Chapter 19

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).

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.

The pulse rate varies much more than the temperature. It differs in different individuals and at different ages, and it often shows great temporary changes, especially during exercise or eating, or as a result of excitement, fear, or other emotion. Definite statements in regard to normal pulse rates are hard to make, because different individuals though in perfect health show marked variations; we generally say, however, that the pulse rate of a normal man at rest is about 72 a minute, and that of a normal woman is about 80 a minute. At birth the pulse is quickest; it may then be from 124 to 144. From the 6th to the 12th month it may be from 105 to 115 a minute, and from 90 to 105 between the 2d and 6th years. About the time of puberty it reaches the adult rate, and during old age it may be decidedly slower than the adult rate.

What we chiefly want to know about the pulse is

1. Its rate, or number of beats per minute,

2. Its force,--whether weak or strong,

3. Its rhythm,--whether regular or irregular.

Much practice is necessary before the pulse rate can be counted with any degree of accuracy, and wide experience with both normal and abnormal pulses is required in order to judge its strength, rhythm, or other characteristics.

The pulse may be felt most conveniently on the thumb side of the front of the wrist. The pulse should be counted while the patient is lying down, and the watch used must have a second hand. To count the pulse, one should place two or three fingers (not the thumb) on the patient's wrist, and after the pulse has been felt distinctly for a few beats, the exact time by the second hand of the watch should be noticed and the counting begun immediately. It is generally best to count for half a minute, multiply the result by two to get the rate for a whole minute, and then to repeat for another half minute. The two results should agree within two beats, if the patient is quiet. A greater variation than two beats may mean that the pulse rate is varying, but when it is counted by inexperienced persons the apparent difference is generally the result of inaccurate counting, and it may be necessary to count two or three times more. The force of the pulse varies also in different individuals; it is, however, important to notice when it grows stronger or weaker in the same person. Normally the pulse-beat is regular like the ticking of a clock; it is called irregular if a few rapid or slow beats are followed by others of a different rate. During sickness the pulse should be counted whenever the temperature is taken, or oftener; and the result should be written down at once. The pulse of a sick person often shows changes both in rate and character; these changes are generally important and should be noticed.

RESPIRATION.--Variations in the rate and character of respiration or breathing should be noticed. The normal rate of respiration for an adult at rest is 16 to 20 each minute, but it may be much faster, especially during muscular exercise. In babies the rate is about 30 to 35 a minute, and 20 to 25 in little children. The respirations, especially of babies, can best be counted during sleep by placing the hand lightly on the chest or abdomen. Since the respiration rate is partly under a person's control, it is almost sure to alter if the patient knows it is being counted; hence when the patient is awake it is better to keep one's fingers on his wrist, to place his hand upon his chest, and then to count the rise and fall of the chest while apparently counting the pulse. Sometimes it is possible to count the respirations merely by watching the rise and fall of the nightgown or bed clothes. The respiration is usually counted for a full minute. A watch with a second hand must be used, and the result should be recorded immediately.

In certain forms of sickness breathing may become rapid, especially if the lungs or air passages are affected. In addition to the rate anything unusual about the breathing should be noticed whether it seems difficult or painful; if noisy, whether the sound is like snoring, or wheezing, or sighing, and so on.

GENERAL APPEARANCE.--Any unusual expression of the face should be noted; whether it is drawn, pinched, anxious, excited, or dull and stupid; and also, whether the face is thin, swollen, or puffy under the eyes. The condition and appearance of the skin are significant: the skin may be dry, moist and clammy, hot or cold; its color, and the color of the face especially, may be flushed or pale or slightly yellow or blue. A bluish tinge about the nose, tips of the fingers, or the feet should be specially noticed. Reddened or discolored areas on any part of the body may be important, and also eruptions, rashes, swellings, or sores. It should be noticed whether the abdomen is normal or whether it is distended and hard.

Strength or weakness is indicated to some extent by the way the patient moves, and by his ability to walk, stand, sit, hold up his head, feed himself, or turn in bed without assistance. The position he habitually takes is sometimes significant; in heart affections, for instance, he may be unable to lie down, in pleurisy he ordinarily lies on the affected side, and during abdominal pain he generally draws the knees up.

SPECIAL SENSES.--The special senses are frequently disturbed in sickness. The eyes may be blood-shot; the patient may be over-sensitive to light, or see spots floating before the eyes, or he may be unable to see at all. The pupils of the eyes may be unusually large or small, or one may be large while the other is small. Swelling, redness, or discharge from the eyes should be noticed. Hearing and touch and smell may be impaired; or they may be abnormally acute, and cause real suffering. Taste may be impaired, especially when the nose is affected or when the mouth is not clean. Discharge from the nose or ears should be reported. Not only discharge, but also trouble of any kind, such as pain, tenderness, or swelling, is important if situated in or near the ears.

THE VOICE is often much altered in sickness. It may be weak, hoarse, or whispered. Speech may be clear or thick, or the ability to speak may be entirely lost; in extreme weakness speaking is generally difficult, and may be impossible. Moaning, groaning, and other unusual sounds should be noted. A loud, sharp cry at night with or without waking, if a repeated occurrence, may be an early symptom of some diseases of children.

THE TONGUE in health is red and moist; when extended it is somewhat pointed and can be held steadily. In sickness it may be cracked, dry and parched, or if the patient is not properly cared for, it may be covered with white, yellow, or brown coating; in many exhausting illnesses it is flabby and trembling. In scarlet fever the tongue is often a vivid red color, and is then called strawberry tongue. The odor of the breath may be foul from decay or neglect of the teeth, from indigestion, constipation, nasal catarrh, or special diseases.

THE THROAT and tonsils are sometimes red and swollen as in simple sore throat; or they may be covered by white patches.

THE GUMS may be swollen, tender, or bleeding. A collection of sticky brownish material may appear on the teeth and gums of neglected patients.

COUGH when present may be: dry, or accompanied by expectoration; painful, frequent, loud, or whooping; and worse by day or by night. The sputum may be yellow, white, gray, rusty, blood-streaked, dark, or frothy. The amount of sputum should be noticed as well as its appearance.

APPETITE or absence of appetite should be noted, and also the amount of food actually eaten by a patient; the amount eaten is frequently not the same as the amount carried to him on a tray.

If VOMITING occurs, the color, consistency, amount, and general appearance of the vomitus should be noted; if its appearance is unusual the vomitus should be saved for the doctor's inspection.

EXCRETIONS.--The number of bowel movements is important, and also their character. The consistency of the feces may be hard, soft or fluid; their color may be any shade of brown, yellow or green, from black to clay color. They should be saved for the doctor to see if appearance or odor is unusual.

THE URINE in health is clear, amber colored, and slightly acid. From 30 to 50 ounces should be excreted in 24 hours; the amount varies, however, especially according to the amount of fluid taken. It is important to notice whether the urine is scanty or greatly increased in amount, dark or pale, clear or cloudy, and whether sediment is deposited after standing. It is essential that urine should be voided in sufficient amount; the necessity for watching its quantity is frequently overlooked in the home care of the sick. Frequency of urination should also be noted. Inability to urinate, particularly where the urine has previously been scanty, is serious if continued; it should be reported to the doctor without delay. Inability to control the bladder and bowels are also symptoms to be reported.

LOSS OF WEIGHT is significant in both adults and children, and failure of babies and children to gain in weight is a danger signal.

SLEEP.--The number of hours a patient sleeps should be noticed and recorded as accurately as possible. The word of the patient on this subject is not sufficient evidence. Character of sleep should also be noted, whether it is quiet or restless, and whether the patient sleeps lightly or is difficult to arouse.

MENTAL CONDITIONS.--It is important to watch carefully the mental condition of a patient; whether, for example, he is normal, or depressed, irritable, restless, apathetic, dull, excited, wandering, delirious, or unconscious. Hasty judgment of mental conditions should be avoided, but close attention to them is necessary.

SUBJECTIVE SYMPTOMS

PAIN is the most important subjective symptom and should never be disregarded. Bodily pain does not occur in persons who are in all regards physically and mentally well; hence pain is a sign that something, small or great, is out of order.

"Of all symptoms pain is the one which interests patients the most. We here emphasize the truth, too little understood, that pain is an unpleasant sensation, nothing more, and is _never_ imagined. Imagination may be its cause, but the pain thus produced hurts just as truly as pain produced by a real disease. Pain is only a phenomenon of consciousness; it is always real, even that felt in a dream. If the patient is too unconscious to feel it, there simply is no pain, no matter how badly the person's body is injured." (Emerson: Essentials of Medicine, p. 356.)

One should remember that no possible method exists to measure the intensity of pain exactly, or to describe its quality accurately. Therefore in describing pain, it is best to use the patient's own language. Four points should especially be observed, (1) its location; (2) its character, which may be dull or sharp, stabbing, throbbing or continuous, slight or severe; (3) the time at which it is worst; certain diseases, for instance, are characterized by more severe pain at night; (4) it should be noticed whether the pain is relieved or increased by change of position, eating or drinking, heat or cold, or the like. Pain may be felt in a part far from the place where the trouble really lies; thus a dislocated shoulder causes pain in the elbow.

Pain is always a danger signal, although the significance is not always so great as the sufferer thinks. The more attention a patient gives to his pain, the more severe it always becomes, therefore his attention should not be called to it unnecessarily. A good observer, however, can get much information by noticing the patient's expression, position, motions, etc., without constantly asking him how he feels. Although many persons overestimate pain, others persistently disregard it, either because they are unwilling to take the necessary measures to remedy it, or because they wish to appear heroic. Both courses of action are mistaken; everyone should realize the folly and danger of bearing pain if it is possible to remove the cause.

Nausea, fatigue and malaise are other subjective symptoms; malaise is the name given to a general feeling of physical discomfort not restricted to any one part of the body. All three are abnormal when there is not apparent or sufficient cause.

RECORDS.--An accurate record should be kept of the patient's symptoms, medicine, diet, treatment, etc., so that the doctor may have a continuous record, and so that another person taking charge temporarily may know just what has been done for the patient. The record must be written; otherwise details cannot be remembered exactly. It should be as simple and concise as possible; it is the place for facts, not for opinions, and if inaccurate it is worse than none. It is better not to keep the record in the patient's room, for the patient should not see his own record, nor hear its contents discussed. The doctor usually writes his orders on the record sheet itself, or on a separate sheet to be attached to the record for reference. Blank record forms can be purchased, but a form that is made at home is entirely satisfactory. An example of a daily record sheet follows.

RECORD

------+----------+----+-----+-----+----------------+----+-----+------- Date | Hour |Tem.|Pulse|Resp.| Diet and |B.M.|Urine|Remarks | | | | | medicine | | | ------+----------+----+-----+-----+----------------+----+-----+------- 1916 | | | | | | | | Jan. 1|4 p.m. |100°| 76 | 24 |Medicine | | | |5 p.m. | | | | | 1 |℥ vii| |6 p.m. | | | |Supper: | | | | | | | | Baked potato, | | | | | | | | toast, fruit, | | | | | | | | tea. | | | |8 p.m. | | | |Medicine | | |Sponge | | | | | | | |bath. |9:30 p.m. | | | | | | |Asleep. Jan. 2|3 a.m. | | | | | |℥ ix | |8 a.m. |99° | 74 | 22 |Medicine | | |Patient | | | | | | | |slept | | | | | | | |most | | | | | | | |of the | | | | | | | |night. |8:30 a.m. | | | |Breakfast: | | | | | | | | Cereal, orange,| | | | | | | | toast, coffee. | | | |9:30 a.m. | | | |Bath. | | | |11:30 a.m.| | | | | | |Sat up | | | | | | | |1 hour. ------+----------+----+-----+-----+----------------+----+-----+-------

TUBERCULOSIS, CANCER, AND MENTAL ILLNESS.--As we have seen, early symptoms of sickness are always important; yet it seems worth while to mention particularly the early symptoms of tuberculosis, cancer, and mental disorders, because each of these diseases, though curable in many cases when taken in the early stages, is serious and often fatal if neglected. Certain facts relating to their cause and prevention should be known to everyone. Tuberculosis, long our greatest cause of death, is gradually growing less; but cancer and mental disease are now on the increase.

TUBERCULOSIS.--Every year tuberculosis causes the death of about 150,000 people in the United States. It is caused by the bacillus tuberculosis, a germ which may attack any tissue of the body, although it most frequently affects the lungs of grown people, and the bones and glands of children. The disease is not inherited, but susceptibility to it appears to be; it is readily communicated from person to person. The germ of tuberculosis is so widely distributed that probably few persons over 30 years of age have not been infected with it at some time, although the infection may have been too slight to be noticed. Indeed, most people have probably been infected many times, though without serious results.

Tuberculosis is spread chiefly in two ways: (1) through any bodily discharges from infected persons, especially through the nose and mouth discharges; (2) through milk from infected cows. The ways by which the disease is spread indicate methods of prevention. Milk, especially for children, should either be pasteurized or should come from cows that have been tested and proved to be free from the disease. Other methods of prevention include avoiding any and all bodily discharges of infected persons, and increasing bodily resistance as far as possible. Good food, sufficient rest and fresh air are not only important preventives, but also the most efficacious means of cure. Persons who suffer from insufficient food, exposure, bad housing, long hours, and bad conditions of work are especially susceptible to tuberculosis, and thus it is rightly called a disease of poverty.

Early symptoms of tuberculosis include cough, hoarseness, loss of appetite, pain in the side, loss of weight, getting tired easily, feeling run down, rise in temperature in the afternoon, night sweats, expectoration, and spitting blood. No one, nor even several, of these symptoms necessarily indicates the presence of tuberculosis; on the other hand, even the cough is not necessarily present when tuberculosis actually exists. When one or more of these symptoms appears and continues, a thorough examination should be made by a doctor; examination can do no harm, certainly, if tuberculosis is not found, and if it is, immediate treatment is of the greatest importance. No known drug or medicine is a cure for tuberculosis. Successful treatment depends on taking the disease in time and in following the doctor's advice unremittingly.

CANCER.--The cause of cancer is not known. All the evidence, however, goes to show that it is neither communicable nor hereditary. Cancer may occur on the skin, stomach, or other organs; in women it most commonly occurs in the breast or uterus (womb). In both sexes it occurs most frequently after 40 years of age. No known medicine will cure cancer; salves and ointments have no effect. Radium and _x_-ray should not be relied upon if the cancer can be removed by operation. Safety consists in removing the growth entirely, and complete removal is possible only in the early stages.

Early diagnosis is consequently of the greatest possible importance, and an examination can do no harm in any case. Warts and moles on the skin may develop into cancer, and should be removed if they show signs of irritation. Loss of appetite and weight, any disturbance of the stomach or intestines, and sores that refuse to heal should lead a person to consult a physician; the same is true of any lump in the breast, and of irregular or persistent bleeding from the uterus in women over forty. The fact that pain is not present in cancer until the late stages leads many persons to neglect the trouble until it is too far advanced for operation. Time is all-important; hope depends on operation in the early stages when there is a very great probability of permanent cure.

MENTAL ILLNESS.--Insanity, like cancer, is increasing. Like both cancer and tuberculosis, hope lies in prevention and early treatment; and like them both, in its early symptoms it is too often unrecognized or neglected.

Many people are surprised to learn that known, avoidable causes are responsible for the condition of about 50% of the insane patients now under treatment. Chief among these known causes is a communicable germ disease called syphilis, to which is due the disease called paresis, or "softening of the brain." About 25% of patients admitted to hospitals for the insane are there from the effects of habitual use of alcohol, even in "moderate" quantities. Other cases of insanity result from diseases of the heart, arteries, and kidneys, and still others have been traced to the poisons of tuberculosis, typhoid, diphtheria, and other communicable diseases. Prevention of insanity caused by these diseases depends upon prevention or complete cure of the diseases themselves.

Still other causes of insanity are known. Hereditary nervous weakness may predispose to insanity, and for such persons, those whose nervous resistance is naturally not very great, the stress of living may prove too much. Mental breakdowns are rarely caused by overwork unless accompanied by worry or bad hygienic conditions, but they result not infrequently from bad mental habits.

"The average person, little realizes the danger of brooding over slights, injuries, disappointments, or misfortunes, or of an unnatural attitude towards his fellowmen, shown by unusual sensitiveness or marked suspicion. Yet all these unwholesome and painful trains of thought, may if persisted in and unrelieved by healthy interests and activities, tend towards insanity. Wholesome work relieved by periods of rest and simple pleasures and an interest in the affairs of others, are important preventives of unwholesome ways of thinking. We should train ourselves not to brood, but to honestly face personal difficulties."--(Why Should Anyone Go Insane?, by Folks and Ellwood.)

Prevention of insanity consequently depends chiefly upon avoiding alcohol and communicable diseases, especially syphilis; upon good hygiene, self-control, and avoidance of bad mental habits; and upon adopting a program of living and working that will not overtax one's nervous strength. Sleeplessness, unusual nervous fatigue following slight exertion, and diminished power to control the emotions, are among the danger signals. And when a person becomes unusually depressed or morose, excited or irritable, suspicious, unreasonable, or "queer," it is probable that expert medical advice should be obtained as quickly as possible.

EXERCISES

1. What is a symptom? Why are early symptoms especially important?

2. Distinguish between objective and subjective symptoms.

3. Tell all you can about normal and abnormal variations in the body temperature. What symptoms would lead you to take a person's temperature?

4. Describe the method of taking temperatures.

5. How should you cleanse a clinical thermometer? What are the dangers of neglecting to cleanse it properly?

6. Describe both normal and abnormal pulse and respiration.

7. Discuss the significance and importance of pain.

8. Describe early symptoms of tuberculosis, cancer, and mental illness. What is the first step to be taken when any one of these symptoms appears?

9. What symptoms of all those mentioned in this chapter did you notice in the last sick person with whom you had anything to do?

10. What are the essentials of a good daily record? The following is an account that a mother gave of the first twenty-four hours of a child's illness. Make a chart for the patient, and include in it all the information the mother gave. Which do you consider more useful, your chart or the narrative?

"Yesterday, October 10th, Johnny came home from school about half past three, and said he was too cold to play outdoors. He lay down and slept till about five, when he vomited a large amount of undigested food. I took his temperature and found that it was 103.8°, pulse 126, and respiration 28. At 10 that night his temperature was 102.5°, pulse 116, and respiration the same as before. The next morning at 8 he had a temperature of 100.6°, pulse 114, respiration 24. At noon his temperature was 101°, pulse 118, respiration 24; and at 4 o'clock his temperature was 100.6°, pulse 122, respiration 22. The doctor came at 6 o'clock yesterday afternoon; according to his orders I put Johnny to bed, gave him half a tablespoonful of castor oil at 6.30, and a special gargle. His throat was red and sore and he seemed to feel very miserable. The doctor took a culture from the child's throat. At 8.15 and again at 8.50 he had fluid bowel movements. At 9.30 he had a glass of milk, after which he slept until 6 a.m. when his bowels moved again and urine was passed. He passed eight ounces of urine at noon and four ounces at 3.30. He drank a glass of water at 6 this morning, and at 6.30 I gave him a cup of hot broth. At 8 he had a glass of milk, but at 10 he refused everything but a glass of water. At 1.30 he had a large dish of ice cream. He had a cool sponge bath last night at 9, and a cleansing bath this morning at 8.45. This morning his throat was still sore but not so red, and I saw that he gargled every half hour when he was awake. This afternoon he seems brighter and asked for his harmonica, so his throat is probably more comfortable."

FOR FURTHER READING

Essentials of Medicine--Emerson, Chapters XVI, XVII.

The Human Mechanism--Hough and Sedgwick, Chapter XII.

Notes on Nursing--Florence Nightingale, Pages 105-136.

Why Worry?--Walton.

Those Nerves--Walton.

Tuberculosis: Its Cause, Cure, and Prevention--Otis.

Publications of the National Association for the Study and Prevention of Tuberculosis--105 East 22d Street, New York City. (Pamphlets free on request.)

Publications of the National Committee for Mental Hygiene--50 Union Square, New York City. (Pamphlets free on request.)

Publications of the Mental Hygiene Committee of the State Charities Aid Association--105 East 22d Street, New York City. (Pamphlets free on request.)

Publications of The American Society for the Control of Cancer--25 West 45th Street, New York City. (Pamphlets free on request.)