CHAPTER XII.

The skin: its construction and function-Importance of keeping it clean-Bathing a patient-Changing clothes-The care of the teeth and hair-Hydrotherapy-Effects of cold water-Modes of using it-Warm and hot baths-Air and vapor baths-Medicated baths-Massage, friction, etc.

THE skin is not only a protective covering for the body, but a complex excretory organ, doing as important a work in the elimination of waste products as the lungs and the kidneys. It consists of two distinct layers, the derma, cutis vera, or true skin, underneath; and the epidermis, cuticle, or scarf-skin, on the outside. The true skin is filled with blood-vessels and nerves; the cuticle contains none of these, but is connected with them by numbers of sudoriferous tubes. The surface of the body is closely covered with the openings of these tubes, known as pores. From these pores, water and excrementitious matters are constantly being thrown off in the form of vapor. By this steady evaporation, the temperature of the body is regulated. If the body be covered with an impermeable coating, so as to entirely obstruct this process, death shortly ensues. The scarfskin is continually scaling off and being renewed from beneath; at the same time, solid matters are to some extent deposited, as the water evaporates from the sweatducts. Besides these, there are another set of glands in the skin, called the sebaceous glands, secreting a kind

of oily matter, which serves to keep the skin soft and supple. The excess of this sebaceous matter, the castoff scales of the cuticle, and the solid deposit from the perspiration, remain on the surface, and, unless removed, fill the pores, and prevent further evaporation. Thus, even in a state of health, frequent and thorough ablution is a matter of the first hygienic import. Dirt of any kind blocks the mouths of the sweat-bearing tubes, and impedes their action. This throws more work upon the other excretory organs, disturbing the balance of their functions, so that disease may often be traced simply to a failure to keep the pores of the skin open.

In sickness, it is even more serious, for the exhalations of disease are morbid and dangerous, yet bathing is often neglected through fear that the patient will take cold. But cleanliness is a positive aid to recovery, and, with proper precautions, there are very few patients who can not be washed without danger. In almost all cases, at least a sponge bath in bed can be given, care being taken neither to chill nor fatigue the patient. The bed should be protected by an extra rubber and draw-sheet. The room should be warm and free from draughts, and everything likely to be needed at hand plenty of hot and cold water, soap, sponges, towels, clean clothing, etc. Take plenty of time, and, exposing only a small part of the body at a time, wash, dry, and cover it before proceeding further. After the bath, some light refreshment may be allowed, if the patient seems at all fatigued. A bath should never be given within two hours after a full meal.

The clothing should always be warmed before it is put on. To change a night-dress, or shirt, slip off the sleeves of the soiled one, and pull it up toward the neck. Then put the arms in the clean sleeves, lift the

patient's head and shoulders, and the soiled garment can be slipped off over the head with the same motion that puts on the clean one. Pull the latter down smoothly under the back, but not too tight. In this way the patient has only to be raised once. If he ought not to be lifted at all, the shirt or gown must be ripped all the way down the front. In taking it off, slip out one arm and put on the corresponding clean sleeve, work it under the shoulders, pushing the soiled one before it, and change the other sleeve. If two garments are worn, fit one inside the other before beginning, and put them on as one. Where there is an injured arm or side, begin with it in putting on a garment, but, in taking one off, begin always with the sound side.

The mouth should be often washed, and the teeth brushed, or wiped off with a bit of soft cloth. Water containing a few drops of tincture of myrrh, or of Condy's fluid, is good to rinse out the mouth. To remove sordes from the teeth, a mixture of lemon-juice, glycerine, and ice water, in equal parts, will be found efficacious.

In combing the hair, begin at the ends, holding the hair firmly near the roots, to avoid pulling and to keep the head steady. When the hair is much matted, it is better to cut it short, though, with time and patience, very bad tangles can be straightened out. If the patient is in the hands of a good nurse from the commencement, it will never be allowed to get into such a condition. It is best braided closely, or twisted on top of the head, so that the patient will not have to lie on a knot. The hair should be combed, the teeth cleaned, and the hands and face washed at least once daily, the feet twice, and the whole body once every week. This applies to every patient.

Baths are used for remedial purposes as well as simply for cleanliness. They may be general or local, simple or medicated, cold, tepid, or hot; in the form of liquid, vapor, or air. Judiciously employed, baths are valuable therapeutic agents, but their unadvised use, as is true of all powerful remedies, may be hurtful, rather than helpful. The exact temperature and duration of any bath ordered must be obtained from the doctor, and the effect upon the patient carefully noted. Tanner gives the following temperatures as to be understood when the definite degree of heat is not specified :

To put a feeble patient in a bath, wrap him in a sheet, and lower it gently into the water. Have a warm, dry sheet ready to roll him in when he leaves the bath. Over this fold a blanket, and, putting him in bed, leave him wrapped in them for a few minutes. In this way he will be made dry without extra fatigue. A few long strokes with a soft towel will be all that is needed to complete the process, when the wrappings are removed. If the bath is to be very soon repeated, it is better not to put on the clothes, but to leave the patient folded in a dry sheet, ready for the next plunge.

Cold baths are employed either to produce reaction, refrigeration, or nervous shock. Cold water abstracts the heat of the body, and affects the internal organs through the nervous system. Upon first entering a cold bath there is experienced a sense of chilliness and depression. The pulse is quickened, but the tempera

ture of the surface is lowered, and the blood accumulates in the internal organs. A condition of reaction soon follows, with invigorated circulation, a feeling of warmth and exhilaration; but if the immersion be too long continued the coldness returns, with weakness of the pulse and general depression. A cold bath should not be given when the patient feels chilly, when there is free perspiration, any visceral inflammation or tendency to congestion of the internal organs, or during menstruation. If shivering comes on during the bath the patient should be at once taken out and put to bed, heat applied, and stimulants given if it persists. The cold bath is sometimes used as a tonic in cases of debility, but there must be a certain amount of vigor to render it endurable. It is best taken in the morning, and followed by vigorous rubbing and gentle exercise. The head must be first submerged, and the bath continued only long enough for the reactionary stage to be reached-not more than five minutes. The colder the water the sooner reaction takes place. The cold bath is a most speedy and effective way of bringing down a high temperature. It may be lowered from one to six degrees. The shock of sudden immersion in cold water may be avoided by beginning with a tepid bath, and gradually reducing it as much as desired, by adding cold water or ice. The personal temperature must be taken by rectum, and the patient removed from the bath before it is lowered to the required point, for it will continue to fall for some little time afterward, until the heat of the interior and exterior of the body becomes equalized.

A more convenient way than plunge baths of applying cold water for the reduction of temperature is by means of a fever-cot. This is a frame covered with