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 a.s.sistance. 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, hoa.r.s.e, 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.

APPEt.i.tE or absence of appet.i.te 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 quant.i.ty 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, hoa.r.s.eness, loss of appet.i.te, 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 s.e.xes 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 appet.i.te 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" quant.i.ties. 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 att.i.tude 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?