Unpacking Complexity In Informational Texts Principles And Practices For Grades 28 Sunday Cummins Elfrieda H Hiebert
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- 8. Also from Sunday Cummins Close Reading of Informational Texts: Assessment-Driven Instruction in Grades 3–8 For more information, visit the author’s website: www.Sunday-Cummins.com
- 9. Unpacking Complexity in Informational Texts Principles and Practices for Grades 2–8 Sunday Cummins Foreword by Elfrieda H. Hiebert THE GUILFORD PRESS New York London
- 10. ©2015 The Guilford Press A Division of Guilford Publications, Inc. 72 Spring Street, New York, NY 10012 www.guilford.com All rights reserved No part of this book may be reproduced, translated, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise, without written permission from the publisher. Printed in the United States of America This book is printed on acid-free paper. Last digit is print number: 9 8 7 6 5 4 3 2 1 Library of Congress Cataloging-in-Publication Data is available from the publisher. ISBN 978-1-4625-1859-3 (cloth) ISBN 978-1-4625-1850-0 (paper)
- 11. v About the Author Sunday Cummins, PhD, is an independent literacy consultant who lives in Chico, California, and consults nationally. Formerly, she was Assistant Profes- sor of Education in the Reading and Language Department at National Louis University and a facilitator for the New Schools Project at the Erikson Institute in Chicago. Before becoming a professor, Dr. Cummins worked in the public schools for 10 years as a middle school and third-grade teacher and as a literacy coach. She is the author of Close Reading of Informational Texts: Assessment- Driven Instruction in Grades 3–8, as well as articles in The Reading Teacher and Educa- tional Leadership, and shares her work on teaching with informational texts by presenting at state, national, and international conferences. Her website is www. Sunday-Cummins.com.
- 13. vii Foreword In the late 1990s, a 24/7 library opened on the Internet. More than 15 years later, this library is massive and increases in size daily. But it is not open to all. Lack of access to digital devices is one obstacle for many, but another obstacle as persistent and crucial is the technical proficiency required to use it. To make the best use of the explosive growth of information for the tasks of work, civic engagement, social interaction, and personal development, one needs to have a finely tuned set of strategies and skills. Most of these strategies and skills are especially relevant to informational texts because these texts— whether traditional print books or unique new forms (e.g., graphic and oral presentations)—dominate in the digital– global age and play a central role in 21st- century classrooms. Simply providing students with infor- mational texts is no longer sufficient, nor is engaging students in read- alouds of compelling texts or having them write the proverbial research report on animals (grade 2), plants (grade 3), states (grade 4), or countries (grade 5). Teachers now face the new demands of instructing students in acquiring knowledge and, even more important, acquiring it independently and at increasingly more complex levels. The goal of the new- generation standards for English language arts (ELA), such as the Common Core State Standards, is to ensure that students have the capabilities and proficiencies for using texts to learn. But teachers need more than standards— they need to know how to select texts and create experiences that help their students acquire the skills and strategies to learn from complex informa- tional texts. Teachers also need to understand how the structures and purposes of these texts contribute in essential ways to creating and communicating meaning. In this timely book, Sunday Cummins addresses these critical issues. Sev- eral features of the book especially are important in understanding the nature of teaching for knowledge in today’s classrooms. Its underlying theme is the need
- 14. viii Foreword for teachers to understand what makes informational texts complex and unique. Authors of informational texts choose from a variety of text structures to orga- nize content based on the purpose they have in mind. They assume a certain level of background knowledge on the part of their readers, they use a more formal tone than that frequently found in literary texts, and they use graphics, such as maps and charts, all of which make informational texts complex. Another significant feature of informational texts is a more specialized vocabulary, which can be a persistent challenge for school- age readers encounter- ing new content. Words, after all, are the means whereby ideas are communi- cated. Informational texts are written to convey unique ideas on specific topics, which means that readers can anticipate that an informational text on a particular topic will have a set of words that are likely to be unfamiliar. A text on gold can be expected to have words about characteristics (e.g., malleable, ductile) and processes (e.g., dissolving, corrosion), whereas a text on an archaeological find such as the terracotta warriors of ancient China has another unique vocabulary (e.g., archae- ologists, excavated, replica, figurines). Authors of informational texts do not use synonyms for archaeological or corrosion but rather choose this unique vocabulary repeatedly to convey information accurately (Hiebert & Cervetti, 2012). When readers know that words critical to understanding the topic are repeated, they can anticipate that they might not understand a word on the first exposure but that they will have subsequent opportunities to learn more about a word’s meaning as they move through the text. Although Cummins does not develop this line of inquiry, the vocabulary of informational texts differs from that of literary texts in other ways. To communi- cate ideas about content, authors of informational texts often need to draw heav- ily on a group of words called general academic words (e.g., compared, developed). Many of these words are among the 2,500 complex word families that account for approximately 90% of the total words in both informational and literary texts (Hiebert, 2014). But frequency of a word should not be equated with ease of understanding. As the following two examples illustrate, a word may appear in both literary and informational writing, but the meaning can vary. James got into his own hammock and oh, how soft and comfortable it was com- pared with the hard bare boards that his aunts had always made him sleep upon at home. (Dahl, 1961, p. 13) This table compares how much a kid might weigh on the Moon, the Sun, and different planets. Which one has the strongest pull? (Beale, 2009, p. 17) In the literature excerpt, compare conveys a noting of similarities and dissimilari- ties. In the informational text, the reader is asked to use the process of comparing to establish specific differences in measurement.
- 15. Foreword ix General academic words also are typically abstract and multisyllabic, fea- tures that can hinder students’ ability to automatically recognize what the words mean. Moreover, the same form of a word can take on different functions (e.g., progress as a noun and verb). In informational texts, verbs can be transformed into nouns—a process called nominalization, a word that itself comes from a verb (nominalize). Other words have common meanings in everyday conversation but precise and technical meanings in content areas (e.g., force). Often, general academic words are in the instructional background, while the content vocabulary of a topic is in the instructional foreground. To under- stand this unique vocabulary, however, requires a facility with general academic words since they are used to explain and describe ideas. The foregrounding of content vocabulary is to be expected in high school content- area classes, which is precisely why facility with general academic words needs to be developed by ELA teachers in the elementary and middle school grades. Classrooms in which the aim is expanding students’ capacity to comprehend increasingly more complex informational text should have many books, maga- zines, online resources, and so forth, for instructional enrichment. Students are acquiring funds of information as they read these materials. For example, after reading the book The Emperor’s Silent Army (O’Connor, 2002), students will have learned about ancient cultures, in particular the nature of emperors in ancient China, and also about the critical role of artifacts in understanding ancient cul- tures. Through reading informational texts, students gain new knowledge that in turn will serve them well as background knowledge for additional reading. Students will have a deeper understanding of The Tale of the Mandarin Ducks (Paterson, 1990) as a result of what they learned about Chinese emperors in The Emperor’s Silent Army (O’Connor, 2002). Increasing capacity for knowledge acquisition with informational texts, how- ever, is not a substitute for in-depth content- area instruction. Through reading informational texts as part of ELA instruction, students can gain knowledge about a topic, but the emphasis in the ELA lesson is on the purpose of the text, the nature of vocabulary in the text, and the structure of sentences and para- graphs that the author uses to communicate aspects of the topic. However, with repeated exposure to the language and structures of complex text, students will be better able to absorb new content in social studies and science, whether it is the facets of different cultures or the elements of the periodic table, as they pursue a deeper knowledge. As Sunday Cummins demonstrates, ELA teachers face challenges in deter- mining how best to support students with complex informational texts. But the rewards are many. In particular, the compelling content of informational text—a terracotta army hidden for centuries, the training of rescue dogs, discoveries of
- 16. x Foreword new species in the deepest parts of oceans— all but guarantees student engage- ment. At the same time, students are acquiring a critical trove of information and a proficiency in reading increasingly complex texts in ways that underlie success- ful participation in the digital– global age. Here is the guidebook that teachers will want to use to design and implement lessons, tasks, and activities that unpack the complexity of informational texts and support students’ capacity to access today’s content- rich world successfully. Elfrieda H. Hiebert, PhD TextProject and University of California, Santa Cruz References Beale, K. (2009). Gravity is everywhere. New York: Amplify. Dahl, R. (1961). James and the giant peach. New York: Puffin Books. Hiebert, E. H. (2014, July 19). Development and application of a morphological family data- base in analyzing vocabulary patterns in texts. Paper presented at the annual meeting of the Society for the Scientific Study of Reading, Santa Fe, NM. Hiebert, E. H., & Cervetti, G. N. (2012). What differences in narrative and informa- tional texts mean for the learning and instruction of vocabulary. In J. F. Baumann & E. J. Kame’enui (Eds.), Vocabulary instruction: Research to practice (2nd ed., pp. 322– 344). New York: Guilford Press. O’Connor, J. (2002). The emperor’s silent army: Terracotta warriors of ancient China. New York: Viking Juvenile. Paterson, K. (1990). The tale of the Mandarin ducks. New York: Puffin.
- 17. xi Contents Introduction: The Issue of Informational Text Complexity 1 One What Do We Mean by Text Complexity? 7 Two What Makes an Informational Text Complex? 13 Purpose and Ideas 13 Structure 19 Language and Vocabulary 24 Knowledge Demands 26 Three What Do We Mean by an Author’s Purpose? 30 To Instruct 32 To Recount 33 To Explain 34 To Describe 36 To Persuade 36 Recommendations for Instruction 38 Four What Do We Mean by a Text’s Structure? 44 Enumerative Structure 45 Sequence, Chronology, and Narrative Structures 48 Comparison Structure 53 Causal Relationships 55 Problem–Solution Structure 57 Recommendations for Instruction 58
- 18. xii Contents Five What Types of Details Are in Non‑Narrative Texts? 66 Details in Texts about Systems 68 Details in Texts about Mechanisms 69 Details in Texts about Processes or Transformations 70 Details in Other Non‑Narrative Texts 71 Recommendations for Instruction 73 Six What Types of Details Are in Narrative Texts? 87 Frequently Used Details 87 Details That Reveal an Author’s Bias 90 Recommendations for Instruction 92 Seven Why Pay Attention to Connective Language? 97 Additive Connectives 98 Temporal Connectives 100 Causal Connectives 102 Adversative Connectives 103 Recommendations for Instruction 104 Eight How Are Main Ideas Constructed? 107 Gist, Theme, and Topic 107 Relationships between Ideas Reveal the Main Idea 110 Main Idea Vocabulary 114 Recommendations for Instruction 115 Closing Thoughts 125 Appendix. Study Guide 133 References 139 Index 143
- 19. 1 Introduction The Issue of Informational Text Complexity Take a moment to read the following excerpt from Bones: Our Skeletal Sys- tem by renowned author Seymour Simon (2000). As you read, consider what you are learning about Simon’s topic: the backbone. Your backbone, or spine, is a flexible column of bones that runs down the middle of your body. It is made up of a chain of thirty- three small bones called vertebrae, which are fastened one on top of another. Each vertebra is hard and hollow, like a bead or a spool of thread. The joint between each vertebra allows only a small amount of movement, but together the vertebrae form a flexible chain of bones that can twist like a string of beads. Your spine lets you bend down and touch your toes, and at the same time it keeps your body upright. (n.p.)1 In this one paragraph, Simon has developed a vivid picture of the backbone. He has included enough details about the physical features of the spine that we can understand why it allows us to bend down but not flop over. Simon writes skill- fully with careful attention to detail, fully aware of his audience. Despite the clar- ity of the writing, there is still a lot of information and details for the reader to learn and retain. Many students would be overwhelmed by the task of “recalling” what they learned in this one paragraph, specifically because this is a complex text for them. But what if, in order to learn Simon’s content, these students understood how informational text authors such as Simon craft their texts? How the author has a purpose? How the purpose drives the author’s structure of the text? How 1Excerpt from Bones: Our Skeletal System. Copyright © 2000 by Seymour Simon. Used by permission of HarperCollins Publishers. All rights reserved.
- 20. 2 UNPACKING COMPLEXITY IN INFORMATIONAL TEXTS the author makes choices about using particular words and phrases that create a cohesion or logical flow of ideas? How this all contributes to the development of the author’s main ideas? Let me explain by returning to Simon’s text for a closer analysis. The author has two purposes for the book from which this passage is excerpted. The first is to describe bones and groups of bones in our skeletal system and the second is to explain how these skeletal features help us. At the whole-text, or macro level, he uses an enumerative text structure in that he introduces a larger topic, the skeletal system, and then moves on to discuss subtopics such as the spine, the rib cage, and the bones of the arm. Each subtopic addressed contributes to a larger under- standing of the larger topic, the skeletal system. In the passage, Simon employs several types of details to describe the spine. He names the subtopic (“the backbone, or spine”) and then gives us the location of this group of bones (“down the middle of your body”). He zooms in closer to the subtopic and identifies the parts of the backbone (“vertebrae”) and how many there are (“thirty- three”). Then he addresses the organization of the vertebrae (“fastened one on top of another”), followed by a description of their physical attributes (“hard and hollow”) and a comparison to an everyday object (“like a bead or a spool of thread”). All of these details are given in just the first three sentences of the passage. In the last three sentences, the author returns to the larger subtopic, the spine, and makes a case for the spine’s flexibility. The word but is an adversative connective that reveals the relationship between two ideas. Simon presents the idea that “each vertebra allows only a small amount of movement,” and then, with the word but, he provides the contrasting idea that “together the vertebrae form a flexible chain of bones that can twist.” He reinforces this fact with a comparison (“like a strong chain of beads”). The last sentence includes an additive connective, “at the same time,” which reveals to the reader that the spine allows a person to “bend down and touch” her toes while also keeping her “body upright.” Finally, there is cohesion in this passage. The author’s purpose, his structure of this passage (as well as the whole book), and the types of details and connec- tive language he has chosen all contribute to the logical flow of ideas. If a reader can keep in mind the different aspects of this complex text that I have described, surely she would be more likely to understand and remember what she reads. What’s more, the reader may grasp one of Simon’s main ideas: that the spine is a sophisticated system of parts with an important function. But it’s harder than this, right? Because, in this case, the reader who just analyzed Simon’s text is not “every reader.” The reader (me) who did this analysis owns a collection of Seymour Simon’s books and has closely read hundreds of informational texts. This reader has extensive background knowledge about the purposes, structures, language choices, and the types of details informational text authors use to convey ideas. This reader knows what vocabulary words such as
- 21. Introduction 3 column, fastened, bead, and spool of thread mean and has some background knowl- edge about the skeleton. And, not to be taken for granted, this reader is moti- vated to understand the text. Hosting learning spaces where students become proficient at reading these texts is a daunting endeavor, but not an insurmountable one. This is especially true if we, as educators, understand the complexity of informational texts in gen- eral, as well as what might make a text complex for particular readers. We have to follow by teaching in a way that has generative value, coaching our students at their points of need. So, what are the implications for our daily practice? Let’s consider your own experience as you read Simon’s text and then thought through my analysis of it. Did your understanding and recall of Simon’s content expand between the beginning and end of this experience? In order to make a text’s complexity visible to students, we ourselves have to understand what makes a text complex. In a sense, we must be able to diagnose the complexity of a text while planning to teach and in the moment of teaching. As educators, we also need to consider whether the tasks we assign students really help them understand how to grapple with complex texts. Many tradition- ally assigned tasks take for granted what the reader must do to read and learn from a text. When we ask students to write what they know about a topic, what they want to know, and what they learned, we are assuming that these students understand the content (and just need help categorizing it). What if they do not? Locating and writing answers to questions in a text also assume a certain capac- ity for grappling with content in a text and how the content is presented. Making connections and asking questions will not get you far in retaining the details in Simon’s text if you do not also grasp his logic and attention to detail.
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- 23. A particle of foreign matter entering the eye will often produce such a flood of tears that it is soon washed out, especially if the eye be kept closed and not rubbed for a few minutes; but sometimes the irritating substance finds its way under the upper eyelid, and remains fixed there by the pressure of the lid. In some cases plunging the face into cold water and opening the eyes under the water will suffice to remove it, but generally the eyelid requires to be turned inside out, and the offending body picked off with a feather; or the upper eyelid drawn forwards off the eye by means of the eyelashes, and the lower eyelid pushed up under it: when the eyelids are released, the eyelashes of the lower lid will brush over the inner surface of the upper lid, and almost certainly remove any substance that may lodge there. To evert the lid, lay a bodkin or pencil along it, and turn it up by taking hold of the eyelashes about the middle, the patient meanwhile looking down. Should such simple means fail, the eye may be tied up with a pad of cotton wool over it, so as to prevent the eyelid moving till professional advice be secured. Serious damage is frequently occasioned by lime or other caustic substance getting into the eye. Wash the eye as quickly as possible thoroughly with cold water or vinegar very much diluted with water (say 1 teaspoonful vinegar in 2 oz. warm water), a stream being allowed to course across the opened eye, while any particle of caustic substance that remains should be carefully removed. A drop of castor oil or olive oil applied every half-hour to the inside of the eye will greatly allay irritation. Never bandage or poultice. In all cases of injury the less done at home the better. A light pad of cotton wool applied over the closed lids and kept in position by a handkerchief or a pledget of cotton wool soaked in cold water reapplied cold at least every 5 minutes, may be employed till the doctor comes. Dr. Louis Fitzpatrick says he has never seen a single instance in which a stye continued to develop after the following treatment had been resorted to: The lids should be held apart by the thumb and index finger of the left hand, or a lid retractor, if such be at hand,
- 24. while tincture of iodine is painted over the inflamed papilla with a fine camel’s-hair pencil. The lids should not be allowed to come in contact until the part touched is dry. A few such applications in the 24 hours are sufficient. (Lancet.) Hair complaints.—Ladies should undo their hair at night, unplait the hair, and wear it loosely in a net. In this way the nourishment of the hair is duly provided for. Night-caps should always be light. When forced to remain in bed for long periods, through illness, have the hair oiled and combed with a coarse comb daily; if circumstances permit, the head may be washed twice a week with soap and water, warm, lukewarm, or cold, as taste or health directs. In long- continued illness, it is often advisable to cut the hair, so as to reduce its length by about a third, not merely from considerations connected with the cleanliness of the hair, but also that stronger aftergrowth may be encouraged. Few realise the injurious effects of curling-irons and hair-dyes. Ordinary baldness may be constitutional or local. The former is a matter for the medical man. For persistent daily loss of hair, the following remedy is recommended by Pincus:—15 gr. soda bicarbonate dissolved in 1 oz. water; a little to be well rubbed into the scalp daily, and persisted in. Sir Erasmus Wilson says that a lotion composed of 1 oz. each spirits of hartshorn, chloroform, and sweet almond oil, added to 5 oz. spirits of rosemary, and well rubbed into the roots of the hair after brushing, is effective; it may be used half-strength, diluted with eau-de-cologne. Other lotions are:—(a) 2 dr. tincture of Spanish flies, ½ oz. tincture of nux vomica, 1 dr. tincture of capsicum, 1½ oz. castor oil, 2 oz. eau-de-cologne; apply night and morning with a sponge to the roots of the hair after brushing. (b) 2 oz. spirit minderus, ½ dr. ammonia carbonate, ½ oz. glycerine, ½ oz. castor oil, 5 oz. bay rum; apply as in (a). These will be found serviceable in the treatment of commencing general baldness, where the whole scalp is parting with its hair. Singeing the hair is not of the slightest use for hair stimulation, and the frequent use of the “curling-tongs” cannot but be detrimental to the health of the head-covering. When the hair demands a tonic application, the
- 25. following—which any chemist will compound—may be tried:—1 oz. tincture of red cinchona bark, 2 dr. tincture of nux vomica, ½ dr. tincture of cantharides, add eau-de-cologne and coconut oil to make up 4 oz.; apply to the roots of the hair with a soft sponge night and morning. Where means are being taken to restore the health in cases of sudden or premature greyness of hair, Dr. Leonard recommends the following application:—2 oz. coconut oil, 3 dr. tincture of nux vomica, 1 oz. bay rum, 20 drops oil of bergamot. Washing with egg yolk is highly commended in such cases. The common trouble known as dandriff (dandruff) frequently occurs in strumous (scrofulous) individuals who are anæmic (poor- blooded) and have a sluggish circulation, marked by cold hands and feet. Adolescence is its peculiar time of appearance, and chlorotic (greenish skinned) young girls are apt to be annoyed by it. It is an attendant upon chronic debilitating diseases, as rheumatism, syphilis, phthisis, and the like, and comes on after profound disturbances of the constitution, such as fevers and parturition. Dyspepsia and constipation are very common exciting causes or aggravants of the disease. Improper care of the scalp, the use of the fine-toothed comb, and of pomades, hair “tonics,” and hair-dyes will give rises to disorder. A good deal in the way of prevention, according to Dr. Jackson, can be accomplished by proper care of the scalp and general health. The brush should have its bristles well set into the back, placed in little clumps at regular distances and rather far apart, and those in each clump should be of unequal length and arranged so that the longest ones are in the centre of the group. It is well to have two brushes, one stiff enough to warm the scalp when used with vigour, and one quite soft. The comb should be made with large teeth set wide apart; held up to the light the teeth should show no roughness or inequality of surface. The fine-toothed comb should be banished from the toilet table, as it is an active agent in producing inflammatory conditions of the scalp. In the morning the hair should be thoroughly opened up in all directions with the comb, and it and the scalp brushed vigorously with the stiff brush. Then the soft
- 26. brush should be used in parting the hair, in polishing it, and in subsequent brushings during the day. Do not wash the head too much. The so-commonly practised daily sousing of the head in water is hurtful to the hair and scalp, especially if they are not carefully and properly dried afterwards, and a little oil or a vaseline rubbed into the scalp. It is not the daily sousing which is objectionable, but the insufficient aftercare. Water renders the hair dry, and the daily sousing only washes the head superficially. A good shampoo every week or ten days for those persons exposed to a good deal of dust, and every 2-3 weeks for other people, is sufficient for cleanliness. For the shampoo, soap and water, borax and water, or the yolk of an egg beaten up in lime water, are all simple and good, but it must not be forgotten to wash out these materials with plenty of clean water, and to thoroughly dry the hair and scalp. Patent hair “tonics,” pomades, washes, and dyes are to be avoided. None of these dressings is needed by the healthy scalp, and proper care will preserve the hair in better condition than they will. The nearer the body can be kept to the standard of perfect health by means of bathing, exercise, and good diet, the less likely is dandruff to develop. When, therefore, the disease has appeared, first inquiries should be concerning the general health, and first efforts addressed to remedying anything found to be wrong. If the case presents itself with a decided accumulation of scales, or if crusts are present, saturate with sweet almond oil, before going to bed, and place over the head a flannel cloth soaked in the oil, and outside of all an oiled silk cap. Next morning shampoo thoroughly with soap and water, using by preference the tincture of green soap, and wash out the soap with plenty of water. The scalp is then to be dried by vigorous rubbing with a coarse towel, and the hair by pulling it through a soft towel. If the crusts by this method are not completely removed, the oil should be kept on during the day, the head again soaked at night, and washed with the soap and water in the morning. If the scalp should appear very hyperæmic after the
- 27. crusts are removed, anoint the head with red vaseline or some simple ointment, as rose ointment, until lessened. When the crusts are removed and the hyperæemia overcome, have an ointment composed of 1 dr. sulphur loti to 1 oz. vaseline, applied every morning to the scalp. If the scales form rapidly, apply every night, and the sulphur ointment every morning, and wash the head every second or third day. As soon as scaling is lessened stop the use of the oil, but continue the ointment, at first using it every second morning, then gradually reducing its application to once a week. Throughout this plan of treatment the head should be shampooed about once a week with a tincture of green soap, borax and water, or the yolks of 3 eggs beaten up in 1 pint lime water, to which ½ oz. alcohol is added. Another excellent ointment for these cases is composed as follows:— ℞ Hydrarg. ammon. gr. xx. Hydrarg. chlor. mitis. gr. xi. Petrolati 1 oz. This applied once or twice a day has yielded admirable results in a number of cases of simple dandruff. Its consistence, being that of a salad dressing, renders it an elegant pomade for private practice. Its use should be combined with the occasional shampoo as directed above. The persistent and systematic use of either of the two plans of treatment, together with a proper oversight over the general health, should cure every case of dandruff. But be prepared for occasional relapses. Headaches.—Headaches vary much in degree and in kind. Their causes may be grouped under 3 types—(1) when the blood-supply of brain and body is at fault; (2) when some distant organ (such as stomach or liver), with which the brain is in sympathy, is out of order; and (3) when there is some affection of the nervous system, and especially of the brain: or “circulation,” “digestive,” and
- 28. “nervous” headaches. Circulation headaches arise from the condition known technically as anæmia (bloodlessness) of the brain, in which the mental powers are weakened, and much brain-work will result in headache. Chief among its causes are a feeble heart and excessive drain on the system, especially among women, the evil frequently lying in the excessive use of purgative medicines. Hyperæmia (excessive blood supply) may also give rise to headache in those who use the brain to such an extent as to cause excessive waste, to repair which an increased flow of blood to the head takes place, and may be so great as to overwhelm the nerve-centres. This is often aggravated by an irregular mode of life and too much stimulants. Interference with the blood return to the heart may be due to causes within the chest, such as chronic bronchitis or heart obstruction, to swellings in the glands of the neck pressing on veins which convey the blood back to the heart, and improper dress, such as tight stays, or tight collars and cravats. In the bilious or dyspeptic headache, also known as the “sick headache,” the brain sympathises with the stomach or liver in its affliction, and thus is due to those errors of diet which lead to indigestion or dyspepsia, e.g., unwholesome food, late suppers, hasty and inefficient mastication, and continuous drinking and wine- bibbing. The nervous system itself seems to be chiefly at fault in organic, nervous, and neuralgic headaches. The organic headache often precedes insanity. The nervous headache, more commonly known from the nausea and vomiting which occur during an attack, as “sick headache,” is due to various exciting causes, such as brooding over unpleasant thoughts, bodily fatigue, dietetic errors, too little exercise, overstraining of vision, loud noises of a disagreeable character, unpleasant smells, and even disturbances of the weather; it is often inherited. The attack may sometimes be warded off by the application of atropine; the tendency to attack has been got rid of by the use of a proper pair of spectacles. The neuralgic headache is a form of tic douloureux, has its seat in one or other of the nerves of the head, and may be excited by decayed teeth, exposure to cold,
- 29. and similar causes. It rarely occurs, even in those conditions, unless the nervous system is lowered in tone. Many people have decayed teeth without suffering the slightest ache so long as they keep their health at par. Too much work, bodily or mental, or exposure to conditions which act injuriously on the health, result in a neuralgic headache. Any irregularity in the mode of life, such as errors in diet and drink, must be particularly shunned by those who are liable to any form of headache. Where alcohol is found to do good, it should be taken only in small quantities and with the meals. All worry and excitement must be avoided. Sleep in sufficiency, as well as moderate exercise, is essential. When headaches continue to burden the frame and to make life miserable, change of air or scene, prolonged absence from business, pleasant society, music, and other enjoyments may help to get rid of them. Sometimes all that is wanted may be cod-liver oil, or some other nutrient and tonic medicine. During the paroxysms of sick headache, complete rest on sofa or bed in a darkened room is found by many to be the only thing which gives relief; while others believe they are assisted to endure by drinking cups of strong tea or coffee. Those who suffer from this tendency, and disorders of vision, should consult an oculist regarding the condition of their eyes. (Dr. Maxwell Rose.) Indigestion.—Indigestion may be due to the food or condition of the stomach. The food may be defective in quality. There may be excess or deficiency of the normal ingredients, saccharine, starchy, albuminous, or fatty, or some of the natural indigestible materials which form a part of all food. The food may be introduced in an indigestible form on account of defects in the cooking of it, or imperfect mastication, or from its having undergone putrefaction or fermentation, which arrests the functions of the stomach. Imperfect mastication of food is a very common cause of indigestion. Eating too much is probably the most common of all causes of indigestion. The secretion of the gastric juice in the stomach seems to be proportioned to the amount of material required for the nourishment of the system. Food taken in excess of this amount acts as a foreign
- 30. substance undergoing fermentation and putrefaction, and occasioning much disturbance in the system. Much may be done for the cure of indigestion by eating very abstemiously of suitable food, thoroughly masticated, taking exercise in the open air, breathing pure air, and observing the laws of health generally. The amount of food should be reduced until the quantity is reached which the stomach can digest without evincing any symptoms of indigestion. Hot water of a temperature varying from 110° F. to 150° F., has been found highly serviceable in relieving painful conditions induced by improper feeding. This beverage, diluting the ordinary fluids and secretions of the digestive system, effects the work of the liver and kidneys, and produces the happiest results. Dr. Cutter, of New York, has summarised the methods of using hot water. He tells us that the water must be really hot, and not merely lukewarm. If lukewarm, it will only excite vomiting; whereas, when really hot, it appears to soothe the irritable lining membrane of the stomach and bowels. The quantity of hot water to be taken at a draught, according to Dr. Salisbury, varies from ½ pint to 1 pint or more at a drinking. The test of benefit being derived from the use of hot water is said to be that derived from the kidney-secretion, which should be pure, free from odour and deposit. Regarding the times at which hot water should be taken, 1-2 hours before each meal, and ½ hour before retiring to rest, are stated as the periods most suitable for its administration; while the water must be sipped, and not taken so fast as to cause distension of the stomach. Dr. Cutter says that ¼-½ hour may be consumed in the draught of hot water. This form of hydropathic treatment, according to the authorities just named, should be practised in cases of digestive troubles for a period of 6 months or thereabouts. Regarding the amount of liquid to be taken with a meal, not more than 8 oz. has been prescribed as the regulation quantity; a larger amount tends to dilute the gastric juice to too great an extent. Various additions may be made to hot water by way of rendering it palatable, although persons accustomed to drink it in time learn to like it.
- 31. Dr. Milner Fothergill made some experiments with our ordinary native fruits, to test the value of correcting the acid by means of alkali to render the fruit more suitable for dyspeptics. The result was that the amount of bicarbonate potash required for each lb. of fruit was found to be about as much as would lie upon a shilling. With all fairly ripe fruit this is just sufficient to neutralise the acidity, and bring out the natural sweetness; indeed, the resultant product was quite sweet enough for most adult palates. Such stewed fruit can be eaten alone, or with milk puddings, cream, or Swiss milk; gooseberries, currants, apples and plums are excellent when so prepared. With dark fruits, as the black plum, the colour is impaired by the alkali, and the fruit is less attractive to the eye than is that of the ordinary stewed fruit, which is of a deep clear crimson. A little cochineal will give the desired colour. Where there is no natural sweetness, to neutralise the acid completely by an alkali leaves nothing, simply a cold mass, to which the palate is indifferent. Such is the case with rhubarb. Here it is well to use half or all the amount of alkali with some sugar. The same is the case with early gooseberries before they have any natural sweetness; no sugar formed in them. Here the full quantity of alkali should be used, and the remaining acidity be met by sugar. When ¾ lb. of sugar is required to sweeten 1 lb. of fruit, only ¼ lb. of sugar is necessary after the alkali has been added. The sour-sweet taste is thus secured, which is toothsome. In these two instances the stewed fruit is only rendered less objectionable to the stomach plagued with acidity, not made quite inoffensive. Infectious Diseases.—All infectious (catching) diseases have several features in common. They begin with a period of dormancy (“latency” or “incubation,”) during which the poison is actively developing. The duration of this period in smallpox is 12 days; in typhus fever, 8-14 days; in typhoid fever, 14-21 days; in scarlet fever, 3-6 days; measles about 4 days, at the termination of which the sickness is said to begin, though its distinctive characters may not appear for some days longer. These diseases (fevers) all commence with a marked, and sometimes sudden, elevation of bodily
- 32. temperature, which, with variations, continues during the course of the illness. Characteristic eruptions appear in scarlatina on the 2nd, smallpox on the 3rd, measles on the 4th day, and so on; with them begins the infection, and increases with the activity of the disease. The following table, modified from that given by Domville in his ‘Manual for Hospital Nurses,’ is exceedingly useful:— Name. Period of Dormancy. Day of Rash. Characters of Rash. Duration of Illness. Observations. Chicken- pox. 21 days — Small rose pimples, becoming vesicles. 6-7 days. Erysipelas 3-7 days 2nd or 3rd. Diffuse redness and swelling. — Most common in face and head, and after surgical operations or injuries. Measles 10-14 days. 4th day of fever. Small red dots like fleabites. 6-10 days. Accompanied with running at eyes and nose. Relapsing Fever. Sudden — Purpuric spots — Caused by want of food. After 7-14 days from the first attack, and during convalescence, it is liable to recur 2 or 3 times. Scarlet Fever. 4-6 days 2nd day of fever. Bright scarlet diffused. 8-9 days Very infectious. Often accompanied by sore-throat, followed by desquamation (peeling off of the skin). Smallpox 12 days 3rd day Small red pimples, becoming 14-21 days. Discrete or confluent. Great pain in back and
- 33. vesicles, then pustules. intense headache. Secondary fever sets in about 11th day of disease. Typhoid Fever. 10-14 days or suddenly 7th to 14th. Rose- coloured spots, few in number. 22-30 days. Seldom infectious. Usually caused by bad drainage. Accompanied by diarrhœa and sometimes bloody stools. Typhus Fever. 1-12 days. 4th to 7th. Mulberry colour general over abdomen. 14-21 days. Very infectious. Usually caused by over-crowding and destitution. In scarlet fever, infection is due to the particles which peel off from the skin, the patient should be anointed once a day with carbolic oil, made with 1 part carbolic acid to 50 of olive oil. The efflorescence (peeling off) occurs first on the skin of neck and arms, sometimes as early as the fourth day. The anointing should include the head, the oil being freely applied to the roots of the hair, and continued for 6 weeks, a warm bath being given weekly during that time. After 6 weeks, the patient may mix with the other members of the family; but children should not return to school for 2 weeks longer. In measles, the same rules are to be observed, with the addition that the discharges from mouth and nostrils should be received on rags and destroyed by burning. In typhoid fever, the poison is chiefly contained in discharges from the bowels. These may infect the air of the sickroom, the bed, body- linen, w.c., and drains, and, by soaking into wells, they poison the drinking-water—a common and dangerous way by which this fever
- 34. spreads. The discharges should be disinfected immediately on their escape from the body as will be directed. Typhus fever is very infectious, and is apt to attack those who are much exposed to it for the first time; therefore engage a nurse who has been previously attacked. The poison is thrown off by the skin and lungs and readily affects clothing, furniture, and everything in contact with the air of the room. Efficient protection from smallpox is proper vaccination, known by a large mark or scar. Re-vaccination after the fourteenth year is advisable. Smallpox affects at a greater distance than any other, the poison escaping chiefly by the skin and mucous membrane. Diphtheria poisons by the breath and expectoration; and to avoid contact with these is absolutely necessary. The expectoration should be received into a vessel containing Condy’s fluid, or on rags that may be at once burnt. Gargle the throat frequently with a solution of the same, of the strength of 1 small teaspoonful to 1 qt. water. Whooping-cough is a disease which is most fatal to children under 2 years of age. The poison comes chiefly from the mucous secretions of the lungs and air passages, and is readily imparted to the clothes of those who nurse the patient; the secretions are infectious from the beginning. Asiatic cholera rarely visits this country. As in typhoid fever, it spreads by means of the bowel discharges, and the same precautions are needed. In any infectious disease, where the home has no accommodation for fully carrying out the precautions, the patient should be removed at once to a fever hospital. No time should be lost in obtaining medical advice. One other source of danger may be mentioned here, and that is the poisonous vapours arising from broken gas mains, which will cause illness and even death from the carbonic oxide present. As a precaution against ground air contaminated with illuminating gas entering houses, open all cellar windows, as well as those on the
- 35. ground floor of threatened houses, so as to prevent directly sucking in the ground air or render it harmless by dilution. The smell of gas should serve as a warning. The following advice is addressed to those who have to visit or attend upon infectious cases. Always have the window open before entering the patient’s room or ward. Never stand between the patient and the fire, but always between him and the open window. If possible change your coat before entering the room. Do not go in for any unnecessary physical examination. Stay as short a time as possible in the room. Never, while in the room, swallow any saliva. After leaving the sickroom, wash the hands with water containing an antiseptic. Rinse out the mouth with diluted “toilet sanitas” or Condy’s fluid; also gargle the throat with it, and bathe the eyes, mouth, and nostrils. Expectorate and blow the nose immediately on leaving the sickroom. Keep up the general health by good food, exercise, and temperance. Filter all the air you breathe while in the sickroom or ward through an antiseptic medium, such as a McKenzie inhaler over the nose and mouth; carefully soak the sponge in a strong solution of carbolic acid before entering the sickroom; all the air breathed must necessarily come through this sponge, and the expired air is emitted, by a valve action, at another place. Nurses should keep themselves and their patients as clean as possible, remembering that the more the infection accumulates, the more dangerous does it become. Special care should be taken, in changing sheets and clothing, not to shake or disturb them more than is absolutely necessary to remove them; as these acts disseminate the particles of skin which are removed with them, and which convey the germs of disease, they should be removed carefully, folded together, and immediately disinfected. Whatever the nature of a malady, so soon as it is pronounced to be infectious the same precautions should in all cases be taken. Let it at once be decided who is to nurse the patient, and make all arrangements by which nurse and patient may be isolated from the rest of the household. If possible, 2 rooms communicating should be
- 36. given up to them, and over the outer doors of these rooms sheets should be hung, which must be kept constantly saturated with disinfectants, either Condy’s fluid or carbolic acid in water. No servant in communication with the rest of the household must enter the sickroom; if she does so, she should be isolated like the nurse, and any message that may require to be given must be spoken through the sheet. The best plan is to have a regular nurse from one of the many excellent institutions which provide them; they make the patient more comfortable, take entire charge of the arrangement of the sickroom, and know exactly what is required to be done in an emergency, and for disinfection. At the very commencement all curtains should be taken down, and at once sent out of the house to be disinfected by properly qualified persons; the same course should be pursued with the carpets (woollen articles hold infection beyond any others), and then the floors can be kept sprinkled with disinfectants, besides having a broom steeped in them passed over every morning. Linen used in the sickroom should always be put into water with either carbolic or Condy, before leaving the room; but, even with this precaution, it is far better to send it to be disinfected than to allow it to go to a laundry. The windows should be open, top and bottom, but more especially at the top, during the entire day, and if possible at night also; a thorough draught through the room is most desirable, if the patient can be kept out of the direct line of it. As much as possible, all cups, basins, jugs, and glasses should be kept upstairs; but those that must occasionally be sent down should be carefully washed in Condy and water, and at once placed outside the door, and again passed through disinfectant on their arrival downstairs. The clothes that may have been worn for the day or two before the disease absolutely declared itself should be sent for disinfection, but those which have only been in casual contact may be disinfected at home. A small room should be chosen for the purpose, and the dresses, petticoats, shawls, or other articles hung up, so as to be fully exposed. The doors, windows, and all other apertures must be kept closed, and the disinfection may be effected either by chlorine, which is formed by pouring hydrochloric acid on chlorate of potash, or else by burning sulphur. In either case the
- 37. quantity must be sufficient to render the atmosphere of the room unbearable to a human being, or otherwise the disease germs will not be destroyed. The bedding and blankets must be sent for proper disinfection at the close of the illness. Nothing should be kept in the room except for use. Clothes in a wardrobe under such circumstances have been known to spread infection 10 years after. Handkerchiefs should be replaced by rags, burnt when used. Letters from the patient should be backed, or written on postcards dipped in carbolic; they are capable of spreading disease otherwise. A thing in which people are often lamentably careless is in allowing books that have been used by the patient to be afterwards used by others. It cannot be too often impressed on the minds of those who have to do with illness, that every book, paper or magazine used by an infectious patient must be burnt without leaving the sickroom. Infection is very often spread by allowing books from a circulating library to be returned to it after use by a person suffering from an infectious disorder. Infection ceases in the individual as soon as the skin has thoroughly peeled—a process which takes a longer or shorter time in different individuals. The danger after this lies in the clothes, furniture, and rooms, and if these are at once thoroughly disinfected all danger is absolutely at an end. It is impossible to reprobate too strongly the conduct of those who wish and endeavour to shirk the expense and trouble of proper disinfection. It would be well if in such cases doctors would always avail themselves of their power to report the existence of a case of infectious disease to the sanitary officer of the district, when official pressure would at once be brought to bear, and all that is necessary be effected under compulsion. The cured patient on the day of leaving home should go into a fresh room to dress, and put on things either new or disinfected, not returning to the sickroom. Brushes and sponges, as coming most in contact with hair and skin, are best destroyed. While a patient is in the infectious stage it is best that no letters should be written; but if, as is sometimes the case, some communication in writing must be
- 38. made, danger is obviated by holding the paper and envelope in the fumes of chlorine. A few words would not be amiss respecting those in the house who do not enter the sickroom. However great the precautions taken, the air of a house in which there is a case of infectious disease can never be absolutely safe, and it is far better to err on the side of caution than the reverse. Visitors should not be allowed to enter the house, and it is far better and more honest for the servants to state clearly at the door what disease is in the house. Special attention should be paid to the health of each member of the household. Any slight disorder is liable to predispose to infection. There is a great variety of good disinfectants, and as many different ways of using them. A good plan, both effective and economical, is as follows:—Freely use moistened chloride of lime all through the house, and even in the sickroom, if the fumes are not found to be irritating; secondly, place in various parts of the room 5 or 6 soup-plates, or other flat vessels, containing Condy’s fluid; or hang about in the room as many perforated boxes filled with solid iodine; thirdly, keep the windows opened freely but the doors as seldom as possible; guard it both inside and outside with a large sheet, hung up to at least the height of the door, and at about 1 ft. distant from it, and kept constantly well moistened with a solution of carbolic acid (strength, about 1 of the acid to 40 of water); and, most important of all, receive as soon as possible all discharges, excreta, soiled linen, and all such matters, in vessels containing a strong solution of Condy’s fluid, chloralum, or carbolic acid. Many infectious diseases have (in addition to their common property of infecting the air through the effete products of respiration from the lungs and skin) some special channel of transmission. In cholera, typhoid (enteric) fever, and, in a less degree, typhus and relapsing fevers, it is principally by the excreta from the bowels and kidneys. These should be received at the very moment of their issue from the body into vessels fully charged with disinfectants. In diphtheria, it is by the throat. In erysipelas, hospital gangrene, and puerperal fever, by discharges peculiar to each. In smallpox, by pustular exudation
- 39. from the skin. In scarlet fever, measles, &c., by desquamation (peeling off of the skin), rendered harmless by slightly moistening the surface of the body once or twice a day with ordinary olive oil or camphorated oil, or a weak solution of glycerine and carbolic acid. Never mix disinfectants; for instance, Condy’s fluid and carbolic acid act in precisely opposite ways, and might decompose each other. The nurse must not neglect proper precautions for her own safety. She should use disinfectants freely about her own person, be sure that she has a sufficient quantity of undisturbed rest and regular meals, and avoid coming into unnecessary close contact with the patient. She should at once give up the occupation if she feel her general health at all injured. She must also be careful not to undertake a non-infectious case after being in attendance upon an infectious one for a considerable time; and until she has put herself through a complete process of disinfection, and done the same with all clothes worn at the time which she has not discarded altogether. Nothing must induce her to go near a confinement for several (at least 3) months. Disinfection.—The most useful agents for the destruction of spore- containing infectious materials are:— (1) Fire: Complete destruction by burning. (2) Steam under pressure: 230°F. for 10 minutes. (3) Boiling in water for 1 hour. This temperature does not destroy the spores of Bacillus subtilis in the time mentioned, but is effective for the destruction of the spores of the anthrax bacillus, and of all known pathogenic organisms. (4) Chloride of lime: a solution of 4 in 100 containing at least 25 per cent. of available chlorine. (5) Mercuric chloride: a solution of 1 in 500 containing at least 3 per cent. of available chlorine. For the destruction of infectious material which owes its infecting power to the presence of micro-organisms not containing spores:—
- 40. (1) Fire: Complete destruction by burning. (2) Boiling water ½ an hour. (3) Dry heat: 230°F. for 2 hours. (4) Chloride of lime: 1 to 4 in 100 solution, containing at least 25 per cent. available chlorine. (5) Solution of chlorinated soda: 5 to 20 in 100 solution, containing at least 3 per cent. available chlorine. (6) Mercuric chloride: a solution of 1 in 1000 to 1 in 4000. (7) Sulphur dioxide: exposure for 12 hours to an atmosphere containing at least 4 volumes per cent. of this gas, preferably in presence of moisture. This will require the combustion of 3-4 lb. sulphur for every 1000 cub. ft. of air space. (8) Carbolic acid: 2 to 5 in 100 solution. (9) Sulphate of copper: 2 to 5 in 100 solution. (10) Chloride of zinc: 4 to 10 in 100 solution. Following are recommendations with reference to the practical application of these agents:— For Excreta. (a) In the sickroom: For spore containing material: (1) Chloride of lime in solution, 4 in 100. (2) Mercuric chloride in solution, 1 in 500; addition of an equal quantity of potassium permanganate as a deodorant, and to give colour to the solution, is to be recommended. In the absence of spores: (3) Carbolic acid in solution, 5 in 100. (4) Sulphate of copper in solution, 5 in 100.
- 41. (5) Chloride of zinc in solution, 10 in 100. (b) In privy vaults: Mercuric chloride in solution, 1 in 500. A concentrated solution containing 4 oz. mercuric chloride and 1 lb. cupric sulphate to 1 gal. water is recommended as a standard solution; 8 oz. this solution to 1 gal. water will give a diluted solution for the disinfection of excreta, containing about 1 in 500 of mercuric chloride and 1 in 125 of cupric sulphate. (c) For the disinfection and deodorisation of the surface of masses of organic material in privy vaults, &c.: Chloride of lime in powder, diluted with plaster of Paris, or with clean, well-dried sand, in the proportion of 1 part to 9. For Clothing, Bedding, &c. (a) Soiled underclothing, bed linen, &c.: (1) Destruction by fire, if of little value. (2) Boiling at least ½ hour. (3) Immersion in a solution of mercuric chloride of the strength of 1 in 2000 for 4 hours. The blue solution containing sulphate of copper, diluted by adding 2 oz. concentrated solution to 1 gal. water, may be used for this purpose. (4) Immersion in a 2 per cent. solution of carbolic acid for 4 hours. (b) Outer garments of wool or silk, and similar articles, which would be injured by immersion in boiling water or in a disinfecting solution: (1) Exposure to dry heat at a temperature of 230° F. for 2 hours. (2) Fumigation with sulphurous acid gas for at least 12 hours, the clothing being freely exposed, and the gas present in the disinfection chamber in the proportion of 4 volumes per cent. (c) Mattresses and blankets soiled by the discharges of the sick:
- 42. (1) Destruction by fire. (2) Exposure to superheated steam—25 lb. pressure—for 1 hour. Mattresses to have the cover removed or freely opened. (3) Immersion in boiling water for 1 hour. (4) Immersion in blue solution (mercuric chloride and sulphate of copper) 2 fl. oz. to 1 gal. of water. Fire.—Materials used in wiping away discharges may be burned in the open fireplace of the sickroom. In general, this method is to be recommended for all substances which have been exposed to infection, which cannot be treated with boiling water, and, could it be carried out in all cases, would make disinfection a very simple matter. If there is no fire in the room, such substances may be wrapped in a sheet soaked with solution, carbolic acid, and in this condition conveyed to a fire elsewhere. Boiling Water.—Boiling in water for ½ hour will destroy the vitality of all known disease germs. This is therefore the best means for all articles which can be thus treated, such as body-clothing of the patient, bed-clothes, towels, &c. All utensils used in the room in feeding the patient should likewise be treated with boiling water before being removed from the room. Food itself, not consumed by the patient, should not be used by others, as it is liable to become infected in the sickroom. If there are no facilities for treating articles with boiling water in the sickroom, they may with safety be removed to another part of the house for this treatment if they are carefully enveloped in a towel or sheet, as the case may require, which has been thoroughly soaked with carbolic acid solution. Thus enveloped, they should be put in the water, and boiled for the required time. Chloride of Lime.—To be effective as a disinfectant this must be of the best quality, and in purchasing it, only that should be accepted which is enclosed in glass bottles, as, when packed in paper or wooden boxes, it is liable to have so deteriorated as to be worthless for disinfecting purposes. Dissolved in water, in the proportion of 4 oz. to 1 gal., it forms a standard solution recommended to be used
- 43. in the disinfection of discharges in contagious diseases, especially in typhoid fever and cholera; 1 pint should be well mixed with each discharge; after 10 minutes, disinfection is completed, and the contents of the vessel may be then safely thrown into the water closet. The expectorated matter of those sick with consumption should be discharged into a cup half filled with this or carbolic acid solution. Solution of Chlorinated Soda.—To be effective, this solution must contain at least 3 per cent. of available chlorine, and care should be exercised to obtain such a quality. This is sometimes spoken of as Labarraque’s solution; but, as this latter is too weak to act as a disinfectant, the name is liable to mislead. A standard solution is made by adding 5 parts water to 1 of the solution of chlorinated soda. The cost of this solution is about 5d. a gallon. When thus diluted it may be used for all the purposes for which chloride of lime was recommended, and is of a somewhat more agreeable odour, though more expensive. It should be used to cleanse portions of the body soiled with discharges of those sick with infectious diseases, or the hands of attendants similarly soiled. Bichloride of Mercury (corrosive sublimate) is recommended to be used only in the disinfection of privy vaults which contain so much material, believed to be infected with the germs of typhoid fever or cholera, that the disinfection by chloride of lime would be impracticable. In using this, it should be dissolved in the proportion of 1 oz. bichloride of mercury to 1 gal. water; this quantity will disinfect 4 gal. infected excremental matter. For Clothing after Recovery or Death. The clothing of the patient should be treated in the manner already described as necessary during the sickness. Whatever can be boiled in water should be thus disinfected; articles which cannot be boiled should, if circumstances will permit, be burned; all other articles should be left in the room to be subjected to the fumigation hereafter to be described, and until thus treated, the room and its
- 44. contents should be closed with lock and key, to prevent any one from entering. If it is desired to burn any articles, and facilities for it do not exist in the house, the authorities should be notified, and an officer will call and remove the articles for destruction. Permanganate of potash (commonly known as Condy’s fluid), Burnett’s fluid, and chloride of lime, can all be mixed with water, and used for clothing if care is taken. Carbolic soap is excellent for scrubbing. Sulphate of zinc and common salt, dissolved together in water in the proportion of 4 oz. sulphate and 2 oz. salt to 1 gal. will do for clothing, bed-linen, &c. Armfield & Son, 15 Lower Belgrave Street, London, W., and Victoria Bridge Road, S.W., disinfect and clean articles after fever, &c., by means of special apparatus. For Furniture and Articles of Wood, Leather, and Porcelain. Washing several times repeated with: (1) Solution of mercuric chloride 1 in 1000. The blue solution, 4 oz. to 1 gal. water may be used. (2) Solution of chloride of lime, 1 per cent. (3) Solution of carbolic acid, 2 per cent. For articles of metal use No. 3. For the Person. The hands and general surface of the body of attendants of the sick, and of convalescents at the time of their discharge from hospital:— (1) Solution of chlorinated soda diluted with 9 parts of water (1 in 10). (2) Carbolic acid, 2 per cent. solution. (3) Mercuric chloride, 1 in 1000; recommended only for the hands, or for washing away infectious material from a limited area, not as a
- 45. bath for the entire surface of the body. For Body of the Patient after Recovery. When the patient has recovered, he should be first sponged over with the solution of chlorinated soda, diluted in the proportion of 1 part to 20 of water; and, indeed, during the course of the illness occasional sponging of the body with this very dilute solution under the direction of the attending physician, will be of value in preventing the escape from the surface of the body of infectious material. When, after recovery, the body has been thus sponged, not omitting the head and hair, a thorough washing of the body with soap and warm water should follow, and the patient dressed in clothes which have not been exposed to infection. This should take place in another room than the one occupied during the illness. For the Dead. Envelope the body in a sheet thoroughly saturated with (1) Chloride of lime in solution, 4 per cent. (2) Mercuric chloride in solution, 1 in 500. (3) Carbolic acid in solution, 5 per cent. The body should be thoroughly sponged with either (1) or (3), and then wrapped completely in a sheet saturated with one of these solutions, and enclosed in a coffin, which is to be closed, and the interment must take place within 24 hours, and be strictly private. If the interment is to take place at a distance requiring transportation by any other means than a hearse, the coffin must be of metal, or metal-lined, and hermetically sealed. When danger is to be apprehended from this source, the body should be, when coffined, surrounded with sawdust, in which these solutions have been placed. Carbolic sanitas powders also present effective means whereby disinfection of the dead body may be performed when coffined; and nitrous acid fumes form the best
- 46. disinfectant for mortuaries or apartments in which the dead have lain for some time. Room and Contents. The room, having been vacated by the patient, should first be fumigated by burning sulphur. This fumigation should be done under the supervision of the physician or some other intelligent person. Nothing should be removed from the room until this is completed, unless it has been disinfected in the manner already described. Everything to be fumigated should be so opened and exposed that the sulphur fumes can come in contact with all portions thereof. All cracks of doors and windows, fire-places, or other channels by which the gas may escape should be tightly closed, using cotton wadding when necessary. For a room 10 ft. in all its dimensions—that is, one containing 1000 cub. ft. of air space—2 lb. broken sulphur and 1 lb. flowers of sulphur should be provided, and an increased amount for larger rooms, in the same proportion. This quantity is important, as less will not so efficiently accomplish the desired disinfection. The sulphur should be put in an iron pot, and this placed on bricks in a large washtub half filled with water, or in a large coal-scuttle containing wet ashes. This precaution is necessary to prevent setting fire to the floor, which would occur if the pot were placed directly on the floor or carpet. The vessel containing the sulphur should not be one with soldered joints, as the intense heat would melt the solder. A pot capable of holding 1 gal. is about the right capacity for 3 lb. sulphur. The pot should be placed in the centre of the room; if the room is a large one, containing several thousand cub. ft. of air space, several pots should be provided, distributed at different points. Everything being in readiness, sufficient alcohol to moisten the sulphur should be poured on it, a lighted match applied, and when it is seen that the sulphur is well ignited, the room should be left and the door shut, and all cracks outside, including the key-hole, closed by paper, cotton, or other material. At the end of 10 hours the fumigation is completed. Great care should be exercised in emptying the room of the sulphur fumes, as these cannot be safely
- 47. breathed, and are excessively irritating to the eyes and throat. If possible, a window should be opened from the outside, and through this the fumes permitted to escape; if this is impracticable, all the windows and doors of adjoining rooms should be opened, and then the door of the fumigated room, and through these outlets the fumes allowed to find an exit. Thorough airing will remove the slight odour which remains. The fumigation being completed, all woodwork, as of floors, windows, and door, and the walls and other surfaces, should be washed over with solution of chlorinated soda, particular attention being paid to cracks, crevices, and out of the way places, in which dirt ordinarily finds a lodgment and from which it is with difficulty removed. A subsequent washing with hot water and soap will complete the cleansing process, and the room may be considered again habitable. (a) While occupied, wash all surfaces with:— (1) Mercuric chloride in solution, 1 in 1000. The blue solution containing sulphate of copper may be used. (2) Chloride of lime in solution, 1 per cent. (3) Carbolic acid in solution, 2 per cent. (b) When vacated:— Fumigate with sulphur dioxide as described in the next paragraph. A pleasant disinfectant for rooms is 20 parts camphor, 50 each hypochlorite of lime, alcohol, and water, 1 each eucalyptus and clove oils. The ingredients must be mixed slowly in a spacious vessel kept cool. A few drops on a plate will suffice to disinfect a chamber pleasantly. Carbolic acid, when combined with water and boiled, evaporates with the steam in a constant ratio, and the steam contains the same relative quantity of the acid as the water from which it evaporates. Pour 20-40 drops of a mixture of equal parts turpentine and carbolic acid into a kettle of water, which keep simmering over a slow fire, so
- 48. that the air of the sick room will be constantly impregnated with the odour. An excellent vaporiser for disinfecting purposes is made by Savory and Moore. To purify the air in a sickroom, place in the bed a small basket or other porous article, containing wood charcoal, for the purpose of absorbing the foul air which, if diffused throughout the surrounding atmosphere, would be constantly returned to the lungs. In a sickroom in which infants are sleeping, put a box or basket containing a piece of quicklime and some wood charcoal, for the purpose of fixing the carbonic acid exhaled from the lungs, and of absorbing all the foul air generated in the system, and given off by exhalation from the skin or otherwise. Cellars, yards, stables, gutters, privies, cesspools, water-closets, drains, sewers, &c., should be frequently and liberally treated with copperas (sulphate of iron) solution. The copperas solution is easily prepared by hanging a basket containing about 60 lb. copperas in a barrel of water, or say 1½ lb. per gal. It stains linen. Another good solution is made thus. Dissolve ½ dr. nitrate of lead in 1 pint boiling water; dissolve 2 dr. common salt in a pail of cold water. Pour the two solutions together, and allow the sediment to subside. Areas, dustbins, heaps of refuse, w.c.’s, or close rooms are all alike benefited by this mixture, which has the advantage of being without smell. Cloths dipped in the solution and hung up in a room will sweeten a fetid atmosphere immediately. It is cheap, nitrate of lead being procurable at about 6d. a lb. Rheumatism.—This common ailment is essentially due to damp or being chilled. One of the easiest and most satisfactory means of treatment is to apply a flannel bandage, pretty tightly, round the chest, in order to restrain the movements of the chest wall. Soothing liniments may also be laid on the side, such as belladonna and chloroform liniments, mixed in equal proportions, or the liniment of turpentine, or cajeput oil mixed with olive oil. Some of the popular domestic remedies for lumbago (rheumatism in the back), are not to
- 49. be despised, such as ironing with a hot smoothing iron (with the interposition of a double layer of flannel between the skin and the iron), the efficacy of which is heightened by wrapping the flannel round the hot iron, and moistening the flannel with vinegar. The iron, thus guarded, is left in contact with the skin for ¼ minute, at various points. Another good remedy is the application of turpentine, effected by taking a doubled piece of flannel, say 12-14 in. long by 8-10 in. wide, and dipping it into boiling water. It is then wrung firmly, and turpentine is sprinkled liberally over it. This is applied to the loins, and kept on for 20-30 minutes. When removed, cotton- wool is applied to the skin. At the outset a strong effective purge ought to be taken. A good hot bath (104° F.) is very beneficial, and it may be advantageous to make it alkaline, by adding about 6 oz. carbonate of soda (washing soda) to the bath before entering it; this will be specially efficacious in stiffness of the joints or muscles. Of the many drugs which have the effect of inducing free perspiration, solution of acetate of ammonia may most safely be used in tablespoonful (adults) doses freely diluted with water. The bowels may be opened by a mild aperient, preferably saline, taken largely diluted in hot water, and early in the morning. The action of the kidneys ought to be kept up by diuretics, the simplest being water, say a tumblerful drunk slowly in the morning, while dressing, or it may be rendered more energetic by the addition of 1 teaspoonful cream of tartar. Diet ought to be restricted to light forms of solid food, e.g., fish, soups, chicken, puddings, vegetables, fruit, milk. Beer and wines should be avoided; ærated waters may be taken freely; smoking is prejudicial. Finally, persons who suffer from rheumatism ought always to wear flannel next the skin, and encourage perspiration. Most alkalies are useful in relieving rheumatism. Potash, or soda bicarbonate may be freely used in doses of ½ teaspoonful, in ½ tumbler of ærated water, twice daily, for 3-4 weeks at a time. Sea-sickness.—Many people, as soon as sea-sickness commences, have recourse to oranges, lemons, &c. Oranges are very much to be
- 50. avoided, on account of their bilious tendency, and even the juice of a lemon should only be allowed in cases of extreme nausea. Champagne, too, is a very common remedy, and, without doubt, in many cases does good; but this appears to be chiefly due to its exhilarating effects, as, if it be discontinued, the result is bad, and a great amount of prostration follows. Creosote is an old, but still good, remedy, and, in cases accompanied by great prostration, is very useful; but if given in the early stages of sea-sickness, it is often followed by very bad results, and even increases the nausea. Bicarbonate of soda is useful in slight cases, as it relieves nausea, and checks the frequent eructations which often follow attacks of sea-sickness; but in severe cases it is absolutely useless, and, in fact, it very often prolongs the retching. A very good remedy in the earlier stages of sea-sickness is a teaspoonful of Worcester sauce; it relieves the symptoms, and renders the patient easier. Its action is probably of a stimulant nature. Hydrocyanic acid is of very little service, and most acid mixtures are to be avoided, except that perhaps for drinking purposes, when it is best to acidulate the water with a small quantity of hydrochloric acid. Of all drugs the most effectual is sodium bromide. When sodium bromide is given in doses of 10 gr., 3 times a day, the attacks entirely subside, the appetite improves, and the patient is able to walk about with comfort. In sea- sickness it is very desirable that the patient should take sufficient food, so that at all times the stomach may be comfortably full, for by this means over-straining during fits of retching is prevented, and the amount of nausea is diminished. The practice of taking small pieces of dry biscuit is not of much use, as although the biscuit is retained by the stomach, yet the amount taken is never sufficient to comfortably fill the stomach. Soups, milk-puddings, and sweets are to be avoided, as they increase the desire to be sick, and are followed by sickening eructations. Fat bacon is easily borne, and does much good, if only the patient can conquer his aversion to it. When taken in moderate quantity it acts as a charm, and is followed by very good results. Of all food, curry is the most useful in sea- sickness, and is retained by the stomach when all other food has been rejected. Next to curry come small sandwiches of cold beef, as
- 51. they look nice on the plate, and are usually retained by the stomach. Brandy should be used very sparingly, as, in many cases, it induces sea-sickness; and its chief use is confined to those cases where the prostration is very great, and even then champagne is more effectual. (Dr. Kendall, Brit. Med. Jour.) Skin complaints.—Many of these are of a character to demand the early attention of the doctor, but there are others which can readily be combated by home treatment. Pimple (Acne).—These are a frequent trouble in young people and may be very disfiguring. They arise from inefficient action in the fat (sebaceous) glands of the skin. Generally they can be dislodged by squeezing with the thumb nails. To promote healthy action of the glands and prevent formation of the pimples, Dr. Liveing recommends the following plan. (a) Steam the face every night by holding it over a basin of hot water for a few minutes. (b) Rub the skin for 5-10 minutes with soap (preferably terebene) and flannel, or with a soft nailbrush; then sponge off the soap with warm water. (c) When the face has been dried, a lotion should be thoroughly applied, composed as follows: ½ oz. precipitated sulphur, 2 dr. glycerine, 1 oz. spirits of wine, with 3 oz. each rose-water and lime-water. This is allowed to dry on the skin and to remain on all night. In the morning the face is cleansed with warm oatmeal and water or weak gruel. If, for any reason, an ointment seems preferable to a lotion, a combination of precipitated sulphur and vaseline is very useful. The treatment must be modified or suspended for 2 or 3 nights if the skin becomes sensitive and somewhat tender. If this plan be unsuccessful, try application of potash soap in the form of a lotion. The lotion is composed of 1 oz. each soft soap and rectified spirits of wine, and 7 oz. rose (or distilled) water. This should be rubbed in vigorously with a piece of flannel for a short time, taking care not to make the skin sore. According to Dr. Liveing, the worst cases of acne will yield to the soft soap treatment if practised with necessary caution.
- 52. Something is often required to be done during the daytime to pacify the heat and throbbing, which are part of the usual history of acne. An excellent lotion is made by combining oxide of zinc, calamine, prepared chalk, lead lotion, and lime-water, to which may be added a small quantity of glycerine. Let the bottle containing this be gently waved about so as to diffuse the materials, which are only held in suspension; then pour a little into a saucer, and with a sponge (reserved for the purpose) sprinkle the face from time to time. Wipe off, when necessary, with a bit of fine muslin the powder which remains on the skin after the evaporation of the fluid, and the face may be washed occasionally with a little starch gruel. The cases are not a few in which it is better not to use any kind of soap as part of the evening ceremonial. After the face has been steamed, put on a medicated jelly composed of zinc oxide, gelatine, and glycerine. It must be liquefied by putting the vessel that holds it into hot water, and then applied with a brush. Some sensitive skins are intolerant of sulphur in any guise. When this is so, try combinations of lead, chalk and zinc, blended as a quasi-ointment with the finest vaseline. Dr. McCall Anderson’s formula of bismuth oleate with vaseline and white wax has been aptly described as “one of the most healing of salves.” Sometimes nothing agrees better than the old-fashioned but capital substance called Kirkland’s “neutral cerate,” which is composed essentially of lead plaster and olive oil. Nettlerash.—A form of nettlerash seen in little children, showing itself as slightly raised red blotches, worst in the night, is referred to “teething,” and that is thought sufficient reason for neglecting it. The best treatment is strict attention to cleanliness and diet. The child should get a tepid bath night and morning. Take care that no part of the dress irritates the skin, flannel not being allowed to touch it; and let the patient enjoy fresh air and sunshine. If itching continues, instead of a simple tepid or warm bath at night, an alkaline bath should be given in this bath: in 8-10 gal. water as warm as the hand; dissolve 1-2 oz. soda bicarbonate. Bathe the child for a few minutes, do not be too exact in drying, and put to bed immediately. Nettlerash in adults requires medical treatment.
- 53. Eczema.—Of this skin disease there are many forms, all arising more or less from a disordered state of the blood, and demanding medical advice. As a general rule, the patient should avoid soap in washing, using oatmeal instead. Starchy food, such as potatoes, are deemed unsuitable, while plenty of green vegetables and fruit should be taken. Clean linen is essential, and the patient’s towel should not be used by any one but himself. Itching.—This troublesome affection may be cured by the use of the following:—(a) 500 grm. milk of almonds; ¼ grm. each corrosive sublimate and ammonium chloride. (b) 60 grm. glycerine of starch; 5 grm. bismuth subnitrate; 5 grm. zinc oxide. (c) 1 litre infusion of mallow; 50 grm. cherry-laurel water (filtered); 10 grm. borax. (d) Vaseline often gives relief. Ringworm.—Whenever the disease is observed, efficient measures should be taken to cure it, instead of wasting time with feeble popular remedies, such as ink, permitting the affection to spread and become established. The hair should be cut for ½ in. round each patch of ringworm. Get a small camel-hair brush, and a solution of the following composition: 30 gr. iodine; 2 drm. colourless oil of tar. Apply the solution carefully with the brush to the diseased part only. Repeat the application in a week. Strong carbolic ointment may be applied around the patch. It is a most obstinate disease, and requires the exercise of great patience. Children suffering from ringworm should not be much confined in the house, and it is a good rule to give them cod-liver oil, or steel wine, or both. Sweating (excessive).—(a) In the Michigan Medical News, Dr. Currie recommends in sweats, from whatever cause, 1 pint alcohol, 1 drm. sulphate quinine. Wet a small sponge with it, and bathe the body and limbs, a small surface at a time, care being taken not to expose the body to a draught of air in doing it. (b) For sweating of the feet, Dr. Meierhof, in the Maryland Medical Journal, directs the patient to immerse his feet morning and night for about 10 minutes, in warm water at 115°-120° F. in which a teaspoonful (1 dr.) powdered commercial soda (impure carbonate of
- 54. soda) is dissolved. The feet are then thoroughly dried, after which they are painted all over with a coating of compound tincture of benzoin, which acts as an antiseptic astringent and by its mechanical presence on the skin. This treatment is continued for about 10 days, after which it is practised once daily, or every other day, as the necessities of the case may require. (c) M. Vieusse, principal medical officer at the Military Hospital at Oran, states that excessive sweating of the feet, under whatever form it appears (whether as mere super-secretion accompanied by severe pain, or with fœtidity), can be quickly cured by carefully- conducted frictions with bismuth subnitrate; and even in the few cases where this suppresses the abundant sweating only temporarily, it still removes the severe pain and the noxious odour which often accompany the secretion. He had never found any ill consequence follow the suppression of the sweating. (d) Napthol has been recommended as an effective remedy against excessive sweating of the palms of the hands, foot-soles, and arm-pits. These places should be moistened once or twice daily, with a mixture of 5 pt. naphthol, 10 pt. glycerine, 100 pt. of alcohol, and afterwards dusted, either with pure starch or with a mixture of 2 pt. naphthol, 100 pt. starch. In the case of sweating feet, small pellets of antiseptic cotton are dipped in the powder and placed between the toes. Tooth Troubles.—To preserve the teeth, rinse the mouth after every meal. If the gums are naturally irritable and tender, a few drops of tincture of myrrh in water should be used to rinse out the mouth, twice or thrice daily. The first tooth brush should be used as soon as there are teeth to use it upon. An ideal tooth powder should be alkaline, since acids dissolve the tooth substance; finely pulverised, that it may not mechanically abrade; antiseptic, to prevent decomposition of food lodged between the teeth, and perhaps to destroy the microbes which are always found choking the tubules of carious dentine; it should contain nothing irritating to the gums; and, lastly, it should be pleasant to the taste, or it will not be
- 55. used. Fluid dentifrices do not, as a rule, clean the teeth effectually, unless they contain some ingredient which acts upon the enamel itself; and those preparations which are eulogised as making teeth white or preventing deposit of tartar, should be avoided. Charcoal was at one time a very popular form of dentifrice, and is even now largely used, but from the amount of silica it contains it will rapidly wear away teeth that are not of exceptional hardness; and moreover, the gums in some instances become tattooed in a curious manner from absorption of minute particles. Pumice-powder, again, is too gritty; and camphorated chalk is said to make the gums spongy. Precipitated chalk forms the best basis for a tooth powder, to the base of which may be added pulv. saponis and ol. eucalypt., 1 dr. of each; and if there is no objection to the taste, ½ dr. carbolic acid. (Lancet.) The tooth brush, which should be used night and morning, should be small, and have its not too stiff bristles arranged in separate bundles (in order that they may pass readily between the teeth and into the natural depression). The outer and inner surfaces of both front and back teeth should be brushed. The direction of the brushing should be from the gums; that is, downwards for the upper teeth, and upwards for the lower. This mode of cleaning the teeth is the best preventive against decay, which causes toothache, and also against the accumulation of tartar, which makes the breath foul, and in course of time causes the teeth to loosen and fall out. Toothache.—(a) The following is a formula recommended by Prof. Babaieff in the British Medical Journal:—Melt 2 parts white wax or spermaceti, and when melted, add 1 part carbolic acid crystals, and 2 parts chloral hydrate crystals; stir well till dissolved. While still liquid, immerse thin layers of carbolised absorbent cotton wool, and allow them to dry. When required for use, a small piece may be snipped off, and slightly warmed, when it can be inserted in the hollow tooth, where it will solidify. The ease produced by this simple method is really very great.
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