CHAPTER II.

SYMPTOMS OF DISEASE, WITH INSTRUCTION TO NURSES.

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.

OF THE TEMPERATURE.

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.

THE RESPIRATION.

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.

OF THE AIR.

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.

VENTILATION.

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 SYMPTOMS OF INFLAMMATION.

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.

OF HEAT AS A SYMPTOM OF INFLAMMATION.

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.

ŒDEMA, DROPSY, ANASARCA.

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.