must not be used in any form.

BRIGHT’S DISEASE.

(Acute Nephritis; Inflammation of the Kidneys.)

=Due= to the action of cold or toxic agents upon the kidneys.

_Causes._—Cold, poisons of specific fevers, toxic agents, pregnancy, blows and injuries of the back, lesions of the skin as in burns or in chronic skin diseases.

=Symptoms.=—Fever, pain in the back over the kidneys, nausea, vomiting, frequent desire to urinate, puffiness of the face, swelling of the ankles, extreme pallor of the skin, shortness of the breath, with the general appearance of complete exhaustion. The urine is very scanty and highly colored.

=Treatment.=—Rest in bed until all symptoms disappear. To promote activity of the skin and kidneys, alcohol or steam sweats should be given daily. To eliminate and purge the bowels give saline cathartics; and alkaline mineral waters may be used freely.

_Diet._—Buttermilk, gruels made of barley or arrowroot, or oatmeal water; animal broths and oysters; substitute cream-of-tartar lemonade or plain lemonade for tea or coffee. Pure milk should be taken freely.

UREMIA.

Uremia occasionally develops during the course of acute or chronic Bright’s disease and other maladies, the result of the retention or accumulation in the blood of an excrementitious material, supposed to be urea, the flow of urine being either normal, lessened, or increased.

TREATMENT FOR TUBERCULOSIS.

Fresh air and sunshine, a rest in bed from one to three months, and proper food are the three vital points of importance. Do not give too many baths.

=Diet= should consist of starch foods—60 per cent. Stale bread and crackers may be prepared in variety. Give albuminoids and tender meats. Milk and eggs should be given about six times a day.

FOR PATIENT IN SITTING POSITION.

A contrivance easily made and very useful in nursing cases where the patient is to be kept in the semirecumbent or sitting position, as, for instance, in pneumonia, or in operations on the upper abdomen, is arranged by taking a broomstick with the broom part sawed off. Wrap around this stick a blanket, large pillow, or something to make it resemble a knee bolster. Place this under the knees of the patient, and to each end of the broomstick attach a stout cord, which may be securely tied to the bed-posts at the head of the bed. This will add to the comfort of the patient in preventing the constant sliding down which is so difficult to prevent. It will also save the nurse a great deal of tugging and lifting.

MISCELLANEUOS NOTES AND REMEDIES.

COLDS.

This was one of the subjects of discussion at one of the meetings of the New York State Medical Association.

One physician thought that cold was only a predisposing factor in these cases, microbes being the chief element in the affection. At the beginning of an ordinary cold in the head the serous flow was an effort of nature to relieve the congestion and eliminate the infection, hence it should not be interfered with at this stage.

Another doctor said that while cold was a separate disease in the minds of the laity, to physicians it always meant a condition secondary to something else. A person with nasal polypi, for example, would complain of almost constant stuffiness of the nose; one with an enlarged lingual tonsil became hoarse after very slight use of the voice in singing.

Dr. —— —— ——, of New York, took up the treatment of colds. He thought some colds in the head are communicable, and that isolation might sometimes be a useful protective measure. Cod-liver oil was a good preventive for those who were in the habit of constantly catching cold. If the temperature was over 100° F., he insisted on the patient staying in bed, or at least in the house. A moderate dose of quinin and Dover’s powder at night, followed in the morning by a laxative, would cut short some colds. A hot mustard foot-bath increased the comfort of the patient. Rhinitis tablets were effectual if taken early, but persons susceptible to belladonna should be careful in using them. The alkaline treatment was often satisfactory—one dram of bicarbonate of soda in half a glass of water, with a few drops of lemon juice. Camphor internally and by inhalation often yielded good results. He was not a great believer in local treatment, though admitting that irrigation with saline solution was often useful. It was, however, dangerous except in skilful hands. When colds showed a tendency to recur, he advocated tincture chlorid of iron in large doses for two or three days, also cod-liver oil, quinin, or the vegetable bitters. Sometimes change of climate was the only cure.

=Cold a Germ Disease.=—Walsh, in the _Medical News_, says a very striking indication that cold is due to _microbic invasion_ is to be found in the fact that the process is nearly always accompanied by _fever_. A distinct period of incubation can be traced, and the efficient cause of the illness is commonly farther off than the patient imagines. The treatment advised when fever and chilliness occur is the use of calomel and hot drinks, especially cream-of-tartar lemonade, which acts as a diuretic as well as a laxative. A diaphoretic at the beginning of the affection will always give the patient comfort and may unload the system of enough depressed toxic material to enable it to react and bring about the abortion of a cold.

Other medical men objected to calling everything an infection. A common cold, they thought, was nothing else than the effect of the lowered temperature on the human system. The dry air of houses caused a chronic postnasal catarrh, which at times increased. To overcome susceptibility to catching cold, overdressing should be avoided and cold baths taken.

TREATMENT OF HYPERIDROSIS.

In sweating of the feet a single application of diluted formaldehyd will bring about permanent relief. For the axilla, use 10 drops of formaldehyd to 2 ounces of water.

TREATMENT OF ERYSIPELAS.

Apply a thick layer of white vaselin twice a day. Protect with linen and gauze bandages.

TO DISTINGUISH CHICKEN FROM SMALLPOX.

If the vesicle in chicken-pox is pricked with a needle, its contents can be completely evacuated and the cell will collapse; whereas, in small-pox the vesicle can be pricked twenty times and it will be impossible to empty it.

TREATMENT OF FELON.

A felon _may sometimes be_ aborted by the application of pure alcohol under exclusion of air. Cover the phalanx with a thin layer of absorbent cotton saturated with alcohol; over this put on a rubber finger-stall. In severe cases the tissues should be deeply incised.

TREATMENT OF BOILS.

Apply hot dressings; incise if necessary. The application of pure alcohol dressings and a plug of cotton saturated in the same solution and inserted in the wound promotes rapid healing.

TO DISLODGE AN INSECT FROM THE EAR.

Saturate a piece of cotton-wool in salt and vinegar. Fill the ear with it. Have patient lie on the ear and give firm pressure with the hand. The insect may be found on the cotton when the plug is taken out. Oil may be used as a substitute.[B]

[B] Foreign bodies in the ear usually cause far less trouble and harm than does the attempt to remove them by anyone not expert.

RELIEF FOR EARACHE.

Make a small funnel of paper, and saturate a ball of cotton with chloroform; drop it into the funnel. Place the funnel in the ear, draw a long breath and then blow the breath into the large end of the funnel; the fumes of the chloroform are thus carried into the ear, and all pain ceases at once. No doubt, heat is the best remedy of all.

RELIEF FROM FLIES AND MOSQUITOES.

Pour into an atomizer half a teaspoonful of lavender oil. Add to this as much alcohol as will make a saturated solution. Use as a spray. Sweet clover hung about the room will banish flies and mosquitoes. The drier the clover becomes the more effectual it is.

A BIT OF ANATOMY.

The entire adult skeleton consists of 200 distinct bones, as follows:

The spine or vertebral column (sacrum and coccyx included) 26 Cranium 8 Face 14 Os hyoids, sternum and ribs 26 Upper extremities 64 Lower extremities 62 ——— 200

The patellæ are included as separate bones; the smaller sesamoid bones and the ossicula auditus are not counted. The teeth belong to the tegumentary system.

BLOOD-CORPUSCLES.

The average number of red blood-corpuscles per cubic millimeter is about 5,000,000 for men, and somewhat less for women. The number is much increased in people who live in altitudes of about 8000 feet or more. The greatest decrease occurs in anemia, when they may number less than 1,000,000, and in leukemia, when there may be not more than 2,000,000.