{"title": "HELPING HEALTH WORKERS LEARN - DAVID WERNER", "content": "Helping Health Workers Learn (2005) \n\n\nHelping \n\nHealth Workers \n\nLearn \n\nA book of methods, aids, \nand ideas for instructors \nat the village level \n\n\nDavid Werner and Bill Bower \n\n\ndrawings by \n\nDavid Werner Pablo Chavez \n\nRegina Faul-Jansen Marie Ducruy \n\n\nHelping Health Workers Learn (2005) \n\n\nLibrary of Congress Cataloging-in-Publication Data \n\nCatalog Card No.: 81-85010 \n\nWerner, David Bradford and Bower, Bill Lamed \nHelping Health Workers Learn \n\nPalo Alto, CA: Hesperian Foundation \n\n632 p. \n\n8111 811015 \n\nISBN: 0-942364-10-4 \n\n\nPUBLISHED BY: \n\nThe Hesperian Foundation \n1 91 9 Addison Street, Suite 304 \nBerkeley, California 94704 U.S.A. \n\n\nCopyright © 1982 by the Hesperian Foundation. All Rights Reserved. \nFirst Edition, January 1982 \n\nThirteenth Printing, January 2005 \n\n\nThe Hesperian Foundation encourages others to copy, reproduce, or adapt to meet local \nneeds any or all parts of this book, including the illustrations, provided that the parts \nreproduced are distributed free or at cost — not for profit. \n\nAny organization or person who wishes to copy, reproduce, or adapt any or all parts of th \nbook for commercial purposes must obtain permission from the Hesperian Foundation. \n\nBefore beginning any translation or adaptation of this book or its contents, please contact \nthe Hesperian Foundation for suggestions, updates on the information, and to avoid \nduplication of efforts. Please send us a copy of any materials in which text or illustrations \nfrom this book have been used. \n\n\nHelping Health Workers Learn (2005) \n\n\nThis book is dedicated to the village \nhealth team of Ajoya, Mexico, from \nwhom we have learned a great \ndeal... \n\nand to health workers everywhere \nwho side with the poor. \n\n\nREQUEST FOR YOUR COMMENTS, \nCRITICISMS, AND IDEAS: \n\nThis book is only a beginning. We want to \nimprove it— with your help. \n\nIf you have any ideas, teaching methods, \nvisual aids, or ways of exploring or learning \nthat you feel might be put into this book, please \nsend them to us. \n\nAlso let us know which parts of the book you \nfind most useful, and which parts, pages, or \nparagraphs you find confusing, badly written, \nleast useful, incorrect, or unfair. We think the \nbook is too long, and ask your help in deciding \nwhat to leave out. \n\n\nWE ARE ESPECIALLY INTERESTED IN \nGETTING SUGGESTIONS FROM VILLAGE \nAND COMMUNITY HEALTH WORKERS \nWHO HAVE BECOME INSTRUCTORS. \n\n\nPlease write to: \n\n\nThe Hesperian Foundation \n1919 Addison Street, Suite 304 \nBerkeley, California 94704 U.S.A. \n\n\nThank you. \n\n\nHelping Health Workers Learn (2005) \n\n\nTHANKS \n\n\nThe creation of this book has been a long, cooperative effort. We have borrowed \nideas from many sources. Included in these pages are methods and suggestions from health \nand development programs in 35 countries on 5 continents. Often we mention the programs \nor countries from which particular ideas have come as we discuss them in the text. Here, \nhowever, we give our warm thanks to all programs, groups, and persons whose ideas, \nsuggestions, and financial assistance have contributed to this book. \n\nOur heartfelt appreciation goes to the village health team in Ajoya, Mexico, \nespecially to Martin Reyes, Miguel Angel Manjarrez, Roberto Fajardo, Miguel Angel \nAlvarez, Pablo Chavez, Jesus Vega Castro, Rosa Salcido, Guadalupe Aragon, Alejandro \nAlvarez, Teresa Torres, Anacleto Arana, and Marcelo Acevedo. It is from working with the \nAjoya team for many years that we have come to understand the meaning of community- \nbased health care. \n\nWe would also like to renew our thanks to the dedicated persons who helped put \nthe first edition of this book together back in 1982: Myra Polinger, Lynn Gordon, Mary Klein, \nMichael Blake, Hal Lockwood, Christine Taylor, Richard Friedman, Susan Klein, Andy Browne, \nKenTull of World Neighbors, Meg Gramto, and Emily Goldfarb. Trude Bock generously \nprovided her home and all-round assistance during the three years it took to give birth to this \nbook \n\nOur special thanks to B.A. Laris for undertaking the editing, layout, and paste-up for the \ntenth printing. Her efforts make this printing easier to use with the 1992 revision of Where \nThere Is No Doctor. Davida Coady updated the antibiotic learning game found in Chapter 19 \nand Martin Lamarque provided current information on organizations that make practical \nteaching materials available. \n\nFor their outstanding drawings, we thank Regina Faul-Jansen, Marie Ducruy, and \nPablo Chavez of the village health team in Ajoya. Pablo also invented and helped develop \nseveral of the most imaginative teaching aids shown in this book. For many of the drawings \nand most of the photographs, credit also goes to David Werner. \n\nDavid Morley, Murray and Gerri Dickson, Fred Abbatt, Pia Moriarity, Sunil Mehra, Laura \nGoldman, and Esther de Gaily reviewed early drafts of this book. We remain grateful for their \nvaluable suggestions and encouragement. \n\nEarly drafts of Helping Health Workers Learn were field tested in Latin America, Africa, \nand the Philippines. From these various field trials we received many helpful ideas and \nsuggestions. We are deeply thankful to all those health workers, instructors, volunteers, and \nhealth officers who contributed. \n\nFor many years our books have been packaged and mailed by a dedicated group of \nvolunteers who contribute their labor to support the Foundation's efforts to make health \ninformation available. Without their commitment, far fewer copies of our publications would \nnow be available to people throughout the world. Our thanks to Barbara and Herb Hultgren, \nTom Beckett, Paul Chandler, Bob and Kay Schauer, Marge West, and Betsy Wallace. \n\nOver the years we have received financial assistance from many sources for the \ndevelopment and distribution of this book. We are grateful to the Ella Lyman Cabot Trust, the \nPublic Welfare Foundation, Brot fur die Welt, OXFAM England, the Sunflower Foundation, \nMisereor, Helmut and Brigitte Gollwitzer, and Reinhart Freudenberg. We also thank the \nCarnegie Corporation of New York for funding gratis distribution of this, and other Hesperian \npublications, in Africa. We wish to thank the many generous friends of the Hesperian \nFoundation who have donated their time and resources to support the struggle for better \nhealth and a better world. \n\n\nHelping Health Workers Learn (2005) \n\n\nHOW TO USE THIS BOOK \n\n\nThis book is mainly for instructors of village health workers— especially those \ninstructors who are village health workers themselves. But it may be of use to \nanyone involved in community education. \n\nThe book can be used in several ways: \n\nOne way is to start at the beginning and read through it. But most of you will \nbe too busy to do this. \n\n\nAnother way is to skim the book, going through it quickly for the main ideas. \nTo do this, look at and read what stands out most, namely: \n\n\n• the pictures \n\n\n• what is written in dark letters \n\n\n• what is inside the boxes like this \n\n\nAs you skim, you can stop and read complete pages or sections about ideas that \nespecially interest you. \n\nStill another way is to use this as a reference book. Review those pages or \nsections that apply to a particular activity you are planning— a class, a role play, \nthe preparation of teaching materials, or whatever. (In most cases, the book will \nnot tell you ‘how to do it', but will give ideas or examples you can choose from, \nthink about, or adapt to your own needs.) \n\nTo find a topic you are looking for in the book, you can use either the list of \nCONTENTS or the INDEX. \n\nThe CONTENTS, at the front of the book, lists the chapters in the order that \nthey appear. On first getting the book, we suggest that you review this list of \nCONTENTS. \n\nThe INDEX, at the back of the book, lists all of the important topics covered, \nin alphabetical order. \n\n\nThis book is organized mostly according to methods, aids, and ideas for \nlearning, rather than according to specific health topics. \n\nFor example, information about 'oral rehydration' appears in several different \nchapters: \"Looking at Learning and Teaching,” \"Appropriate and Inappropriate \nTechnology,\" and \"Children as Health Workers.\" If you are planning a class or \nactivity on oral rehydration, you may want to look up all 3 of these references. \nSo check the INDEX. \n\nFor more suggestions on how to use this book, see the inside of the \nback cover. \n\n\nHelping Health Workers Learn (2005) \n\n\nHOW TO USE THIS BOOK \n\n(continued) \n\n\nThis book is arranged into 5 major parts, each with a brief introduction. To \nmake them easier to find, the introductory pages of each part are marked with a \nblack strip at different heights along the outer margin. The margins of fhe Contents \nand Index pages are also lined with black. \n\n\nBy looking \nat the edges \nof the book, \nyou can see \nwhere each \npart begins. \n\n\nPage numbering: \n\nPages are numbered according to the sections or chapters they are in. In each \nchapter or section, page numbering starts again from page 1. In the top outer \ncorner of each page, you will see numbers like these: \n\nFront-3, or 4-12, or Part Two-7 \n\nThe first word or number in dark letters is the section or the chapter number. \nThe last number is the page number of that particular section or chapter. Thus, \n4-12 means Chapter 4, page 12. At first this numbering system may seem \nconfusing. But it will make it easier for us to add more pages or rearrange chapters \nin future editions. \n\n\nLanguage: \n\nWe have tried to keep language simple. Where difficult words are used, we try \nto explain them, or to use them in such a way that the meaning is clear. \n\nSometimes we put difficult words in italics (letters like these). And sometimes \nthe word is explained in small letters at the bottom of the page, after an asterisk*. \n\n\nSocial viewpoint: \n\nIn this book we take a strong social position in favor of the poor. Recognizing \nthat health is closely linked with self-reliance and politics, we have combined \ndiscussion of social factors with practical aspects of health education. \n\nTo better understand our social viewpoint and the practical experiences on \nwhich it is based, we suggest that you start by reading the front matter— the \nintroduction (Front-1 ) and \"Why This Book Is So Political\" (Front-7). Chapter 1, \n\"Looking at Learning and Teaching,\" will also help you put the rest of the book \nin perspective. \n\n\n'Asterisk: This little star is called an asterisk. It is used to indicate that there is more information about a \nword or idea at the bottom of the page. \n\n\nHelping Health Workers Learn (2005) \n\n\nCONTENTS \n\npage \n\nINTRODUCTION Front 1 \n\nWARNING Front-5 \n\nWHY THIS BOOK IS SO POLITICAL Front-7 \n\nPART ONE: APPROACHES AND PLANS \n\nChapter 1: Looking at Learning and Teaching 1-1 to 1-30 \n\nChapter 2: Selecting Health Workers, Instructors, and Advisers 2-1 to 2-18 \n\nChapter 3: Planning a Training Program 3-1 to 3-32 \n\nChapter 4: Getting off to a Good Start 4-1 to 4-14 \n\nChapter 5: Planning a Class 5-1 to 5-18 \n\nChapter 6: Learning and Working with the Community 6-1 to 6-20 \n\nChapter 7: Helping People Look at Their Customs and Beliefs 7-1 to 7-13 \n\nChapter 8: Practice in Attending the Sick 8-1 to 8-16 \n\nChapter 9: Examinations and Evaluation as a Learning Process 9-1 to 9-22 \n\nChapter 10: Follow-up, Support, and Continued Learning 10-1 to 10-18 \n\nPART TWO: LEARNING THROUGH SEEING, DOING, AND THINKING \n\nChapter 1 1 : Making and Using Teaching Aids 11-1 to 11-32 \n\nChapter 12: Learning to Make, Take, and Use Pictures 12-1 to 12-22 \n\nChapter 13: Story Telling 13-1 to 13-14 \n\nChapter 14: Role Playing 14-1 to 14-14 \n\nChapter 15: Appropriate and Inappropriate Technology 15-1 to 15-18 \n\nChapter 16: Homemade, Low-Cost Equipment and Written Materials . . . 16-1 to 16-20 \n\nChapter 17: Solving Problems Step by Step (Scientific Method) 17-1 to 17-14 \n\nChapter 18: Learning to Use Medicines Sensibly 18-1 to 18-14 \n\nChapter 19: Aids for Learning to Use Medicines and Equipment 19-1 to 19-18 \n\nPART THREE: LEARNING TO USE THE BOOK, WHERE THERE IS NO DOCTOR \n\nChapter 20: Using the Contents, Index, Page References, \n\nand Vocabulary 20-1 to 20-12 \n\nChapter 21 : Practice Using Guides, Charts, and Record Sheets 21-1 to 21-1 8 \n\nPART FOUR: ACTIVITIES WITH MOTHERS AND CHILDREN \n\nChapter 22: Pregnant Women, Mothers, and Young Children 22-1 to 22-20 \n\nChapter 23: The Politics of Family Planning 23-1 to 23-10 \n\nChapter 24: Children as Health Workers 24-1 to 24-30 \n\nPART FIVE: HEALTH IN RELATION TO FOOD, LAND, AND SOCIAL PROBLEMS \n\nChapter 25: Food First 25-1 to 25-44 \n\nChapter 26: Looking at How Human Relations Affect Health 26-1 to 26-38 \n\nChapter 27 : Ways to Get People Thinking and Acting: \n\nVillage Theater and Puppet Shows 27-1 to 27-39 \n\nA CALL FOR COURAGE AND CAUTION Back-1 \n\nADDRESSES FOR TEACHING MATERIALS Back-3 \n\nINDEX Back-5 \n\nABOUT PROJECT PIAXTLA AND THE AUTHORS Back-13 \n\nOTHER BOOKS BYTHE HESPERIAN FOUNDATION Back 16 \n\n\nHelping Health Workers Learn (2005) \n\n\nFront 1 \n\n\nINTRODUCTION \n\n\nHealth for all by the year 2000 has become the goal of the World Health \nOrganization (WHO) and most countries around the earth. \n\n\nSuch a world wide goal is very worthy. But in some ways it is dangerous. For \nthere is a risk of trying to reach that goal in ways that become so standardized, so \nimpersonal, so controlled by those in power, that many of the human qualities \nessential to health— and to health care— are lost. \n\nThere is already evidence of this happening. In the last 10 or 15 years, a great \nmany attempts have been made to bring basic health care to poor communities. \nBillions have been spent on large national or regional programs planned by highly \ntrained experts. But the results have often been disappointing. In most countries, \nthe number of persons suffering from preventable or easily curable illness \ncontinues to grow. \n\nOn the other hand, certain community health programs have been more or less \nsuccessful in helping the poor meet their health-related needs. Studies by \nindependent observers* have shown that programs generally recognized as \nsuccessful, whether large or small, often have the following things in common: \n\n1. Small, local beginnings and slow, decentralized growth. Even the more \nsuccessful large programs usually have begun as small projects that gradually \ndeveloped and evolved in response to the needs of particular communities. \n\nAs these programs have grown, they have remained decentralized. This means \nthat important planning and decision making still take place at the village or \nneighborhood level. \n\n2. Involvement of local people— especially the poor— in each phase of the \nprogram. Effective programs recognize and try to deal with the conflicts of \ninterest that often exist between the strong and the weak, even in a small \ncommunity. Not just local leaders, but the most disadvantaged members of \nsociety, play a leading role in selecting their own health workers and \ndetermining program priorities. A conscious aim of such programs is to help \nstrengthen the position and bargaining power of the poor. \n\n3. An approach that views planning as a 'learning process'. The planning of \nprogram content and health worker training does not follow a predetermined \n'blueprint'. Instead, planning goes on continually as a part of a learning \nprocess. Participants at every level (instructors, student health workers, and \nmembers of the community) are invited to help shape, change, and criticize \nthe plans. This allows the program to constantly evolve and adapt, so as to \nbetter meet people's changing needs. Planning is both local and flexible. \n\n\nSee, for example, David Korten's analysis of successful programs in Asia, \"Community Organization and \nRural Development: A Learning Process Approach,\" Public Administration Review, Septernber/October, \n1980. p 480-510. \n\n\nFront-2 \n\n\nHelping Health Workers Learn (2005) \n\n\n4 Leaders whose first responsibility is to the poor. Programs recognized as \neffective usually have leaders who are strongly committed to a just society. \nOften they have had intense personal experience working with the poor in \ncommunity efforts to help solve critical needs. Even as their programs have \ngrown and expanded, these program leaders have kept up their close relations \nwith the poor working people in individual communities. \n\n\n5 A recognition that good health can only be attained through helping the \npoor improve the entire situation in which they live. Successful programs link \nhealth activities with other aspects of social development. Health is seen as a \nstate of wholeness and well-being in which persons are able to work together \nto meet their needs in a self-reliant, responsible way. This means that to become \nfully healthy, each person needs a clear understanding of himself or herself in \nrelation to others and to the factors that influence all people's well-being. \n\nIn many of the most effective health programs, activities that help people to \ndevelop a more critical awareness have become a key part of training and \ncommunity work. \n\n\nIn view of these features common to success, the failure of many national and \nregional 'community heal th ' programs is not surprising. Most are carried out in \nquite the opposite way. Although their top planners speak proudly of \"decision \nmaking by the community,\" seldom do the people have much say about what \ntheir health workers are taught and told to do. 'Community participation' too \noften has come to mean \"getting those people to do what we decide.\" Rather \nthan helping the poor become more self-reliant, many national health and \ndevelopment programs end up increasing poor people's dependency on outside \nservices, aid, and authority. \n\n\nOne of the biggest obstacles to 'health by the people' has been the unwillingness \nol experts, professionals, and health authorities to let go of their control. As a \nresult, community health workers are made to feel that their first responsibility \nis to the health system rather than to the poor. Usually they are taught only a \nvery limited range of skills. They become the servants or 'auxiliaries' to visiting \ndoctors and nurses, rather than spirited leaders for change. They learn to follow \norders and fill out forms, instead of to take initiative or to help people solve \ntheir problems on their own terms. Such health workers win little respect and \nhave almost no influence on overall community health. Many of them get \ndiscouraged, grow careless, become corrupt, or quit. Results have been so \ndisappointing that some experts, even within WHO, have begun to feel that the \ngoal of 'health for all through community involvement' is like the pot of gold at \nthe end of the rainbow— a dream that has been tried, but failed. \n\n\nHelping Health Workers Learn (2005) \n\n\nFront-3 \n\n\nIn spite of the failure of most large, centrally controlled programs to achieve \neffective community participation, in many countries there are outstanding \nexamples of enthusiastic community involvement in health. This is especially \ntrue in small, non-government programs that take what we call a people-centered \nor community-strengthening approach to health care. \n\nWithin these community-based programs, there is a wealth of variety in terms \nof innovation and adaptation to local conditions. But at the same time, there is a \nstriking similarity in their social and political objectives in many parts of the \nworld— Pakistan, India, Mozambique, the Philippines, Mexico, Nicaragua, \nHonduras, El Salvador, and Guatemala. \n\nIn these community-based programs, a new kind of health worker has begun to \nplay a leading role. These health workers speak out for the 'voiceless' poor. Their \ngoal is health for all— but health that is founded on human dignity, loving care, \nand fairer distribution of land, wealth, and power. \n\nTo us, one of the most exciting aspects of this new world-wide community- \nbased movement, decentralized and uncoordinated as it may be, is that it goes far \nbeyond any rigid religious or political doctrine. Most of the leaders in these \nprograms recognize the dangers to ordinary people in any large, centrally \ncontrolled system, be it capitalist or communist. They have far greater faith in \nsmall, self-directed groups of working people. Rather than accept any established \ndogma, they are asking searching questions. They welcome criticism, and \nencourage others to observe for themselves and form their own conclusions. They \nbelieve in helping the powerless to gain strength through a greater understanding \nof the factors that shape their health and their lives. \n\nAround this practical human vision has gradually grown a whole new approach \nto the training, role, and responsibilities of community health workers. Ideas and \nmethods are being shared and further developed through a series of informal \nnetworks around the world. \n\nMany of the ideas in this book have been gathered from these networks of \ncommunity-based health programs, and especially from Project Piaxtla, a small, \nvillager-run program based in Ajoya, Sinaloa, Mexico. \n\n\nHelping Health Workers Learn (2005) \n\n\nHelping Health Workers Learn (2005) \n\n\nFront 5 \n\n\nWARNING \n\n\nThis is not a 'recipe book' of how to plan and conduct a training course for \nhealth workers. Experience has taught us that such a book could easily do more \nharm than good. Instead, this is a collection of examples and ideas, of group \nexperiences and outrageous opinions, of 'triggers to the imagination'. It is an \ninvitation to adventure and discovery. \n\nPart of the value and excitement of learning is in finding out 'how to do it' for \nyourself and with others. It lies in looking at the ways things have been done \nbefore, then improving and adapting them to suit your own circumstances. This \nsort of open-ended, creative learning process is as important for instructors of \nhealth workers as for the health workers themselves. After all, finding ways to do \nthings better is the key to improving health. The instructor can set the example. \n\nTo be fully alive and meaningful, a training course cannot be either pre- \npackaged or 'replicable' (able to be copied). It needs to be redesigned not only \nfor each area and set of conditions where it is taught, but each time it is taught. \n\nA training program, like a person, ceases to be interesting when it ceases to \ngrow or be unique! \n\nSo rather than being a 'blueprint' on how to build a training program, this \nbook is a craftsman's kit of nuts and bolts and tools. Many of the methods and \nsuggestions come from our personal experience, which has been mostly in Latin \nAmerica. So pick and choose from them critically. Use and adapt what you can, \nin order to create— and continually re-create— your own very special, unique, and \nalways-new program. Try to make planning a continuous learning process for \neveryone concerned: instructors, students, and members of the community. \n\n\nMany of the ideas and suggestions in this book are controversial and will not \napply to all areas. We do not ask anyone simply to accept and use them. \nInstead, we ask you to challenge them, adapt them, criticize them— and use \nonly what makes sense for the people and needs in your own area. \n\n\nWe ask you to consider— and urge you to \ndoubt and question— everything we say. \n\n\nHelping Health Workers Learn (2005) \n\n\nfrom Where \nThere Is No \nDoctor, p. 1 14 \n\n\nwww. ncspenan.org \n\n\nHelping Health Workers Learn (2005) \n\n\nFront-7 \n\n\nWHY THIS BOOK IS SO POLITICAL \n\n\nWhen, 1 7 years ago, I (David Werner) first began working for improvements in \nhealth with villagers in western Mexico, I did not look far beyond the immediate \ncauses of ill health. As I saw it, worms and diarrhea were caused by poor hygiene \nand contaminated water. Malnutrition was mainly caused by scarcity of food in a \nremote, mountainous area where drought, floods, and violent winds made farming \ndifficult and harvests uncertain. The high death rate in children (34%) resulted \nfrom the combination of infection, poor nutrition, and the long distance to the \nclosest health centers. \n\n\nIn short, I saw people's needs in physical terms, as determined by their \nphysical surroundings. This short-sightedness on my part was understandable, for \nmy training had been in life sciences. I had little social or political awareness. \n\n\nI might have remained that way, as do many health workers, except that I \ncame so close to the mountain people. I knew from the first that they had \nstrengths, skills, and endurance that I lacked. And so I was able to let them teach \nme about the human— and inhuman— side of their needs and their lives. They did \nnot sit down and spell things out for me; rather they shared with me their homes, \ntheir hardships, and their dreams. Many times I have struggled with a family, \nagainst odds, to prevent the loss of a child, a cornfield, or hope. Sometimes we \nwon; sometimes we lost. \n\n\nLittle by little, I became aware that many of their losses— of children, of land, \nor of hope— not only have immediate physical causes, but also underlying social \ncauses. That is to say, they result from the way some people treat or affect the \nlives of others. Time and again, I have experienced occasions where death and \nsuffering of children and other persons I have to come to love have been the direct \nor indirect result of human greed. \n\n\nOn page 114 of Where There Is No Doctor there is a photograph of a very thin \nlittle boy in the arms of his malnourished mother The boy eventually died — of \nhunger. The family was — and still is — very poor Each year the father had to borrow \nmaize from one of the big landholders in the area. For every liter of maize \nborrowed at planting time, he had to pay back 3 liters at harvest time. With these \nhigh interest rates, the family went further and further into debt. No matter how \nhard the father worked, each year more of his harvest went to pay what he owed \nto the landholder. Each year he had to borrow more, and pay back 3 times as \nmuch. Eventually, the family had to sell their few chickens and pigs, and finally \neven the beans they had grown on the steep mountain slopes, to buy enough corn \nto survive. \n\n\nWith no eggs or beans to eat, the mother became increasingly malnourished. Her \nbreasts failed to produce milk for her baby. So she fed him the only food they \nhad— cornmeal and water. In time the child died. \n\n\nFronts \n\n\nHelping Health Workers Learn (2005) \n\n\nPart of the problem may also have been that the father occasionally drinks with \nthe other men. When he gets drunk, he loses his judgement and sometimes, to buy \nrounds of drinks, sells a part of the family's precious supply of corn. \n\nThis is sad. But look at the father's life. The hard work he does only to go \ndeeper into debt. The death of a child he loved and whom he feels he failed. The \napparent hopelessness of his situation. And frequently his own hunger— not only \nfor food, but for a fair chance to benefit from his own hard work. We cannot \nblame him if he occasionally drinks too much! \n\nPerhaps no one is really to blame. Or perhaps we all are— all of us, at least, who \nlive with more than we need while others hunger. In any case, it is not right, it is \nnot kind, it is not human, to remain silent in a world that permits some persons \nto grow fat from the hard work of others who go hungry. \n\nThe child in the photograph who died is not alone. In the mountain villages I \nknow, there are hundreds of similar children— some dead and some waiting. In the \nworld there are millions. One fourth of the world's children are undernourished, \nmost for reasons similar to those I have just described. Their problems will not be \nsolved by medicines or latrines or nutrition centers or birth control (although all \nof these, if approached decently, may help). What their families need is a fair \nchance to live from their own labor, a fair share of what the earth provides. \n\n\nDo I make myself clear? Let me tell you about Chelo and his family, whom I \nhave become close to over the years. Chelo has advanced tuberculosis. Before the \nvillager-run health center was started in his village, he received no treatment. He \nknew he had tuberculosis. He wanted treatment. But he could not afford the \nmedicines. (Basic tuberculosis medicines are not expensive to produce. But in \nMexican pharmacies, they are sold at up to ten times their generic price in the \nUnited States and other developed countries.) Although the government's \ntuberculosis control program does give free medication, it requires that patients \ngo often to one of its city health centers for tests and medication. For Chelo, \nthis would have meant 250 kilometers of travel every two weeks. He simply \ncould not afford it. \n\nFor years, Chelo had worked for the richest landholder in the village. The \nlandholder is an unhappy, overweight man who, apart from his enormous \nlandholdings, owns thousands of cattle. When Chelo began to grow weak from \nhis illness and could not work as hard as before, the landholder fired him, and \ntold him to move out of the house he had been lending him. \n\nChelo, his wife, Soledad, and his stepson, Raul,* built a mud-brick hut and \nmoved into it. By that time Chelo was coughing blood. \n\nAround the same time, the community-based health program was getting \nstarted in the area, but as yet no health worker had been trained in Chelo's \nvillage. So a visiting health worker taught Chelo's 1 1 -year-old stepson, Raul, to \ninject him with streptomycin. Raul also learned to keep records to be sure Chelo \ntook his other medicines correctly. The boy did a good job, and soon was \ninjecting and doing follow-up on several persons with tuberculosis in the village. \nBy age 13, Raul had become one of the central team of health workers in the \narea. At the same time, he was still attending school. \n\n\n•These are real persons, but I have changed their names. \n\n\nHelping Health Workers Learn (2005) \n\n\nFront 9 \n\n\nMeanwhile, Chelo's family had cleaned up a small weed patch and garbage area \nat the lower edge of town. With much hard work they had constructed a simple \nirrigation system using ditches and grooved logs. At last they had a successful \nvegetable plot, which brought in a small income. Chelo's health had improved, \nbut he would never be strong. T reatment had begun too late. \n\nEconomically, Chelo had one setback after another. Just when he was \nbeginning to get out of debt to the storekeepers and landholders, he fell ill with \nappendicitis. He needed hospital surgery, so health workers and neighbors carried \nhim 23 kilometers on a stretcher to the road, and from there took him to the \ncity by truck. The surgery (in spite of the fact that the doctor lowered his fee) \ncost as much as the average farmworker earns in a year. The family was reduced \nto begging. \n\nThe only valuable possession the family had was a donkey. When Chelo \nreturned from the hospital, his donkey had disappeared. Two months later, a \nneighbor spotted it in the grazing area of one of the wealthier families. A new \nbrand— still fresh— had been put right on top of Chelo's old one. \n\nChelo went to the village authorities, who investigated. They decided in favor \nof the wealthy thief, and fined Chelo. To me, the most disturbing thing about \nthis is that when he told me about it, Chelo did not even seem angry— just sad. \n\nHe laughed weakly and shrugged, as if to say, \"That's life. Nothing can be done.\" \n\nHis stepson, Raul, however, took all these abuses very hard. He had been a \ngentle and caring child, but stubborn, with an enormous need for love. As he got \nolder, he seemed to grow angrier. His anger was often not directed at anything \nin particular. \n\nAn incident with the school was the last straw. Raul had worked very hard to \ncomplete secondary school in a neighboring town. Shortly before he was to \ngraduate, the headmaster told him in front of the class that he could not be given \na certificate since he was an illegitimate child— unless his parents got married. \n\n(This happened at a time when the national government had decided to improve \nits statistics. The president's wife had launched a campaign to have all unwed \ncouples with children get married. The headmaster's refusal to give graduation \ncertificates to children of unwed parents was one of the pressures used.) Chelo \nand his wife did get married— which cost more money— and Raul did get his \ncertificate. But the damage to his pride remains. \n\nYoung Raul began to drink. When he was sober, he could usually control \nhimself. But he had a hard time working with the local health team because he \ntook even the friendliest criticism as a personal attack. When he was drunk, his \nanger often exploded. He managed to get hold of a high-powered pistol, which he \nwould shoot into the air when he was drinking. One night he got so drunk that \nhe fell down unconscious on the street. Some of the young toughs in town, who \nalso had been drinking, took his pistol and his pants, cut off his hair, and left \nhim naked in the street. Chelo heard about it and carried Raul home. \n\nAfter this, Raul hid in shame for two weeks. For a while he did not even visit \nhis friends at the health post. He was afraid they would laugh. They did not. But \nRaul had sworn revenge— he was never quite sure against whom. A few months \nlater, when drunk, he shot and killed a young man who had just arrived from \nanother village. The two had never seen each other before. \n\n\nFront 1 0 \n\n\nHelping Health Workers Learn (2005) \n\n\nThis, to me, is a tragedy because Raul was fighting forces bigger than himself. \n\nAs a boy of 1 2, he had taken on the responsibilities of a man. He had shown care \nand concern for other people. He had always had a quick temper, but he was a \ngood person. And, I happen to know, he still is. \n\nWho, then, is to blame? Again, perhaps no one. Or perhaps all of us. Something \nneeds to be changed. \n\nAfter the shooting, Raul fled. That night, the State Police came looking for \nhim. They burst into Chelo's home and demanded to know where Raul was. \n\nChelo said Raul had gone. He didn't know where. The police dragged Chelo into \na field outside town and beat him with their pistols and rifles. Later, his wife \nfound him still lying on the ground, coughing blood and struggling to breathe. \n\nIt was more than a year before Chelo recovered enough to work much in his \ngarden. His tuberculosis had started up again after the beating by the police. \n\nRaul was gone and could not help with the work. The family was so poor that, \nagain, they had to go begging. Often they went hungry. \n\nAfter a few months, Chelo's wife, Soledad, also developed signs of tuberculosis \nand started treatment at the village health post. The local health workers did not \ncharge for her treatment or Chelo's, even though the health post had economic \ndifficulties of its own. However, Chelo's wife helped out when she could by \nwashing the health post linens at the river. (This work may not have been the best \nthing for her TB, but it did wonders for her dignity. She felt good about giving \nsomething in return.) \n\nAbout 4 years have passed since these last incidents. Chelo and his wife are \nnow somewhat healthier, but are still so poor that life is a struggle. \n\nThen, about a year ago, a new problem arose. The landholder for whom Chelo \nhad worked before he became ill decided to take away the small plot of land \nwhere Chelo grew his vegetables. When the land had been a useless weed patch \nand garbage dump, Chelo had been granted the rights to it by the village \nauthorities. Now that the parcel had been developed into a fertile and irrigated \nvegetable plot, the landholder wanted it for himself. He applied to the village \nauthorities, who wrote a document granting the rights to him. Of course, this \nwas unlawful because the rights had already been given to Chelo. \n\nChelo took the matter over the heads of the village authorities to the Municipal \nPresidency, located in a neighboring town. He did not manage to see the President, \nbut the President's spokesman told Chelo, in no uncertain terms, that he should \nstop trying to cause trouble. Chelo returned to his village in despair. \n\nChelo would have lost his land, which was his one means of survival, if the \nvillage health team had not then taken action. The health workers had struggled \ntoo many times— often at the cost of their own earnings— to pull Chelo through \nand keep him alive. They knew what the loss of his land would mean to him. \n\nAt an all-village meeting, the health workers explained to the people about the \nthreat to Chelo's land, and what losing it would mean to his health. They produced \nproof that the town authorities had given the land rights to Chelo first, and they \nasked for justice. Although the poor farm people usually remain silent in village \nmeetings, and never vote against the wishes of the village authorities, this time \nthey spoke up and decided in Chelo's favor. \n\n\nHelping Health Workers Learn (2005) \n\n\nFront- 1 1 \n\n\nThe village authorities were furious, and so was the landholder. \n\nThe health team had taken what could be called political action. But the health \nworkers did not think of themselves as 'political'. Nor did they consider themselves \ncapitalists, communists, or even socialists. (Such terms have little meaning for \nthem.) They simply thought of themselves as village health workers— but in the \nlarger sense. They saw the health, and indeed the life, of a helpless person \nthreatened by the unfairness of those in positions of power. And they had the \ncourage to speak out, to take action in his defense. \n\nThrough this and many similar experiences, the village health team has come \nto realize that the health of the poor often depends on questions of social justice. \nThey have found that the changes that are most needed are not likely to come \nfrom those who hold more than their share of land, wealth, or authority. Instead, \nthey will come through cooperative effort by those who earn their bread by the \nsweat of their brows. From themselves! \n\n\nMore and more, the village team in Ajoya has looked for ways to get their \nfellow villagers thinking and talking about their situation, and taking group \naction to deal with some of the underlying causes of poor health. \n\nSome of the methods they have developed and community actions they have \nled are described in several parts of this book. For example, three of the village \ntheater skits described in Chapter 27 show ways in which the health team has \nhelped the poor look at their needs and organize to meet them. \n\nThese 3 skits are: \n\nSMALL FARMERS JOIN TOGETHER TO OVERCOME EXPLOITATION \n(page 27-27), \n\nUSELESS MEDICINES THAT SOMETIMES KILL (page 27-14), and \n\nTHE WOMEN JOIN TOGETHER TO OVERCOME DRUNKENNESS (page \n27 19). \n\nThese popular theater skits had, and are still having, a marked social influence. \nVillagers participate with new pride in the cooperative maize bank set up to \novercome high interest on loans. Women have organized to prevent the opening \nof a public bar. And storekeepers no longer carry some of the expensive and \ndangerous medicines that they sold before. In general, people seem more alert \nabout things they had simply accepted. \n\nOn the other hand, new difficulties have arisen. Some of the health workers \nhave been thrown out of their rented homes. Others have been arrested on false \ncharges. Threats have been made to close down the villager-run program. \n\nBut in spite of the obstacles, the health team and the people have stood their \nground. The village team knows the road ahead will not be easy. They also know \nthat they must be careful and alert. Yet they have chosen to stand by their \npeople, by the poor and the powerless. \n\nThey have had the courage to look the whole problem in the eye— and to look \nfor a whole answer. \n\n\nFront 12 \n\n\nHelping Health Workers Learn (2005) \n\n\nThe story of Cheio and his family is true, though I have not told the half of it. \nIt is typical, in some ways, of most poor families. Persons in several parts of the \nworld who are poor or know the poor, on reading Chelo's story have commented, \n\"It could have been written here!\" \n\nI have told you Chelo's story so that you might understand the events that \nhave moved us to include in this book ideas and methods that might be called \n'political'. \n\n\nWhat I have tried to say here has been said even better by a group of \npeasant school boys from Barbiana, Italy. These boys were flunked out of \npublic school and were helped, by a remarkable priest, to learn how to \nteach each other.* \n\nThe Italian peasant boys write: \n\nWhoever is fond of the comfortable and the fortunate stays out of politics. \nHe does not want anything to change. \n\nBut these school boys also realize that: \n\nTo get to know the children of the poor and to love \npolitics are one and the same thing. You cannot love \nhuman beings who were marked by unjust laws and not \nwork for other laws. \n\n\n* Letter to a Teacher, by the school boys of Barbiana. For more ideas of these school boys, see p. 16 16. \n\n\nHelping Health Workers Learn (2005) \n\n\nPart One 1 \n\n\nPART ONE \n\nAPPROACHES AND PLANS \n\n\nIn Part One of this book, we look at approaches to planning and carrying out a \ntraining program for community health workers. \n\nBut before getting into different aspects of planning, in Chapter 1 we explore \nalternative approaches to learning and teaching. We do this because the educational \nmethods instructors decide to use will in part determine how the training course is \ndesigned and who takes part in the planning. In health education, the methods are \nas important as the message. \n\nChapter 2 is about the selection of both health workers and instructors. We \nconsider the reasons why persons selected from and by their own communities \nusually make the best leaders for change. We also discuss why experienced village \nhealth workers often make the best instructors of new health workers. \n\nIn Chapter 3, we consider steps in planning a training course, and in Chapter 4, \nhow to get the course off to a good start. \n\nChapters 5, 6, 7, and 8 explore activities in the 3 main places of learning in a \ntraining course: the classroom (Chapter 5), the community (Chapters 6 and 7), \nand the clinic or health center (Chapter 8). We point out that in each of these \nplaces, the classroom included, the most effective form of learning is through \nactual practice in solving common problems. \n\nChapter 9 discusses ways of finding out how well people are teaching, learning, \nand meeting local needs. Here we look for ways in which tests, exams, and \nevaluation can be organized to strengthen the position of the weak and help \neveryone reach a better understanding of the training program as a whole. \n\nIn Chapter 10, we consider what happens after the initial training course is \ncompleted and health workers are back in their own communities. This includes \nsupportive follow-up and continued opportunities to learn. \n\n\nHelping Health Workers Learn (2005) \n\n\nHelping Health Workers Learn (2005) \n\n\n1 1 \n\n\nT x . CHAPTER + \n\nLooking at Learning 1 \n\nand Teaching \n\n\nA health worker's most important job is to teach— to encourage sharing of \nknowledge, skills, experiences, and ideas. The health worker's activities as an \n'educator' can have a more far-reaching effect than all his or her preventive and \ncurative activities combined. \n\nBut depending on how it is approached, and by whom, health education can \nhave either a beneficial or harmful effect on people's well-being. It can help \nincrease people's ability and confidence to solve their own problems. Or, in \nsome ways, it can do just the opposite. \n\nConsider, for example, a village health worker who calls together a group of \nmothers and gives them a 'health talk' like this: \n\n\nWhat effect does this kind of teaching have on people? \n\nYou can discuss this question with your fellow instructors or with the health \nworkers you are training. Or health workers can discuss it with people in their \nvillages. You (or the learning group) may come up with answers \nsomething like these: \n\n\"It's the same old message everybody's heard \na hundred times! But what good does it do?\" \n\n\"It goes in one ear and out the other!\" \n\n\"The mothers just sit and listen. \n\nThey don't take part.\" \n\n\n1-2 \n\n\nHelping Health Workers Learn (2005) \n\n\nThe more deeply your group explores this example of 'health education', the \nclearer the picture wi II become. Encourage the group to notice ways in which \nthis kind of teaching affects how people view themselves, their abilities, and their \nneeds. Persons may observe that: \n\n\"That kind of teaching makes the mothers \nfeel ashamed and useless— as if their own \ncarelessness and backwardness were to blame \nfor their children's ill health.\" \n\n\n\"The health worker acts like she is God \nAlmighty! She thinks she knows it all and \nthe mothers know nothing!\" \n\n\n\"Her uniform separates her from the mothers \nand makes her seem superior. It gives her \noutside authority. This may strengthen \npeople's respect for her, but it weakens \ntheir confidence in their ability to take \nthe lead themselves.\" \n\n\n\"I don't think her health advice is realistic. Not for \nthe poor in our area! It's easy to tell people to \nboil drinking water. But what if a mother with \nhungry children spends her food money to buy \nfirewood? Also, where we live, the land is already \nbeing turned into a desert because so many trees \nare being cut. For us, this 'health message' would \nmake no sense.\"* \n\n\n\"This is the way most of us were \ntaught in school. The teacher is \nthe boss. The students are \nconsidered to 'know nothing'. \nThey are expected simply to \nrepeat what they're told. \n\nBut isn't this just another \nway of keeping the poor \non the bottom?\" \n\n\n\"I agree! This kind of 'health \neducation' might get mothers \nto boil water, wash their \nhands, and use latrines. But \nin the long run it may do \nmore to prevent than to \npromote the changes we \nneed for lasting \nimprovements in our \nhealth.\" \n\n\nThe instructors, health workers, or villagers who discuss this question may \narrive at answers similar to or very different from those suggested above. Their \nresponses will depend, in part, on the local situation. But in part they will depend \non how carefully the group looks at, thinks about, and 'analyzes' the issues involved. \n\n\nFor more discussion about boiling drinking water, see p. 15-3. \n\n\nHelping Health Workers Learn (2005) \n\n\n1-3 \n\n\nMow consider another example. Here, a health worker gets together with a \ngroup of mothers and discusses their problems with them. She starts by asking \nquestions like these: \n\n\nWhat effect does this kind of teaching have on people? In discussing this \nquestion with your group, you may hear answers like these: \n\n\"Everybody takes part. It gets the group of mothers \nthinking and talking about their own problems.\" \n\n\"The health worker doesn't just tell them the answers. I \n\nEveryone looks for answers together.\" \n\n\"The health worker dresses like the other mothers and \nputs herself on their level. She is their friend, not their \n'master'. It makes everyone feel equal.\" m fir ' 'r \n\n\"This sort of teaching certainly * * “| \n\nisn't like what we got in \nschool! It lets people feel their \nideas are worth something. It helps people figure out \ntheir problems and work toward solving them \nthemselves.\" \n\n\"I'll bet the mothers will want to keep working and \nlearning together, because they are respected as \nthoughtful, capable human beings. It makes learning \nfun!\" \n\n\nOnce again, when you discuss this teaching example with fellow instructors, \nhealth workers, or villagers, their answers may be very different from the ones \nshown here— or from your own. But if the group discusses the issues in depth, \nrelating them to their own concerns and experiences, they will make many \nvaluable observations. You will all learn from each other. \n\n\n1-4 \n\n\nHelping Health Workers Learn (2005) \n\n\nHow something is taught is \njust as important as what is \ntaught. \n\nAnd the most important \npart of how something is \ntaught is the caring, respect, \nand shared concern that go \ninto it. \n\n\nAristotle, \"Father of \nScience,\" wisely said . \n\n\nHOW CAN I TEACH \nBUT TO A FRIEND? \n\n\nDIRECTING HEALTH EDUCATION TOWARD THOSE \nWHOSE NEEDS ARE GREATEST \n\nPeople usually teach in the way they themselves were taught— unless something \neither alarming or loving happens to change the way they view things and do \nthings. This is true for health workers. And it is true for those of us who are \ninstructors of health workers. Most of us teach as we were taught in school. \n\nUnfortunately, the purposes and methods of public schools are not always in \nthe best interests of those whose needs are greatest. As we shall discuss, schools \ntend to reward the stronger students and leave the weak behind. \n\nBut the aim of 'people-centered' learning is just the opposite. It is to help \nthose who are weakest become stronger and more self-reliant. \n\n\nCommunity health education is appropriate to the \nextent that it helps the poor and powerless gain \ngreater control over their health and their lives. \n\n\nTo become effective community educators, health workers need to develop \napproaches very different from what most of us have experienced in school. \n\nFor this to happen, it is essential that student health workers critically examine \ndifferent ways of teaching during their training. They need to develop and practice \nteaching methods that can help ordinary working people to gain the awareness \nand courage needed to improve their situation. \n\nIn this chapter, we will look at the educational roles of both health workers \nand their teachers. Then we will consider some ways of helping health workers \nexplore alternative approaches for teaching and learning with people. \n\n\nHelping Health Workers Learn (2005) \n\n\n1-5 \n\n\nTHE TEACHING ROLE OF HEALTH WORKERS \n\n\nV \n\n\nEarly during training, be sure to have health workers think about the range of \nopportunities they will have for sharing and exchanging ideas in their communities. \n\nAfter discussing the many possibilities, they might post them on a wall as a \nreminder: \n\n\nOPPORTUNITIES FOR SHARING AND EXCHANGING IDEAS WITH PEOPLE \n\nIN OUR VILLAGES \n\n\n/ \n\n\nWe health workers can look for ways to . . . \n\n\nHelp families of sick \npersons find ways to care \nfor them better and to \nprevent similar sickness \nin the future. \n\n\nHelp mothers find ways \nto protect their own health \nand that of their children. \n\n\nInterest school children \n(and those who do not go \nto school) in learning to \nmeet the health needs of \ntheir younger brothers and \nsisters. \n\n\nHelp organize village \nmeetings to discuss local \nproblems. Encourage \nothers to become ‘health \nleaders’. \n\n\nExchange ideas and \ninformation with local \nmidwives, bone setters, \nand traditional healers. \n\n\nTalk with youth groups \nand farmers about possible \nways to improve their \ncrops or to defend their \nland and rights. \n\n\nThis list is only a beginning. Your group may think of many other possibilities. \n\nAlso, try to get the group thinking about the different ways people learn. In \ntheir village, there may be many people who have never gone to school. They may \nnot be used to classes, lectures, or 'health talks'. Traditionally, people learn from \nstories and play, by watching, copying, and helping others work, and through \npractical experience. Ask your students what are the customary ways of learning \nin their villages. \n\n\nEncourage your students to think of ways that they might adapt health \neducation to people's local forms of learning. Here are some possibilities, which \nwe discuss in the chapters indicated. \n\n\n• story telling, Ch. 13 \n\n• songs, p. 1-26 and 15-1 5 \n\n• play (learning games), Ch. 1 1 , 19, and 24 \n\n• make-believe (learning by imitating), Ch. 24 \n\n• role playing (acting out problems and \nsituations), Ch. 14 \n\n• popular theater and puppet shows, Ch. 27 \n\n• apprenticeship (learning by helping someone \nmore skilled) , Ch. 8 \n\n\n• practical experience, Ch. 6 and 8 \n\n• smal I group discussions, Ch. 4 and 26 \n\n• solving real problems, Ch. 8, 10, 14, 17, 25, 26, \nand 27 \n\n• trial and error (finding things out for oneself), \nCh. 11, 17, and 24 \n\n• building on the knowledge, skills, customs, and \nexperience that people already have, Ch. 7 \nand 1 3 \n\n\nWe health workers need to adapt our teaching to people's \ntraditional ways of learning— ways they are already used to and enjoy. \n\n\n1-6 \n\n\nHelping Health Workers Learn (2005) \n\n\nTHE ROLE OF HEALTH WORKER INSTRUCTORS \n\nIt is not enough to explain to health workers about 'people-centered' education. \nWe teachers must set an example. This means we must carefully and frequently \nexamine our own teaching habits, in terms of both the methods we use and the \n\nway we relate to our students. \n\n• The methods we use. If we would like health workers to use stories when \nteaching village mothers, then we, too, need to use stories for helping health \nworkers learn. If we would like them to help children learn through puppet \nshows, games, and discovering things for themselves, we must let them \nexperience the excitement of learning in these ways. If health workers are to \nhelp farm workers discuss problems and choose their own courses of action, \nthen we must give health workers similar opportunities during training. Health \nworkers will be more able to help others learn by doing if they, themselves, \nlearn by doing. \n\n• How we relate. How we instructors teach health workers is just as important \nas what we teach them. But how we teach depends greatly on how we feel \ntoward our students. \n\nIf we respect our students' ideas, and encourage them to question our \nauthority and to think for themselves, then they will gain attitudes and skills \nuseful for helping people meet their biggest needs. \n\nBut if we fail to respect our students, or make them memorize lessons \nwithout encouraging them to question and think, we may do more harm than \ngood. Our experience has shown us that health workers trained in this way \nmake poor teachers and bossy leaders. Rather than helping people gain the \nunderstanding and confidence to change their situation, they can even stand \nin the way. \n\n\nTo set a good example for health workers, we instructors need to: \n\n• T reat the health workers as our equals— and as friends. \n\n• Respect their ideas and build on their experiences. \n\n• Invite cooperation; encourage helping those who are behind. \n\n• Make it clear that we do not have all the answers. \n\n• Welcome criticism, questioning, initiative, and trust. \n\n• Live and dress modestly; accept only modest pay. \n\n• Defend the interests of those in greatest need. \n\n• Live and work in the community. Learn together with the people, and \nshare their dreams. \n\nThese ideas are beautifully expressed in this old Chinese verse: \n\n\nQ-o in search, of If our people- ■. \n£ove Them -, \n\nTeam from Them. ; \nflan with Them*-, \n\n \n\nof each crutch. Then he wrapped the kapok in ([ \n\nplace with strips of cloth Pepe tried the crutches \n\nagain and found them comfortable. 1 1 (j | J | \n\n\"Gosh, Dad, you really fixed them great!\" cried O y f/ ijf \n\nthe boy, smiling at his father with pride. \"Look f a / if \n\nhow well I can walk nowl\" He bounded about the I I j J \n\ndusty patio on his new crutches. \n\n\"I'm proud of you, son!\" said his father, smiling too. \n\nAs the health worker was saddling his mule to leave, the whole family came \nto say good-bye \n\n\nI can't thank you enough,” said \nthe father. \"It's so wonderful to see \nmy son able to walk upright. I don't \nknow why I never thought of making \ncrutches before . . .\" \n\n\"It's I who must thank you,\" said \nthe health worker. \"You have taught \nme a great deal.” \n\nAs the health worker rode down \nthe trail he smiled to himself \"How \nfoolish of me,\" he thought, \"not to \nhave asked the father's advice in the \nfirst place. He knows the trees better \nthan I do. And he is a better \ncraftsman. \n\n\"But how fortunate it is that the \ncrutches that I made broke. The idea \nfor making the crutches was mine, and \nthe father felt bad for not having \nthought of it himself. When my \ncrutches broke, he made much better \nones. That made us equal again!” \n\nSo the health worker learned many things from the father of the crippled \nboy— things that he had never learned in college. He learned what kind of \nwood is best for making crutches. But he also learned how important it is to \nuse the skills and knowledge of the local people— important because a better \njob can be done, and because it helps maintain people's dignity. People feel \nmore equal when each learns from the other. \n\nIt was a lesson the health worker will always remember. I know. I was the \nhealth worker. \n\n\n1-10 \n\n\nHelping Health Workers Learn (2005) \n\n\nIDEAS FOR A DISCUSSION ABOUT \nSHARING AND SELF-RELIANCE \n\n\nPeople's health depends on many things— on food, on water, on cleanliness, on \nsafety. But above all, it depends on sharing— on letting everyone have a fair share \nof land, opportunity, resources— and knowledge. \n\nUnfortunately, many doctors (and many traditional healers) tend to carefully \nguard their knowledge rather than to share it openly. Too often they use their \nspecial knowledge to gain power or privilege, or to charge more for their services \nthan is fair. \n\n\nHealth workers can easily fall into these same unhealthy habits. So their \ntraining must help them guard against this. It should help them realize that to \nshare their knowledge and skills freely is important to people's health. Sharing of \nknowledge helps people become more self-reliant. \n\n\nSelf-reliance as a measure of health: A person who \nis very sick needs to be cared for completely. He \ncan do almost nothing for himself. But as his \nhealth improves, so does his capacity for self-care. \nHealth is closely related to people's ability to care \nfor themselves and each other— as equals. \n\n\nThese may be important ideas. But at present they are just our ideas. How is it \npossible to get a group of health workers thinking about and reacting to ideas \nlike these? And forming their own ideas? Lecturing will do little good. A better \nway is to help people discover things through thoughtful discussion. \n\n\nTo start, you might find it helpful to ask questions like these: \n\n\nHealth Is The \nOpposite of \n\n\nHow are persons who are sick different from persons who are healthy? \nWhich are better able to care for \nthemselves? Who needs to be taken \ncare of? \n\nWho have more health problems, \nthe rich or the poor? Why? \n\nWhat do health and well-being have \nto do with self-reliance? Of a \nperson? Of a family? Of a village \nor community? Of a nation? \n\nCan you give examples from your \nown experience? \n\n\nAfter discussing these questions, \nyou might ask: \n\n• What should be the main goal of \nhealth education? \n\n• What should be your responsibilities \nas a health worker? \n\n\nDO VOU THIN K THIS \nIS TRUE ? \n\n\nSTARTING A DISCUSSION \n\n\nGuide the students in discussing these things, but let them come up with their \nown answers. \n\n\nHelping Health Workers Learn (2005) \n\n\n1-11 \n\n\nA PUZZLE TO GET PEOPLE THINKING IN NEW WAYS \n\n\nAll of us, teachers \nand students alike, get \ninto 'ruts'. And like \nhorses with blinders, we \noften tend to look at \nthings from a narrow \npoint of view. We keep \non trying to solve \nproblems in the same \nold way. \n\n\nNew approaches to health care require new approaches to teaching and learning. \n\nThis means tearing off the conventional 'blinders' that limit our vision and \nimagination. It means going beyond the walls of the standard classroom and \nexploring afresh the world in which we live and learn. \n\nA number of 'tricks' or puzzles can be used to help planners, instructors, or \nstudents realize the importance of looking at things in new ways— of going beyond \nthe limits their own minds have set. Here is an example: \n\nDraw 9 dots on a paper, on the blackboard, or in the \ndust, like this: \n\nAsk everyone to try to figure out a way to connect \nall the dots with 4 straight lines joined together \n(drawn without lifting the pencil from the paper). \n\nYou will find that most persons will try to draw lines \nthat do not go outside the imaginary square or 'box' \n\nformed by the dots. \n\nSome may even conclude that it is impossible to join all \nthe dots with only 4 lines. You can give them a clue by \nsaying that, to solve the puzzle, they must go beyond \nthe limits they set for themselves. \n\nAt last, someone will probably figure out how to do \nit. The lines must extend beyond the 'box' formed by \nthe dots. (Be careful not to shame the students or make \nthem feel stupid if they cannot solve the puzzle. Explain \nthat many doctors and professors also have trouble \nwith it.) \n\n\nAfter the group has seen how to solve the puzzle, ask some questions that help \nthem consider its larger significance. You might begin with questions like these: \n\n\n• In what way is a classroom like the box formed by the dots? \n\n• • • \n\n• How does the idea that 'education belongs in a classroom' \n\naffect the way we look at learning? At health? At each * # » \n\nother? • • • \n\n\nAnd end with questions like these: * * \n\n• What can we do to help each other climb out of the mental 'boxes' or 'ruts' \nthat confine our thinking, so we can explore new ways with open minds? Is \nthis important to people's health? How so? \n\n\n1-12 \n\n\nHelping Health Workers Learn (2005) \n\n\n'CRITICAL STUDY OF TEACHING METHODS' \nAS PART OF HEALTH WORKER TRAINING \n\n\nSome training programs schedule several hours a week for the study of 'learning \nhow to teach'. The learning group starts by exploring and critically analyzing \ndifferent educational approaches. Next they practice teaching— first with each \nother, then with mothers and children. They also learn to develop their own \nteaching materials. \n\nTo start by looking at and analyzing alternative teaching methods is especially \nimportant. Sometimes health workers go through a people-centered course \nwithout fully understanding the value of the new methods used. They may not \nrealize that the way they teach can either break down or build up people's \nself-confidence and community strength. Without such understanding, they may \nlater slip back into the more conventional 'teacher as boss' style of teaching. We \nhave often seen this happen. \n\n\n' U‘ \n\n\nt*> / \n\n\n\\7\\ TV:* \"VJH \n\n\nA'm \n\n\n>h \n\n\n\"\\ \n\n• r-y 'J \n; . ,r' \n\n\nPRACTICE \n\n\nHealth workers need to \nexperience and to \npractice appropriate \nteaching methods during \ntheir training. \n\nBut they also need to \nfully understand why such \nmethods are so important. \n\n\nUNDERSTANDING \n\n\nTo assist health workers in developing this understanding, be sure to allow time \nfor the critical study of alternative approaches to learning. Help the group to: \n\n• Experience, analyze, and compare contrasting educational methods. \n\n• Look critically at the existing school system in your area and how it affects \nthe lives, economy, social position, and health of the poor. Discuss how \nconventional schooling influences the values and job performance of health \nofficers, civil servants, teachers, and others. \n\n• Look for ways that they (the health workers) can begin to change unfair or \ninappropriate social structures, especially the school system. This would \nmean to . . . \n\n• Explore possibilities of working with school children, non-school children, \nand teachers in ways that relate learning to the lives and needs of the \nchildren. (See Chapter 24.) \n\n• Try using more appropriate, friendlier teaching methods. And help others \ndiscover for themselves the value and excitement of people-centered learning. \n\nThe study of these issues will, of course, be more effective if you use the same \nmethods you want your students to learn (see p. 16). Students can conduct their \nown investigation of different educational methods. Your role as instructor is to \nhelp the learning group ask searching questions, look critically at alternatives, and \ntry out more people-centered teaching methods during training. \n\n\nHelping Health Workers Learn (2005) \n\n\nM3 \n\n\nIDEAS FOR DISCUSSION ABOUT \nTHE PURPOSE OF SCHOOLING \n\n\nMany educators agree that the primary purpose of education should be to help \npersons gain the knowledge, skills, and awareness necessary to meet life's needs. \n\nBut do the schools that most children— or health workers— attend really do \nthis? \n\nTo answer this question, you and your group of teachers or health workers may \nfirst want to consider carefully: What are the biggest problems or needs of most \npeople in your village or community? To do this, you probably do not have to \nconduct a survey or 'community diagnosis'— at least not at first. You may already \nhave a good idea of how most people in your area live, whether they have enough \nto eat, what they suffer from most, and why. \n\nWhat is necessary is to openly and honestly discuss the people's needs, why \nthey exist, and what might be the biggest obstacles to overcoming them. \n\nIf you live in a village or poor community— as do most of the people in the \nworld— your local situation may be something like this: \n\n\nA TYPICAL VI LLAGE (How does it compare with your own?) \n\n\nPROBLEMS OR NEEDS \n\nPoor health, unnecessary \nsuffering \n\n• many children are thin, small, \nbig bellied, often sick; many die \n\n• mothers are often pale, weak, \nand tired; many die, especially \nduring or after childbirth \n\n• many fathers cannot find work, \nare not paid enough, or do not \nhave enough land to meet the \nfamily's needs for food, water, \nhousing, health care, and \neducation; many get drunk or \nlose hope; violence is the main \ncause of death in young men \n(between ages 15 and 40) \n\n\nCAUSES \n\nPoverty, too much in the \nhands of too few \n\n• poor food, sweets and 'junk \nfood', poor sanitation, \ninadequate health care; \npoor nutrition lowers \nresistance to infectious \ndisease \n\n• large families because of \neconomic necessity (children \nprovide low-cost labor) \n\n• most of the land, wealth, \nand power are in the hands \nof a few; the rich underpay \nand exploit the poor \n\n• government (local, national, \nand international) favors the \nrich \n\n\nOBSTACLES TO IMPROVEMENT \n\nSelfishness of some, \nhopelessness of others \n\n• greed and corruption of those \nin control \n\n• people's lack of self- \nconfidence; no hope that \nthings can be changed \n\n(fatalism) \n\n• lack of organization and \neffective leadership among \nthe poor \n\n• increasing dependency of \nthe poor on outside services, \ngiveaways, resources, \nentertainment, and authority \n\n• inadequate and inappropriate \neducation (for rich and poor \nalike) \n\n\nAfter discussing the needs in your village, ask questions about the local schools \nand whose needs they are designed to serve. \n\n\n1-14 \n\n\nHelping Health Workers Learn (2005) \n\n\nExamples of questions to get people thinking \n\nand talking about the purpose of schooling: \n\n• How much of what children are taught in \nschool is relevant (related) to their daily \nlives and needs? \n\n• How long do most of the children stay in \nschool7 Which children drop out early? \n\nWhy? What becomes of them? \n\n• Which children continue with their \nschooling? Why? Do they usually return to \nserve the community? Why or why not? \n\n• In what ways does the teacher set a good \nexample or a bad example for the students? \n\nHow does he or she relate to them? As a \nfriend? As an equal? As their master? \n\n• Who does the work that makes money available for schooling? \n\n• Who decides what is taught in the schools and how7 Should the people in a \nvillage or community have some say as to what their children are taught? \nShould the opinions of the children be listened to?* (See footnote.) \n\n• In what ways do schools shape children's values? How does this affect their \nfamilies? Their community? The poor? \n\n• Are children taught to question those in positions of authority, or to obey \nthem? Why7 How does this affect those who are powerless? \n\n• Whose needs does schooling serve the most, the weak or the strong? In what \nways? \n\n• In what ways does schooling benefit or harm people in villages? In slums? \n\n• What changes have been taking place in recent years in the content or approach \nto schooling? Why? What changes would be needed for the schools to better \nserve the interests of the poor? \n\n\nIn what ways do our \nschools help this child \nto meet his needs? \n\n\n‘For those who believe that children are too unwise or loo inexperienced to make intelligent judgements about \ntheir educational needs, we suggest you read Letter to a Teacher, by the school boys of Barbiana, Italy \n(see p. 16-16). \n\nThese school boys from poor farming communities make remarkably sound and challenging suggestions \nfor changing the school system to better meet the needs of the poor majority. Recognizing that many \nchildren of the poor leave school after only a few years, they insist that, \"If schooling has to be so brief, \nthen it should be planned according to the most urgent needs.\" They question the usefulness of each major \nsubject. They ask, \"How much math does one have to know for his immediate needs at home and at work?\" \nHistory as taught in schools, they insist, is \"no history at all,\" but \"one-sided tales passed down to the \npeasants by the conqueror. There is talk only of kings, generals, and stupid wars among nations. The \nsufferings and struggles of the workers are either ignored or stuck into a corner.\" \n\nThese boys also criticize the fact that most schools encourage competition among students. It would be \nbetter, they say, if schools helped each child to feel that \"Others' problems are like mine. To come out of \nthem together is good politics. To come out alone is stinginess.\" \n\n\nHelping Health Workers Learn (2005) \n\n\n1-15 \n\n\nSchooling as a form of social control \n\n\nGovernment schools tend to serve \ngovernment purposes. Only to the extent \nthat government is truly by and for the \npeople, is schooling likely to prepare \nstudents to work toward meeting the \nneeds of the majority of citizens in \neffective and lasting ways. \n\n\nREAD AGAIN -WITH MORE' \nFEELING -THE PASSAGE \nABOUT THE HEROES OF J \nTHE REVOLUTION. \n\n\nWhose needs does your school system serve? \n\n\nIn the world today, most governments do not represent all their people equally. \nMany governments are controlled by a powerful minority of politicians, \nbusinessmen, wealthy landholders, military leaders, and professionals (especially \nlawyers and doctors). These persons often care more about protecting their own \ninterests than about looking for ways to improve the well-being of the poor \nmajority. When they do consider doing something to help the poor, they are \nusually careful to do so in ways that do not threaten their own interests and \nauthority. \n\nSchooling, from the viewpoint of those in power, involves a risk. When the poor \nlearn to read and write, they can communicate and organize in new ways, in \ngreater numbers, over larger distances. They can read things that help them \ndiscover their legal and human rights. They may ask themselves if it is really \n'God's will' that a few persons have far more than they need, while others do not \nhave enough to eat. They may even begin to realize that they can do something to \nchange their situation. \n\nThis means that, for the few to keep their control, schools must teach poor \npeople to obey authority as well as to read and write. So most schools teach \nstudents to fit into the existing social order rather than to question or try to \nchange it. \n\nHow is this done? By putting emphasis on following rules, being on time, and \n'behaving'. Students are encouraged to compete more than cooperate, to memorize \nrather than think. School books paint the present government as completely good \nand just, with leaders who always have the interests of all the people at heart. \n\nBut perhaps the most powerful means the schools have for teaching children to \n'listen and obey' are the teaching methods themselves. Students are led to believe \nthat the only way to learn is to be taught— by someone who knows more than \nthey do. The teacher is set up as the 'master', an authority whose statements must \nnot be questioned. \n\nThis kind of education is called authoritarian, because its purpose is to \nstrengthen the authority of those in control. It is education designed to keep \nthings as they ar e-education that resists change. \n\n\n\" The lecture method of \nteaching is the best way to \ntransfer the teacher's notes \nto the students' notebooks \nwithout ever passing through \ntheir minds. \" \n\n\n6 \n\n\nHelping Health Workers Learn (2005) \n\n\nDOES YOUR TEACHING RESIST CHANGE, \nOR ENCOURAGE IT? \n\n\nOne of the main purposes of conventional or \nauthoritarian education is to teach students to \nfit obediently into the existing social order. The \nteacher provides the approved knowledge, and \nthe students receive it. The emptier the student's \nhead to begin with, the better a student he is— \naccording to the teacher and the system. \n\nUnfortunately, many training programs for \nvillage or community health workers use this \nsame kind of authoritarian approach. Students \nare taught to follow, not to explore; to \nmemorize, not to think. They are taught to \nbelieve that their first responsibility is to the \nhealth system rather than to the poor. \n\n\nLEARN THIS AND DON’T ASH \nWHY !~ BLA, BL A, BL A. . . \n\n\nEDUCATION OF AUTHORITY: \nputting ideas in \n\n\nUsually instructors teach this way, not because they mean any harm, but \nsimply because they themselves grew up in an authoritarian school system. They \nmay not know any other way to teach. \n\n\nEDUCATION THAT ENCOURAGES CHANGE: \n\n\nBut there are other ways— ways that build \nthe students' confidence in their capacity to \nobserve, criticize, analyze, and figure things \nout for themselves. These ways let the students \ndiscover that they are just as good as their \nteachers and everyone else. They learn to \ncooperate rather than compete in order to \ngain approval. They are encouraged to \nconsider the whole social context of their people's needs, and to look for \nimaginative and courageous ways of meeting them. \n\n\nTeaching suggestion \n\nRather than tell the members of \nyour group these things, help them \nto recall their own experiences and \nto figure things out for themselves. \n\n\n(SO WHAT DO you THINK 'j \nOF THAT IDEA ? J \n\n\nEDUCATION OF CHANGE: \ndrawing ideas out \n\n\nThis we will call education for change. Emphasis \nis more on learning than on teaching. Students are \nencouraged to voice their own ideas. They figure \nthings out for themselves, and explore ways to \nhelp people free themselves from the causes of \npoverty and poor health. \n\nIf a health worker is to be a 'leader for change', \nhelping people find ways to solve their biggest \nproblems, then it is important that his training \nitself set an example. \n\n\nGood teaching is the art, \nnot of PUTTING IDEAS INTO people's heads, \nbut of DRAWING IDEAS OUT. \n\n\nHelping Health Workers Learn (2005) \n\n\n1-17 \n\n\nROLE PLAYS THAT HELP PEOPLE \nEXPLORE TWO KINDS OF TEACHING \n\n\nFor health workers to appreciate the \nimportance of appropriate teaching, it \nhelps if they experience two kinds of \nteaching and then compare them. \n\n\nA good way to do this is through 'role \nThe bossy teacher playing' (see Chapter 14). Here we give \nideas for two role plays to compare the bossy teacher with the good group leader. \n\n\nThe friendly \ngroup leader \n\n\nThese role plays are most effective if they take the students by surprise. \nAlthough the whole class participates, at first students will not realize that the \ninstructor is 'acting'— and that they are actors, too! \n\nIn the role plays, the instructor (or two different instructors) will teach the \nsame health topic in two very different ways. Then the students compare their \nreactions to the two lessons. They discuss how each of the classes affects the \nlearners personally, and how each prepares them to meet important needs in \ntheir communities. \n\n\nThe two role plays we present here deal with dental care. They have been used \neffectively in Latin America and Africa. But of course you can choose any health \ntopic you want. \n\n\nThe first role play: THE BOSSY TEACHER in a conventional classroom \n\nSuggestions to the instructor: \n\n• Before the students arrive, put chairs or benches in \nneat rows, with a desk or podium at the front. \n\n• When the students arrive, greet them stiffly and ask \nthem to sit down. Make sure they are quiet and \norderly. \n\n• Begin the lecture exactly on time. Talk rapidly in a \ndull voice. Walk back and forth behind the desk. \n\nIf some students come late, scold them! Use big words the students \ncannot understand. Do not give them a chance to ask questions. (It helps \nif you prepare in advance a few long, complicated sentences that use \ndifficult medical terminology. Look in a medical dictionary, or copy \nphrases out of any professional textbook.) \n\n• If any student does not pay attention, or whispers to a neighbor, or begins \nto go to sleep, BANG on the table, call the student by his last name, and \nscold him angrily. Then continue your lecture. \n\n• From time to time, scribble something on the blackboard. Be sure it is \ndifficult to see and understand. \n\n• Act as if you know it all, as if you think the students are stupid, lazy, \nrude, and worthless. Take both yourself and your teaching very seriously. \nPermit no laughter or interruptions. But be careful not to exaggerate too \nmuch ! Try not to let the students know you are acting. \n\n\n; Helping Health Workers Learn (2005) \n\nThe first role play: THE BOSSY TEACHER \n\n\nthe teacher talks over the heads of the bored and confused students, like this: \n\n\nTHE BUCCAL CAVITY, OR MOUTH, VS THE ANTERIOR - THAT \nIS TO SAY PROXIMAL- PORTION OF THE ALIMENTARY CANAL, \nSITUATED IN THE INFERIOR PORTION Of THE FACE ANO \nCIROOMSCRABEO BY THE LIPS, CHEERS, PALATOGLOSSAL ARCH, \nUVULA, ORAL PHARYNX, AND TONGUE — MR.. GOME^. I \n\nMUST ASK. VOU hot TD-SPEAVL DURING CLASS. \n\n.HAVE VOU HO \n\n\\MAHHBRS ? - the \n\n-LJt \\ TEETH ARP EACH ONE \nOF A SET OF HARD, \nWHITE STRUCTURES \nPCCO-EOnNfc INTO THE \nBUCCAL CAVITY FROM \nTHE ALVEOLAR. BONE \nOf THE MAXILLA ANO \nMANDIBLE AND \nUTIH7ED FOR, THE \nMASTICATION CF \nFOOD... \n\n\nTHERE are TWO SETS OF DENTITION- DECIDUOUS AND PERMANENT \n\nKS. HECLNANDEX, PLEASE WY ATTENTION. DO NOT \nGLEAM YOUR- MAILS IW CLASS -these are composed cf \n\nINFERIOR AND SUPERIOR INCISORS , CANINES, PREMOLARS, AND \nMOLARS- MR.. VEGA. WAViE UP. THIS IS NO PLACe POR. \nLAXY STUDENTS — carves vs the molecular decay cf \n\n*tja*AEL DENTINE AND PULP, PRODUCING DISCOLORATION , CHRONIC \n, INFLAMMATION CF THE \n\nPERIOSTEUM AND \nNECROSIS OF THE \nMEDIAL NERVE LEADIN6 \n\nTD- MR.. VEGA.THIS \n\\S MOT SIESTA TIME-. \nPLEASE STAND IN \nTHE CDPK1EC,- leading \n\nTO A PYOGENIC ABSCESS \nON THE OSSEOUS tissue \nCONTIGUOUS WITH THE \nAPEX Of THE ROOT AMD \nPRECIPITATING A \nSYSTEMIC,., \n\n\nThe lecture goes on and on— all very serious. At the end of the class, the teacher \nmay simply walk out. Or he may ask a few questions like, \"MR. REYES, WILL \nYOU GIVE US THE DEFINITION OF CAR I ES?\" And when he gets no answer, \nscold him by shouting, \"SO, YOU WERE SLEEPING, TOO! THIS GROUP HAS \nTHE ATTENTION SPAN OF 5-YEAR-OLDS!\" And so on. \n\n\nHelping Health Workers Learn (2005) \n\n\n1- \n\n\nThe second role play: THE GOOD GROUP LEADER or 'facilitator' \n\nThis time, the instructor treats the students in a friendly, relaxed way— as \n\nequals. (This role can be played by the same instructor or a different one. Or \n\nperhaps a student could prepare for it in advance.) \n\nSuggestions to the group leader: \n\n• At the beginning of class, suggest that people sit in a circle so they can see \neach others' faces. Join the circle yourself as one of the group. \n\n• Asa group leader, you 'teach' the same subject as the instructor in the \nfirst role play. But whenever possible, try to draw information out of the \n\nstudents from their own experience. \n\n• Be careful to use words the students understand. Check now and then to \nbe sure they do understand. \n\n• Ask a lot of questions. Encourage students to think critically and figure \nthings out for themselves. \n\n• Emphasize the most useful ideas and information (in this case, what the \nstudents can do in their communities to prevent tooth decay). \n\n• Use teaching aids that are available locally and are as close to real life as \npossible. For example, you might invite a young child to the class so \nstudents can see for themselves the difference between baby teeth and \npermanent teeth. \n\n• Do not waste a lot of time \ndiscussing detailed anatomy, \n\nInstead, include such information \nwhen it is needed for understanding \nspecific problems. \n\n• Have students look in each others' \nmouths for cavities. Then pass \naround some rotten teeth that were \npulled at the health center. Let \nstudents smash the teeth open with \na hammer or rock, so they can see \nthe different layers (hard and soft) \nand how decay spreads inside a \ntooth. Ask someone to draw the \ninside of a tooth on the blackboard. \n\n• Encourage students to relate what \nthey have seen and learned to real \nneeds and problems in their own \ncommunities. Discuss what action \nthey might take. \n\n\nStudents can break open teeth that \nhave been pulled to see for them- \nselves what the inside of a tooth \nlooks like and what damage a cavity \ncan cause. \n\n\n1-20 \n\n\nHelping Health Workers Learn (2005) \n\n\nThe second role play: THE GOOD GROUP LEADER \n\nThe teacher or leader tries to get a discussion started— then stays in the \nbackground as much as possible, like this: \n\n\nTo follow this discussion, \nstart here and follow \nthe arrows. \n\n\nWE'VE SEEM THE HARM \nDONE ©V TOOTH DECAY. \nBUT DO YOU KNOW \nW HAT CAUSES IT ? \nWHAT DO YOU THINK, \nJOSE ? \n\n\nTHEY SAY THAT \nEATVN& A LOT \nOF SWEETS ROtS | \nTHE TEETH . BUT \n\n\nI •'vie heard \n\nTHAT BAD TEETH \nRESULT FROM \nWOT EATING \nENOUGH SOOD \nFOOD ... \n\nTHEN HOW COME1 \nTHE CHILDREN \nOF THE RICH \nHAVE WORSE \nTEETH THAN A \nLOT OF THE \nPOOREST KIDS \nIN THE \nvillage? I \n\n\n1 \n\n\nGETTER STILL, MAYBE WF CAW HELP \nTHE SCHOOL CHILDREN CONDUCT \nTHEIR OWN STUDY. IF THEY FIND \nOUT FOR THEMSELVES WHAT \nCAUSES THEIR TEETH TO ROT. \nTHEY’LL <3E MORE LIKELY TO \nTAKE 6ETTER CARE OF THEM. \n\n, WHAT DO YOU TH I NK ? \n\n\nAND HOW \nOFTEN THEY \nCLEAN THEIR \nTEETH. \n\n\nI’LL BET 1Tb \nBECAUSE THEIR \nPARENTS ARE \nALWAYS BUYING \nTHEM CANDY \nAND SWEET \nSOFT DRINKS. \n\nAGREE WITH \nSANDRA. \n\n\nWHY DON’T WE MANE A \nSTUDY Of THE SCHOOL \nCHILDREN . WE COULD LOOK \nAT HOW GOOD OR BAD \nTHEIR TEETH ARE AND \nTHENGOTOTHEIR homes \n\nAND FIND OUT FROM THEIR \nMOTHERS HOW MUCH \n. CANDY AND SWEET THINGS \n\\THEV EAT AND DRINK. \n\n\nAt the end of class, the leader asks the group what they have learned and what \nthey plan to do with what they have learned. He helps them realize that the ideas, \nraised in class need not end in the classroom, but can be carried out into the real \nworld— into the communities where the health workers live and work. \n\n\nHelping Health Workers Learn (2005) \n\n\n1-21 \n\n\nGroup discussion following the two role plays \n\n\nYou may want to discuss what the students think about the first role play as \nsoon as it is over. Or you may want to wait until both role plays have been \npresented, so the students can compare them. \n\n\nGood questions to start a \ndiscussion might be: \n\n• What did you think of the \ntwo classes (on dental care)? \n\n• From which class did you \nlearn more? \n\n• Which did you like better? \nWhy? \n\n• Who do you think was the \nbetter teacher? Why? \n\n\n' FROM WHICH I \nCLASS DID V \n. YOU LEARN / \nWMORE? J \n\n\nFROM THE FIRST/) \nBECAUSE THE \n\nTEACHER \nTOLD US / \nMOR T-jJ \n\n\nBUT HOW MUCH \nOF IT DID YOU \nUNDERSTAND ? \n\n\ny>f\\ WAS LUCKY IF \nI UNDERSTOOD \ny ONE OUT OF \n\nFive words, it \n\n~s MADE ME FEEL \nLIKE A FOOL/ \n\n/ MAYBE 1 AM. \n\n\nYou may be surprised at some of the answers you get! Here are a few answers \nwe have heard students give: \n\n\n\"I learned more from the first class, because the teacher told us more. I learned \na lot of new words. Of course, I didn't understand them all . . \n\n\n\"The first class was much better organized.\" \n\n\n\"I liked the second class better, but the first one was better taught.\" \n\n\n\"The second class was too disorderly. You could scarcely tell the teacher from \nthe students.\" \n\n\n\"The first teacher wasn't as nice, but he had better control of the class.\" \n\n\"The first teacher was by far the best. He told us something. The second one \ndidn't tell us anything we didn't already know!\" \n\n\"I felt more comfortable in the first class— I don't know why. I guess I knew \nthat as long as I kept my mouth shut, I'd be all right. It was more like real \nschool !” \n\n\n\"The second class was more fun. I forgot it was a class!\" \n\nBy asking still more questions, you may be able to get the students to look \nmore closely at what they learned— and have yet to learn— from the two classes. \nFollow through with questions like these: \n\n• In which class did you understand more of what was said? Does this matter? \n\n• From which class can you remember more? Does this matter? \n\n\n1-22 \n\n\nHelping Health Workers Learn (2005) \n\n\n• Do you remember something better when you are told the answer, or when \nyou have to figure out the answer for yourself? \n\n• In which class did students seem more \ninterested? More bored? \n\n• In which class did you feel freer to speak \nup and say what you think? \n\n• Which class had more to do with your own \nlives and experience? \n\n• From which class did you get more ideas about ways to involve people in \ntheir own health care? \n\n\n• Which class seemed to bring the group closer together? Why? Does this matter? \n\n• Which teacher treated the students more as his equals? Could this affect the \nway the students will relate to sick persons and to those they teach? \n\n\n• Which is the better teacher— one who has to \nbe 'tough' in order to keep the students' \nattention? Or one who keeps their attention \nby getting them interested and involved? \n\n• Did you learn anything useful from these \nclasses, apart from dental care7 What? \n\n\n• In what ways are the relations between each teacher and the students similar \nto relations between different people in your village? For example, between \nlandholders and sharecroppers? Between friends? \n\n\nWith questions like these, you can help the students to look critically at their \nown situation. As much as you can, let them find their own answers, even if they \nare different from yours. The less you tell them, the better. \n\n\nIf the discussion goes well, most of the questions listed above will be asked — \nand answered— by the students themselves. Each answer, if approached critically, \nleads to the next question— or to even better ones! \n\n\nIf the students do not think \nthings over as carefully as you \nwould like, do not worry. And \nwhatever you do, do not push \nthem. Your answers have value \nonly for yourself. Each person \nmust come up with his or her \nown. There will be many other \nopportunities during the training \nto help students discover how \neducation relates to life. In \nthe last analysis, your example \nwill say far more than your \nwords— for better or for worse. \n\n\nIf you want lasting results: \nPOINT but don’t PUSH. \n\n\nPeople will move by themselves once they \nsee the need clearly and discover a way. \n\n\nHelping Health Workers Learn (2005) \n\n\n1-23 \n\n\nAnalysis of the two role plays \n\nAfter discussing the differences between the two approaches to teaching, it \nhelps to summarize them in writing. (Or you may want to do this during, rather \nthan after, the discussion.) One of the students can write the group's ideas on a \nblackboard or large sheet of paper. \n\n\n71 \n\n\n\\aT CLASS \n\ni. Teacher lr> control \na. Teacher was mean \n4. Class v/erq&isciplined \" \nWords we dont understand \nicher knows it all \nicher makes us -feel stupid \njcher -talks but doesn't \n^ listen \n%. Class net nsictted to life. \n\n9, Bari na ■ w a fell asleep. \n(C. Ug atfempt -to rmke it \n\nin9 \n\n\nWE CAN*T > \nco anything \n\nWITH WHAT \nWE WE£E \nTAUGHT lH \n\nthe first , \n\nv CLASS! / \n\n\n3.^0 CLASS \n\nu -Students self-con trolled \n^ Teacher friend Ilj *equal \ni3. Class not well srganised \nM. We understood ewefq-thina \n\n6. Teacher made us feel important \nListened to and respected \n\noor iaeas . \n\n7. Class gave. us ideas row to \n\nirwonoe, ch i Idren \n\n8. We liked seeing nsal teeth \n\nand doing -thi rgs ourselues \n1. We can , . , \n\n\n' EOT THE SECOND \nCLASS GAVE OS \nIDEAS OF THINGS \n\nto do/ \n\n\nAs everyone is leaving the classroom, perhaps one of the students will put his \nhand on your shoulder and say: \n\n\"You know, I don't really think those two classes were to teach us about \nteeth. I think they were to help us learn about ourselves.\" \n\n\"They were to do both at once. That's the secret of education,\" you will \nreply. But you will want to hug him. \n\nIf no one says anything, however, don't worry. It takes time. You and your \nstudents will learn from each other. \n\n\n1-24 \n\n\nHelping Health Workers Learn (2005) \n\n\nTHREE APPROACHES TO EDUCATION \n\nThis chart gives a summary of 3 approaches to teaching. It may help instructors to evaluate \ntheir own teaching approach. But we do not recommend that this analysis be given to health \nworkers. Analyzing stories and role plays will work better. So pass by this chart if you want. \n\n\nCONVENTIONAL \n\nPROGRESSIVE \n\nLIBERATING \n\nFunction \n\nto CONFORM \n\nto REFORM \n\nto TRANSFORM \n\nAim \n\nResist change. \n\nKeep social order stable. \n\nChange people to \nmeet society's needs. \n\nChange society to \nmeet people's needs. \n\nStrategy \n\nTeach people to accept \nand 'fit in' to the social \nsituation without changing \nits unjust aspects. \n\nWork for certain \nimprovements without \nchanging the unjust \naspects of society. \n\nActively oppose social \ninjustice, inequality, \nand corruption. Work \nfor basic change. \n\nIntention \n\ntoward \n\npeople \n\n\nCONTROL them- \nespecia I ly poor working \npeople— farm and city. \n\n\nPACIFY or CALM them— \nespecially those whose \nhardships drive them \nto protest or revolt. \n\n\nFREE them \nfrom oppression, \nexploitation, \nand corruption. \n\n\nGeneral \n\napproach \n\nAUTHORITARIAN \n\n(rigid top-down control) \n\nPATERNALISTIC \n\n(kindly top-down control) \n\nHUMANITARIAN and \nDEM OCR A TIC \n\n(control by the people) \n\nEffect \non people \nand the \ncommunity \n\nOPPRESSIVE— rigid central \nauthority allows little \nor no participation by \nstudents and community. \n\nDECEPTIVE— pretends to \nbe supportive, but \nresists real change. \n\nSUPPORTIVE— helps \npeople find ways to gain \nmore control over their \nhealth and their lives. \n\nHow \n\nstudents \n(and people \ngenerally) \n\nBasically passive. \nEmpty containers \nto be filled with \nstandard knowledge. \n\nBasically irresponsible. \nMust be cared for. Need \nto be watched closely. \n\nBasically active. \nAble to take charge \nand become self- \nreliant. \n\nCan and must be tamed. \n\nwhen spoon fed. \n\nand as equals. \n\nWhat the \nstudents \nfeel about \nthe teacher \n\nFEAR— Teacher is an \nabsolute, all-knowing boss \nwho stands apart from \nand above the students. \n\nGRATITUDE— Teacher isa \nfriendly, parent-like \nauthority who knows what \nis best for the students. \n\nTRUST— Teacher is a \n'facilitator' who \nhelps everyone look \nfor answers together. \n\nWho decides \nwhat should \nbe learned \n\nThe Ministry of \nEducation (or Health) \nin the capital. \n\nThe Ministry, but with \nsome local decisions. \n\nThe students and \ninstructors together \nwith the community. \n\nTeaching \n\nmethod \n\n• Teacher lectures. \n\n• Students ask few \nquestions. \n\n• Often boring. \n\n• Teacher educates and \nentertains students. \n\n• Dialogue and group \ndiscussions, but the \nteacher decides which \nare the 'right' answers. \n\n• Open-ended dialogue, \nin which many answers \ncome from people's \nexperience. \n\n• Everyone educates \neach other. \n\nMain \nway of \nlearning \n\nPASSIVE— students \nreceive knowledge. \nMemorization of facts. \n\nMore or less active. \nMemorization still \nbasic. \n\nACTIVE— everyone \ncontributes. Learning \nthrough doing and \n\ndiscussing. \n\n\nHelping Health Workers Learn (2005) \n\n\nImportant \nsubjects or \nconcepts \ncovered \n\n\nCONVENTIONAL \n\n• the strengths and \nrightness of the present \nsocial order \n\n• national history \n(distorted to make 'our \nside' all heroes) \n\n• rules and regulations \n\n• obedience \n\n• anatomy and physiology \n\n• much that is not \npractical or relevant— \nit is taught because \n\nit always has been \n\n• unnecessary learning \n\nof big words and boring \ninformation \n\n\nPROGRESSIVE \n\n• integrated approach to \ndevelopment \n\n• how to make good use \nof government and \nprofessional services \n\n• filling out forms \n\n• desirable behavior \n\n• simple practical skills \n(often of little use- \nsuch as learning 20 \nbandages and their \nLatin names). \n\n\nmonocular \n\nDRESSING \n\n\nLIBERATING \n\n• critical analysis \n\n• social awareness \n\n• communication skills \n\n• teaching ski! Is \n\n• organization skills \n\n• innovation \n\n• self-reliance \n\n• use of local resources \n\n• local customs \n\n• confidence building \n\n• abilities of women \nand children \n\n• human dignity \n\n• methods that help the \nweak grow stronger \n\n\nFlow of \n\nschool or \n\nschool or \n\nstudents -^-group -^-school i \n\nknowledge \n\nhealth \n\n■ ail \n\nhealth \n\n■ \n\nmostly \n\nleader health \n\nand ideas \n\nsystem \n\n1 one \n\nsystem \n\n♦ \n\nteacher \n\n] \n\none \n\n•s. system \n\nteacher \n\n/T\\ way \n\n/\\ \n\nway \n\n• - -•*- ,E3 \n\n\\ \n\n• • • \n\n\\ \n\n• • • \n\n#• \n\nstudents \n\nstudents \n\nboth ways \n\nArea for \n\nThe classroom. \n\nThe classroom and other \n\nLife— the classroom \n\nstudying \n\ncontrolled situations. \n\nis life itself. \n\nHow does the \n\n• \n\n# \n\nclass sit? \n\n• \n\n• \n\n. • . \n\n• • \n\n• • • • \n\n• \n\n• \n\n• • \n\n• • \n\n• \n\n• . • \n\n• • \n\n• • • • \n\n• \n\n• \n\n• • \n\nClass Often LARGE. Emphasis Often fairly small, to Often SMALL, to \n\nsize on quantity, not encourage participation. encourage communication \n\n\nquality, of education. and apprenticeship learning. \n\n\nAttendance \n\nStudents have to \nattend. cyj \n\nStudents often want to \nattend because classes \nare entertaining and \nthey will earn more if \nthey graduate. \n'Incentives' are given. \n\nStudents want to \nattend because the \nlearning relates to \ntheir lives and needs, \nand because they are \nlistened to and respected. \n\nGroup \n\ninteraction \n\nCompetitive (cooperation \nbetween students on tests \nis called cheating). \n\nOrganized and directed \nby teacher. Many games \nand techniques used to \nbring people together. \n\nCooperative— students \nhelp each other. Those \nwho are quicker assist \nothers. \n\nPurpose of \nexams \n\nPrimarily to 'weed out' \nslower students; grades \n\nVariable, but generally \ntests are used to pass \n\nPrimarily to see If ideas are \nclearly expressed and if \nteaching methods work \nwell. No grades. Faster \nstudents help slower ones. \n\nstudents pass. \nOthers fail. \n\n<5jrj7 \n\n| others. \n\nL \n\nEvaluation \n\nOften superficial— \nby education or health \nsystem. Students and \ncommunity are the \nobjects of study. \n\nOften over-elaborate— \nby education or \nhealth 'experts'. \nCommunity and \nstudents participate \nin limited ways. \n\nSimple and continual— \n\nby community, students, \nand staff. Students \nand teachers evaluate \neach, others' work and \nattitudes. \n\nAt end of \n\n• diplomas \n\n• diplomas gg O \n\n• uniforms \n\n• encouragement to work \n\ntraining, \n\n• irregular. \n\nhard and keep learning \n\nstudents \n\npolice-like j \n\n£ =J \n\n• salaries Jr^ Ljf \n\n• supportive assistance \n\nare given . . . \n\nsupervision \n\n• supportive supervision \n\nwhen asked for \n\nAfter training, \na health \nworker is \naccountable to . . . \n\nhis supervisor, the \nhealth authorities, \nthe government \n\nmainly to the health \nauthorities, less so \nto local authorities \nand the community \n\nmainly to the \ncommunity— especially \nthe poor, whose \ninterests he defends \n\n1-26 \n\n\nHelping Health Workers Learn (2005) \n\n\nAPPROPRIATE AND INAPPROPRIATE TEACHING: \n\nTWO STORIES \n\nIn addition to role plays, you may want to use stories to help students and \nother instructors see the value of the new teaching methods. Telling stories often \ntakes less preparation than role plays, and if the stories are imaginary or from \nanother area, no one will be blamed for the mistakes that are described. Here are \n2 stories comparing different teaching approaches and their results. \n\nSTORY 1* \n\n\nA health worker named Sophie completed her training and passed all the exams \nat the end of the course. Then she went back to her village. It was a long journey \nbecause the village was far away. When Sophie arrived everybody was pleased to \nsee her again. Her mother was especially pleased and proud that her daughter had \ndone so well. \n\n\nAfter the first greetings, Sophie's mother said, \"It's good that you're back, \nbecause your baby cousin is ill with diarrhea and doesn't look well at all. Do you \nthink you could help?” \n\n\nSophie went to see the baby and realized that \nhe was badly dehydrated. She thought the baby \nshould go to a health center, but the journey \nwas too long. So she thought about what she \nhad been taught. She could remember the \nanatomy of the gastro-intestinal tract, and ail \nabout electrolyte balance. And she remembered \nthat a mixture of salt and sugar in water would \nhelp. But she could not remember how much \nsugar and how much salt to put in the water. \n\nSophie was very worried that the amounts \nwould be wrong. She did not know whether to \nsend for help or to guess how much to use. She \nthought that the baby was so sick she would \nhave to do something. In the end, she made up \nthe sugar and salt solution in the wrong \nproportions, and the baby died. \n\n\nMoral of the story: Some training courses \nspend too much time on detailed \nfacts, many of which have little \nimportance. As a result, the most \nimportant things are not learned \nwell The most important facts are \nthose needed for solving common \nproblems in the community. \n\n\n’Adapted from Teaching for Better Learning, \nby Fred Abbatt, WHO, Geneva, 1980. \n\n\nHelping Health Workers Learn (2005) \n\n\n1-27 \n\n\nSTORY 2 \n\n\nIn a short training program for village health workers, students decided that \none of the most serious problems in their villages was diarrhea in children. They \nlearned that the main danger with diarrhea is dehydration. They discussed Oral \nRehydration Solution, and agreed that teaching mothers and children how to \nmake and use it should be one of their first responsibilities. \n\n\"It won't be easy,\" said one of the students, herself a mother. \"People don't \nunderstand funny words like oral, rehydration, or solution.” So the group \ndecided it would be better to speak of Special Drink— eye n among themselves, \nso they would not be tempted to use fancy words in their villages. \n\n\"What if the mothers put in too much salt?\" asked a student whose uncle was \na doctor. \"Wouldn't that be dangerous?\" \n\n\"Yes,\" said the instructor. \"We need to find ways of teaching that will help \nparents and children remember the right amounts. How do people remember \nthings best in your villages?\" \n\n\"We all remember songs,\" said one of the health workers. \"People are always \nsinging and learning new ones. We remember every word!\" \n\nSo the group decided to write a song about diarrhea and Special Drink. They \nall worked on it together. But they got into an argument over what to call the \nbaby's stool. For most people, a stool was something to sit on. \n\nNobody understood words like feces and excrement. The word shit \nsome people considered dirty. \"But it's the word everyone \nunderstands— even children,\" argued one health worker. \"Especially \nchildren!\" said the mother. Finally they agreed that shit was the \nmost appropriate word— at least in their area. \n\nThe song they wrote is shown below. (It can be sung to \"Twinkle, Twinkle, \nLittle Star\" or another simple tune. With children, have them SHOUT the words \nprinted in CAPITAL LETTERS.) \n\n\nH \n\n\n” The P and V Blues” \n\n(Di arrhea and Vomiting') \n\nBabies who have D and v \nShrivel up and fail to pee. \n\nTo regain their health we oughta \nFill them up with LOTS OF WATER. \n\nMaking Special Drink’s a cinch-- \nSugar *. 1 Teaspoon. Salt : 1 Pinch \nWater ; 1 Glass --or BIG FAT CUP \nToss them in and Stir it op ! \n\nBut careful / You would be. at fault \nIf you put \\r» too much Salt f \nSo mix it. T/\\STE IT. GIVE 3 CHEERS \n\n\nit's no Saiti Pi \n\n\nEach time your baby dribbles Shit \nGive one glassful -- bit by bit. \n\nAnd if the darling's on the breast \nGive breast milk too-* for BREAST IS BEST/ \n\n\n1-28 \n\n\nHelping Health Workers Learn (2005) \n\n\nSeveral months later, after the course \nwas over and the students were back in \ntheir villages, one of the health workers, \nnamed Rosa, was met in the street by a \nmother. The mother gave her 7 eggs \nwrapped in a leaf. \n\n\"Thank you,\" said Rosa with surprise. \n\"But why . . .?\" \n\n\"You saved my baby's life!\" said the \nmother, hugging the health worker so \nhard she broke 3 eggs. \n\n\"But I didn't even see your baby!\" \nsaid Rosa. \n\n\n\"I know,\" said the mother. \"You see, She hugged the health worker \n\nmy baby had diarrhea, but the river was so hard she broke 3 eggs! \n\nflooded so I couldn't bring him to the \n\nhealth post. He was all shriveled up and couldn't pee. He was dying and I didn't \nknow what to do! Then I remembered a song you had taught the children in \nschool. My daughter's always singing it. So I made up the Special Drink, tasted it, \nand gave it to my baby, just like the song says. And he got well!\" \n\n\nMoral of the story: T raining gives better results if it keeps language simple, \nfocuses on what is most important, and uses learning methods people are \nused to and enjoy. \n\n\nWhat other ideas about teaching and working with people can your students \ndraw from these stories? Have them list different teaching methods on the black- \nboard and discuss which are most appropriate and why. Can the students tell \nsimilar stories from their own experience— ways they have learned things both in \nand outside of school? (For more ideas about story telling as a teaching method, \nsee Chapter 1 3.) \n\n\nTo be a good teacher of health workers, you don't \nneed to know a great deal about medicine, about latrine \nbuilding, or about weighing babies. These things you \ncan learn together with your students. What you do need \nto know about is people, how they feel, how they relate \nto each other, and how they learn. \n\n\nHelping Health Workers Learn (2005) \n\n\n1-29 \n\n\nON CHANGING HABITS AND ATTITUDES \n\nMany experts now tell us that the principal goal of health education should be \nto change people's habits and attitudes. \n\nUnfortunately, such a goal points the finger at what people do wrong, rather \nthan building on what they do right. It is based on the paternalistic view that the \n'ignorance' of poor people is the main cause of their ill health, and that it is \nsociety's job to correct their bad habits and attitudes. \n\nA people-centered approach to health education takes the opposite position. It \nrecognizes that the ill health of the poor is, in large part, the result of a social \norder that favors the strong at the expense of the weak. Its main goal is not to \nchange the poor, but to help them gain the understanding and skills needed to \nchange the conditions that cause poverty and poor health. \n\n\nTHE AIMS OF HEALTH EDUCATION \n\n\nBEHAVIOR CHANGE or \n\n\nSOCIAL CHANGE \n\n\nW£ ARE\\ \nGOING TON \nCHANGE 1 \nVOU.^ \n\n\nIn education that focuses on behavior and \nattitude change, people are acted upon by \nthe system and the world that surrounds \nthem. \n\n\nIn education that works for social change, \npeople act upon the system and the world \nthat surrounds them. \n\n\nIn making these points, we are not saying that there is no need for changes in \npersonal attitudes and behavior. But whose attitudes need changing the most? \nWhose attitudes and habits cause more human suffering— those of the poor or \nthose of the 'well-educated' dominating classes? \n\nThe unhealthy behavior of both rich and poor results partly from the unfair \nsocial situation in which we live. So rather than trying to reform people, health \neducation needs to focus on helping people learn how to change their situation. \n\nAs people become more sure of themselves and their capacity for effective \naction, their attitudes and behavior may change. But lasting changes will come \nfrom inside, from the people themselves. \n\n\n1-30 \n\n\nHelping Health Workers Learn (2005) \n\n\nWhen considering your effectiveness \nas a health educator, ask yourself: \"How \nmuch does what I do help the poor gain \nmore control over their health and \ntheir lives?\" \n\n\nHelping Health Workers Learn (2005) \n\n\n2-1 \n\n\nSelecting Health Workers, CHAPTER 2 \nInstructors, and Advisers \n\n\nWHO MAKE THE BEST HEA LTH WORKERS? \n\nSHOULD HEALTH WORKERS BE FROM THE VILLAGE \nOR COMMUNITY WHERE THEY WORK? \n\nMany health programs, large and small, agree that it is important for health \nworkers to be selected from the communities where they will work. But their \nreasons differ: \n\n\nTWO EXPLANATIONS FOR WHY IT IS BETTER THAT HEALTH \nWORKERS BE FROM THE COMMUNITIES WHERE THEY WORK \n\n\nThe ‘expert’ with \nlittle community experience: \n\n\nPersons living and \nworking in the community: \n\n\nPEOPLE ARE n \n\nQuicker to trust \nAnd listen to \nSomeone from \ntheir own \ncommon i ty \nwho speaks \n\nIN THEIR TERMS \nAND KNOWS \nTHEIR CUSTOMS \n\nAnd prorlems. \n\n\n* \n\n\npeople are \nslower to trust \n\n\nTHE NEW SKILLS \nOF A LOCAL PER50N. \n\nBut while an \noutsider brings \n\nDEPENDENCY , THE \nLOCAL HEALTH \nWORKER SHOWS \npeople THEY CAN \nDO MORE FOR \n. THEMSELVES. \n\n\nTheory has it that community health \nwork is easier for the local person than \nfor an outsider, because people know and \ntrust him. And he knows the community. \n\n\nExperience shows that at first it is \noften harder for the local person. But in \ntime, health workers from the community \ncan do more to help build people’s self- \nconfidence and self-reliance. \n\n\nThere is an old saying: No one is a prophet in his own land. A villager complains, \n\"What does Mary, the health worker, know? I remember her as a skinny little \ngirl!\" \n\n\nSuch distrust in their own health worker reflects people's lack of confidence in \nthemselves: \"How could one of us understand new ideas or master new skills?\" \nThis lack of self-confidence is especially great when it comes to health care. Most \npeople believe that modern medicine requires mysterious knowledge that only \n\"strangers better than ourselves\" can master. \n\n\n2-2 \n\n\nHelping Health Workers Learn (2005) \n\n\nSome American Indian health workers in Arizona found it so hard to win the \ntrust of people in their own villages that they traded jobs with health workers in \ndistant villages. They found that as 'outsiders' they could command more \nimmediate authority. People were quicker to follow their advice without question. \n\nSimilar 'swaps' have been made by health workers in several countries. And \nsome of the larger health programs make it a point not to send health workers to \nwork in their own communities. \n\nWe feel this is a mistake. A stranger to a community, no matter how well he \nworks, perpetuates dependency on outside help. Only when a health worker is \nfrom the community can his example show \"what we people in this village can do \nfor ourselves.\" \n\n\nWHO SELECTS HEALTH WORKERS AND HOW? \n\nMany programs feel that health workers should not only be from the \ncommunity where they work, but that they should also be selected by the \ncommunity. These are the reasons: \n\n• If everyone takes part in the selection, chances are greater that the health \nworker will be well accepted. \n\n• Participation in the selection process is a step toward greater responsibility \nand control by people over factors that affect their health. \n\n• A health worker chosen by the community is more likely to feel that his or \nher first responsibility is to the community. \n\n\nProblems with selection by the community \n\n\nMy young nephew is ' \nthe only one in the \n\nVILLAGE WHO HAS BEEN \nTO SECONDARy SCHOOL. \n\ni am sure you will all \nagree that he should \nBe the health worker. \n\n\nTHAT Boy IS A I5RUI \nAN V A CROOK .' \n\n\nProblem: In many \nvillages, the local headman, \nmayor, or a powerful \nlandowner insists that one \nof his children or family \nmembers be chosen as \nhealth worker. Even if a \npublic vote is taken, the \npoorer people may be afraid \nto suggest or vote for \nsomeone else. As a result, \nthe health workers selected \nmay represent the interests \nof those with land and \npower rather than those \nwith greatest need. This \nis a problem reported from \nmany countries. \n\n\nHelping Health Workers Learn (2005) \n\n\n2-3 \n\n\nAnother problem: Sometimes villagers select a person who is very young, \ninexperienced, or irresponsible. This may be because people feel that \"study is for \nthe young.\" Also, older persons frequently have too many other responsibilities. \n\nPart of the reason for poor choice of health workers, however, is that often the \nselection is made in a hurry, without enough critical discussion. Somebody \nsuggests a friend, or someone he likes. Someone else suggests another friend, and \na vote is taken. More often than not, the winner is the person for whom the first \nshow of hands is called. \n\nStill another problem: Many programs find that health workers with more than \na primary school education are likely to leave their villages for better-paying jobs \nin the cities. \n\nTo avoid these and other problems, some community-based programs in the \nPhilippines do not accept the following persons for health worker training: \n\n• close relatives of village leaders or officials \n\n• young people and those likely to marry soon \n\n• those with more than a primary school education \n\n• those with many other responsibilities or official positions \n\nIn a similar way, a health program in Iran decided to exclude from health \nworker selection, family members of any village authority or large landholder. \nAfter this decision was made, villagers chose health workers who were more \nrepresentative of the poor and more concerned with their needs. \n\n\nWays to help communities select wisely \n\nRather than deciding for the community what kinds of persons it should or \nshould not select, it is often better to help the community decide wisely for itself. \nBut this takes time and care. \n\nFor example, instructors from the villager-run health program in Ajoya, \n\nMexico ride on muleback to mountain villages, spending a few days in each. \n\nOften they will make several visits, \ngetting to know the people better. \n\nThen an all-village meeting is held. \n\nWomen and children are encourage \nto attend (instead of only men, as \nis customary). The instructors try \nto get an active discussion going: \n\nWhat are our health needs ? Do we \nneed our own health worker ? \n\nWhat qualities should this person \nhave? As the people make \nsuggestions, these are written \non large sheets of paper or a \nblackboard, and discussed further. \n\n\n2-4 \n\n\nHelping Health Workers Learn (2005) \n\n\nThe people's list might include any combination of the following. \n\n\nWe want a health worker who: \n\n• is kind \n\n• is responsible \n\n• is honest and shows good judgement \n\n• has a mature personality \n\n• is interested in health and community work \n\n• is humble: feels equal to and not superior to others \n\n• will probably stay in the village (not move away) \n\n• is accepted and respected by all the people, or at least by the poor \n\n• has the full agreement and cooperation of his or her family \n\n• can read and write (preferably) \n\n• does not have more than a primary school education \n\n• is eager to learn; open to new ideas \n\n• is a good leader and organizer \n\n• has healthy habits (does not smoke, does not drink too much) \n\n• can draw, or is a good storyteller \n\n• works well with mothers, children, and working people \n\n• has a good record of taking part in or leading community activities \n\n• has some experience in health care or healing (preferably) \n\n• understands and respects people's beliefs and traditional practices \n\n• identifies with and defends the interests of those in greatest need \n\n\nTHIS LIST CONTAINS \nSUGGESTIONS FROM \nSEVERAL PROGRAMS \n\n\nThe team in Ajoya feels it is important for the villagers to develop the list of \nqualities themselves, rather than to have a list handed to them. If, however, the \npeople forget certain important qualities, the instructors may ask questions that \nhelp the people consider those points. \n\nOnly after the list of qualities has been developed and thoroughly discussed, \nare the people asked to suggest names of persons who might make good health \nworkers If certain persons are known to dominate discussions or decisions, they \nare asked, politely, to remain silent so that those who seldom speak can make \ntheir suggestions first, When necessary, the vote is taken by secret ballot. \n\nIn this way, selection of a health worker is \nthe beginning of a process in which the poor \nfind a voice and fairer representation. But all \nthis takes time, in the Makapawa program in \nthe Philippines, a team works in the village \nfor at least 3 months, helping the poor \norganize and consider their needs before a \nhealth worker is selected. \n\nA village health committee is often chosen \nat the same time. (See page 10-3). \n\n\n^PLEASE LET OTHERS DO1 \nTHE TALKING \n\n\nOther programs take different approaches to the selection of health workers. \nSome have requirements for age, sex, schooling, physical health, etc. Some give \nsimple tests to check for such things as skill with one's hands. Generally, the \nmore distant the headquarters, the more requirements are set in advance. \n\n\nHelping Health Workers Learn (2005) \n\nJoint selection by the community and program leaders \n\nSome programs feel the best selection of health workers results from combining \nthe community's knowledge of its people with the program leaders’ experience. \n\nThe village is asked to pick 3 or 4 'candidates' From these, the instructors choose \nthe one they think most suited— perhaps after testing their skills and attitudes. \n\n\nHANDICAPPED PERSONS AS HEALTH WORKERS \n\n\nSome programs require that \nhealth workers be in “excellent \nphysical health.\" Clearly, health \nworkers should be free of \ncontagious diseases such as \nuntreated tuberculosis, and healthy \nenough to handle their \nresponsibilities. \n\nWe have found, however, that \nsome of the best health workers are \npersons with serious physical \nhandicaps; polio, for instance, or an \namputated arm or leg. Unable to do \nhard physical labor, they may find \nmore time for health work and \ngreater satisfaction in doing it. \nBecause of their own problems, \nthey also have more understanding \nfor others who are ill or \nhandicapped. In some ways, their \nweakness becomes their strength. \n\nAs health workers serving their \ncommunity, they set an example \nfor others who are handicapped. \n\n\nHandicapped persons often make excellent \nhealth workers. Here a young man, himself \ncrippled by juvenile arthritis, repairs braces for \na child with polio. (Mexico— Project Piaxtla) \n\n\nWHO MAKE BETTER HEALTH \nWORKERS-MEN OR WOMEN? \n\nSome programs train only men as health \nworkers. Others only women. Others train both. \n\nReasons often given for selecting women as \n\nhealth workers: \n\n• Women and children make up % of the \npopulation. Their health needs are \nespecially great. And women usually prefer \nhealth workers who are women. \n\n• Women have more experience in caring for \nchildren, and may be more tender. \n\n\nHelping Health Workers Learn (2005) \n\nWomen usually stay closer to \nthe village, and so are more \navailable when needed. \n\nWomen often are more \nexploited and abused than \nmen. Therefore their \nsympathies are more likely to \nlie with those who have less \npower and greater need. A \nhealth program in India states \n\"Women and children are the \nmore vulnerable groups in the \nrural area, therefore a woman \nis best able to motivate and bring about change.\"* \n\n\"With women there is less fear of misuse or malpractice,\" states the same \nprogram from India, In many areas, women tend to be more responsible, and \nthey drink less. They may also be more willing to work for the people, not \nthe money. \n\n\nWomen health workers in Bangladesh ride \nbicycles, which only the men used to do. \n\nThis is helping women gain more equal rights \n\n\nReasons often given for selecting men as health workers: f A \n\n• Men often can move about more safely and freely than \nwomen. They can go alone or at night to a distant house or \n\nvillage to attend an emergency. f y' \\ \n\n• Much of the work to improve health involves farming, water (r-| . j^ \n\nsystems, latrine building, and other activities for which the \n\nhelp of men is needed. Men can perhaps be better led by a male leader \n\n• Where part of the health worker's job is to work toward social change, men \nare more likely to take action and to organize the people than, are women. \n(This is not necessarily true. It is interesting to note, however, that in some \ncountries where human rights are often violated, government-run \n\nhealth programs train mostly women health workers. In those \n\nsame countries, community-based programs working for land \\ J \n\nrights and social change often train mostly men health workers.) I ! \n\n\nSome programs happen to train mostly men, others mostly women. Usually this \nis not because they feel one sex makes better health workers. In some places there \nare difficulties in recruiting either men or women. Men (especially young men) may \nbe too 'proud' to consider training for 'nursing' work— especially if on a volunteer \nbasis. In some areas, unmarried women may not be permitted to leave home to \nattend a training program. And married women may be unable to leave their \nchildren and their work, or their husbands may not let them. \n\nExperience shows that both women and men can make good health workers. \n\nOften men are able to relate better to the health needs of men, and women to the \nneeds of women and children. Some health programs resolve this difference by \ntraining both a man and a woman (sometimes a married couple) from each village. \n\n\nFrom Moving Closer to the Rural Poor, by the Mobile Orientation and Training Team, Indian Social \nInstitute, New Delhi. \n\n\nHelping Health Workers Learn (2005) \n\n\n2-7 \n\n\nYOUNGER OR OLDER HEALTH WORKERS- \nWHICH WORK OUT BEST? \n\n\nAlthough most health programs train \nhealth workers who are quite young, many \nfind that somewhat older or middle-aged \npersons often work out better. Young \npeople sometimes have more open minds \n(and may be easier to recruit), but they \nhave more difficulty in winning people's \nconfidence and cooperation. Also, younger \npersons may be less likely to stay in the \nvillage. Some programs find that unmarried \ngirls are likely to get married and move away. Other programs find that young \nmen often move to the cities or to migrant farm-working camps. \n\n\nOlder persons are usually more likely to remain in their communities, and to \nwork with great dedication and responsibility. Also, people are more likely to \nrespect and listen to them. But they may be more fixed, or even rigid, in their \nideas. This can be both a strength and a problem. \n\n\nIn the experience of many programs, the most reliable age group is from about \n25 to 40. When health workers are younger or older than that, more difficulties \nseem to arise. There are, of course, many exceptions. In Ajoya, Mexico, the \npresent leaders of the program began as 'junior health workers' when they were \n13 to 16 years old. \n\n\nEDUCATIONAL LEVEL \n\nCapable health workers have been trained from every educational level, from \npersons who cannot read to those with university or medical degrees. Each level \npresents special strengths and special problems. \n\nPersons who cannot read and write often have unusually well -developed \nmemories— sometimes far better than those of us who depend on writing things \ndown. But to train health workers who cannot read and write calls for somewhat \ndifferent educational methods. Few instructors have been taught these methods, \nbut they can learn them with the help of the students. \n\nIn most programs, the average education level of community health workers is \nfrom 3 to 6 years of primary school. Yet some programs make 6 years of primary \nschool a minimum requirement. Others require completion of secondary school. \n\nEducation requirements sometimes give rise to problems. For example, in \nGuatemala, a government training program for 'health technicians' in the highland \nIndian communities started with two requirements: 1 ) Applicants must speak a \nnative Indian language as well as Spanish. 2) They must have completed secondary \nschool. However, it turned out that very few native language speakers had finished \nsecondary school. One of the two requirements had to be dropped. \n\n\n2-8 \n\n\nHelping Health Workers Learn (2005) \n\n\nUnfortunately, the language requirement was dropped and the education \nrequirement kept. This meant that almost all the health technicians trained were \nof Spanish (Ladinoj origin. They neither spoke the local languages nor represented \nthe people where they were to work. As a result, the program has had many \ndifficulties. \n\nAs we have already mentioned, persons who have completed secondary school \noften do not make as good health workers as those with less schooling. Their \neducation seems to separate them from the majority of their people. Many are \nmore interested in getting 'higher education' or 'better jobs' in the city. They are \nmore likely to abandon their people. \n\nAlso, as we discussed in Chapter 1, persons with much formal education may \nhave an extra burden of unhealthy values. They need to unlearn and relearn a \ngreat deal in order to become effective community health workers. \n\nBy contrast, persons with less formal education tend to feel themselves more \nin harmony with, and equal to, the poor majority. They may be more ready to \ncommit themselves to community health work. \n\n\nPersons with only a few years of schooling often make \nmore reliable, more community-strengthening health \nworkers than those who have had more formal education. \n\n\nOnce again, of course, there are exceptions. \n\n\nTRADITIONAL HEALERS AND \nMIDWIVES AS HEALTH WORKERS \n\nMany programs have trained traditional healers, \nherbalists, bone setters, and traditional midwives as \nvillage health workers— often with good results. \n\nAdvantages to training traditional healers as health \nworkers: \n\n• They already have the confidence of the people in \ntheir own special area of health care. \n\n\n• They have a strong grounding in traditional and spiritual forms of care and \nhealing. To these they can add concepts of modern health care and medicine. \nOften the combination of the old and the new, unique to the area, is better \nthan either way by itself. \n\n\n• They are usually persons with great experience and strong beliefs. So they \nmay be more able to defend their people's culture and resist the use of \nforeign ideas and technologies not suited to local needs. \n\n\n• They are often persons firmly rooted in their communities and deeply \ncommitted to serving people in need. (But be careful. Some traditional \nhealers use their special knowledge to exploit or gain power over others.) \n\n\nHelping Health Workers Learn (2005) \n\n\n2-9 \n\n\nDifficulties in training traditional healers as health workers: \n\n\nTraditional healers \noften are very set in \ntheir ways. Like \nmodern medicine, \ntraditional medicine \nincludes many \npractices that are \nhelpful, others that are \nuseless, and some that \nare harmful. Traditional \nhealers, like many \nmodern doctors, may \nbe reluctant to examine \ncritically the practices \nthey have always \nfollowed. They may be \nunwilling to omit or \nchange harmful but \nprofitable practices. \n(These may include the \nmisuse or overuse of \ncertain modern \nmedicines, sometimes \ncombined with herbal \nmedicines.) \n\n\nThis 'herb doctor' was chosen by his village to train as a \nhealth worker. His art of healing adds much to the science \nof health care. Today, he combines aspects of modern and \nfolk medicine. (Mexico) \n\n\nA common difficulty with traditional healers relates to their approach to \nproblem solving. Most traditional healers rely, to a large extent, on the \npsychological 'power of suggestion'. This is a very important part of the healing \nprocess as they know it. The traditional healer convinces the sick person and his \nfamily that he or she knows immediately just what the illness is, what caused it, \nand how to treat it. This immediate and absolute certainty is a key to traditional \nhealing. \n\nBut the science of modern medicine calls for just the opposite approach. The \n\nscientific healer begins with doubt, not certainty. He starts by asking questions, \ncollecting related information, and systematically considering and testing \npossibilities (seeCh. 17). \n\nIt is often difficult for persons used to traditional healing to learn the more \nscientific approach. As established healers, they may find it especially difficult to \nask for advice or suggestions, or to admit when they have trouble diagnosing an \nillness. \n\n\nAn instructor who is unaware of all this, may treat these persons as if they were \nignorant or dishonest. This makes it more difficult for both to admit their doubts \nor mistakes. In our own experience, however, we have found that when an \ninstructor understands and appreciates the local forms of healing, most \nmisunderstandings with traditional healers can be avoided. When this is so . . . \n\n\nTraditional healers can become some of the most \ncapable and dedicated primary care workers. \n\n\n2-10 \n\n\nHelping Health Workers Learn (2005) \n\n\nPERSONAL QUALITIES, ATTITUDES, \n\nAND CONCERNS \n\nOf far more importance than age, sex, experience, education, and even place of \norigin, are a health worker's personal qualities— his or her understanding of people \nand their needs. It is essential that the health worker identify with the poor and \nhave a strong sense of fairness and social justice. To some extent, these attitudes \ncan grow and develop during training. But the seeds need to be there already. \nPeople's attitudes are far more easily strengthened than changed. \n\n\nPerhaps the most important quality to look for \nwhen selecting a community health worker is \nthe person's concern for social justice. \n\nDoes he treat other people as his equals? \n\nIs his first concern for those in greatest need? \n\n\nI WAS HERB FI \nDON'T /DU REAL \n\\WHO T AM t \n\n\n/l'M SORRy MA'AM. MY RES PON S l Bl LIT7 \nIS TO SERVE FIRST THOSE WHOSE ^ \n.NEED IS GREATEST. \n\n\nThis is a scene from a ‘Farmworkers’ Theater1 production in Ajoya, Mexico. It was \npresented to help villagers recognize the differences between a good health worker and \nthe typical doctor. \n\n\nHelping Health Workers Learn (2005) \n\n\n2-1 1 \n\n\nWHO MAKE THE BEST TEACHERS \nOF VILLAGE HEALTH WORKERS? \n\n\nSelection of appropriate instructors is just as important as selection of the \nhealth workers themselves. Instructors provide the example or 'role model' for \nteaching and learning that health workers follow when they return to their \ncommunities. \n\nIf the instructor bosses and 'talks down' to students, the students, in turn, will \nbe more likely to 'talk down' and act superior to others when they become village \nhealth workers. But if the instructor relates to the students as his equals, building \non strengths and knowledge that they already have, then the health workers will \nbe more likely to work with their people in a similar way. \n\n\nTHE EDUCATION GAP \n\nA common problem: Instructors often have a very \ndifferent social and educational background from \nthat of the health workers they teach. They may be \ndoctors, nurses, social workers, or health officers who \nhave grown up in cities and have had far more formal \neducation. They can easily lose touch— if they ever \nwere in touch— with the wisdom, hardships, strengths, \nand weaknesses of people who still live close to the \nland, the seasons, and physical work. \n\nThe knowledge of highly educated persons is not \nnecessarily better than that of most of us, but it is \ndifferent. It is as difficult for the doctor to speak in the basic, clear, colorful \nlanguage of the villager, as it is for the villager to understand the long Latin words \nof the doctor. \n\nThis wide separation between instructor and students is called an 'education \ngap'. When the 'gap' is too wide, it is often difficult to bridge. So teacher and \nstudents never really come to know, appreciate, or learn very much from each \nother. \n\n\n2 12 \n\n\nHelping Health Workers Learn (2005) \n\n\nMany kinds of professionals have served as trainers of health workers: \n\n\n• doctors \n\n• senior medical students \n\n• nurses \n\n• paramedics \n\n• intermediate-level health workers \n\n• public health graduates (often \n\nforeigners) \n\n\n• social workers \n\n• school teachers \n\n• teaching teams made up of \n\ndoctors, nurses, anthropologists, \nsocial workers, agricultural \nextension officers, and \nforeign experts \n\n\nLittle study has been done to compare the strengths and weaknesses of these \ndifferent professionals as health worker trainers. But here are some common \n\nDoctors. As a general rule, doctors make poor instructors of \nhealth workers. Their curative, hospital-based training does \nnot prepare them to look at the needs of a whole community. \nAttitudes are also a problem. Doctors have a tendency to \ntake charge, to regard themselves as decision-makers even in \nareas they know little about. Feeling that even simple \ndiagnosis and treatment are 'risky' without years of medical \nschool, they often limit teaching of curative medicine to a \nfew minor chores. This severely weakens the role of health \nworkers in the community. Yet the courses doctors teach usually include a deadly \noverdose of anatomy, with countless Latin names. This gives the health worker a \nmagic vocabulary with which to confuse and impress the people in his community. \n\nNurses. Some nurses make excellent instructors of health \nworkers. But such nurses are exceptional. The nurses' job has \ntraditionally been to take orders without question, and to \nclean up after the doctors. They are given little decision- \nmaking responsibility. So it is not surprising that, when \nnurses instruct village health workers, they place strong \nemphasis on unquestioning obedience, filling out forms, and \nfunctioning as errand boys or girls. As they have been \ndominated and undervalued, they tend to do the same with \nhealth workers. For a nurse to effectively prepare health workers as leaders of \nsocial change, she must be a true rebel. Fortunately, many such nurses exist! \nUnfortunately, they are rarely chosen as instructors. \n\nSchool teachers. In Honduras, some young school teachers \nhave proved to be surprisingly good instructors of village \nhealth workers. These teachers are given 2 or 3 months of \nspecial training in community development and primary care \nactivities. Then they are sent to teach and work with village \nhealth workers. The young teachers are far more willing to go \nto remote villages than are nurses or doctors. They also are \nable to relate well to the health workers and local people. \nHaving a limited background in health, they do not set \nthemselves up as 'authorities'. Rather, they explore and learn with others about \napproaches to solving different health problems. This puts them on a more equal \nfooting with students and villagers. It seems that, in some circumstances at least, \nteaching skills may be more important than an extensive background in medicine \nand health care. \n\n\nimpressions: \n\n\nHelping Health Workers Learn (2005) \n\n\n2-13 \n\n\nBridging the education gap \n\n\nIf, as an instructor, you find you are separated \nfrom your students by a wide social and educational \ngap, there are things you may be able to do to help \nbridge it: \n\n\n1 . Admit openly to your students that the gap \n\nexists— and that the shortcoming is yours as \nmuch as theirs. Invite your students to discuss \nand look for ways of bridging the gap together. \n\n\n2. Do whatever you can to understand in a personal way the life, language, \ncustoms, and needs of your students and their communities. Live, if you can, \nwith one of the poorer families in the community (paying your way). Eat \ntheir food. Drink their water. Help each day with some of the physical or \nfarm work. Accept no more income than an average member of the \ncommunity earns. (This is only a suggestion— but a good one.) \n\n\n3. If you are from out of the area, or are specialized in a narrow field of health \ncare (like medicine), try not to be the main teacher, but rather a teaching \nassistant or auxiliary. (The main teacher will need a wide range of skills and \nknowledge, including, above all, teaching skills and inside knowledge of the \nlocal people. He or she needs personal understanding of what it is like to \napproach learning new things without much formal education.) \n\n\n4. When teaching, make every effort to always begin with the knowledge and \nskills the health workers already have, and help them build on these. You are \n\nthe stranger, so try to adapt your language to theirs; don't make them adapt \nto yours. If they are used to learning from stories or from actually doing \nthings, rather than from lectures and books, try to adapt to their way of \nlearning— even if this means exploring forms of teaching and learning that are \nnew to you. \n\n\n5. Most important! Make yourself as unnecessary as possible, as soon as \npossible. Look for local persons who are socially more qualified (less \nschooled, more in harmony with the people) to take over the training. Work \ntoward having more experienced village health workers become the teachers \nof new village health workers as soon as possible. Every chance you get, move \none step further into the background. Become the teacher of teachers. Then, \njust an adviser or 'person with ideas'. Then leave. \n\n\n2-14 \n\n\nHelping Health Workers Learn (2005) \n\n\nBRIDGING THE \nEDUCATION GAP \n\n\nIf the student is \nat this level \n\n\nPrimary \n\nEducation \n\n\nSecondary \nEducation \n(or more) \n\n\n■ and you try to teach him \nfrom this level, \n\nyou will be talking over his \nhead. You will bore him \nand, in time, lose him. You \nwill make him feel stupid \nand he may hate you for \nit— because he is not \nstupid. There are probably \nmany things he can do \nmuch better than you can, \nand many important things \nhe knows that you do not. \n\n\nIf you try to learn from \nhim, and to make good \nuse of the language, \nknowledge, and skills \nhe already has, often \nyou can help him \nbridge the gap \nto learning \nnew skills. \n\n\n4 A / \nf'A M \n\n\nThere are many shortcuts \nto increasing the student's \nskill and understanding: \nteaching aids, problem \nsolving, role playing, \nlearning by doing, etc. But \nit is important to begin \nwith the skills and \nunderstanding the person \nalready has. \n\n\nGo more than halfway to \nmeet him. \n\n\nStart with the knowledge and skills a person \nalready has— and help him build on these. \n\n\nCLOSING THE GAP \n\nIf the educational gap is \nwide, better than trying to \nbridge it is to close it. \n\nWork toward training \ncommunity persons n \n\nwho are closer to the CyC, \neducational level f i \n\nof the students, \nso they can take \\ T) \n\nover most or ; / L \n\nall of the | \n\nteaching. \n\n\nThe sooner a local health \nworker can be trained to \ntake over the teaching of \nnew health workers, the \nbetter. Then training is \nmore likely to be \nappropriate and helpful. \n\n\nIf you are an outsider, work toward making yourself as unnecessary as \npossible, as soon as possible. \n\n\nHelping Health Workers Learn (2005) \n\n\n2-15 \n\n\nClosing the education gap: \ncommunity persons as instructors \n\nWhen there is a wide 'education gap' between \ninstructor and students, try, instead of bridging it, to \nclose it or avoid it. This means trying to find or \nprepare instructors who: \n\n• are from the same immediate area as the health \nworkers-in-training \n\n• speak the local language \n\n• have the same cultural and social background \n(a farmer, worker, father, mother, etc.) \n\n• have had more or less the same amount of \nformal education as those they teach (although they may have had far more \nexperience or training in health care at the community level) \n\n• dress, act, speak, and feel as equals to the students and villagers \n\nIt is important that instructors be culturally close to the students. But they also \nneed enough basic knowledge and skills (in health care, in problem solving, and in \nteaching) to help students learn effectively. At first it may be difficult to find \nlocal persons with this combination of culture and skills. During the first few \nyears, 'outside' instructors may be needed. But their first responsibility should be \nto prepare local people to take over most or all of the instruction. The more \noutstanding and experienced health workers are often the best ones for the job. \n\n\nCAN LOCAL PERSONS BECOME EFFECTIVE \nINSTRUCTORS OF HEALTH WORKERS? \n\nHealth professionals may be skeptical (doubtful) about whether villagers can \nmake effective instructors. But community-based programs in many countries \nhave found that: \n\n\nExperienced village health workers— \nwith appropriate preparation, back-up, \nand friendly criticism from the learning \ngroup— can make excellent instructors. \n\n\nJust as with doctors and nurses, villagers who make good instructors are \nexceptional. The challenge is to find persons with the right combination of \nattitudes, interests, and talents, and then to create the situation that permits and \nhelps them to grow. \n\n\n2-16 \n\n\nHelping Health Workers Learn (2005) \n\n\nSTRENGTHS AND WEAKNESSES OF VILLAGE-LEVEL INSTRUCTORS \n\n\nA story: \n\n\nWhen a training program is taught and run by village-level instructors, certain \nproblems and obstacles are avoided. But others commonly arise. Once, when we \nwere observing a training course taught by villagers, a visiting nurse was present. \nHerself a trainer of health auxiliaries in a neighboring program, she was highly \ncritical of the way the village-level instructors conducted the course: \n\n\nTOO INFORMAL. \n\nCLASSES DO NOT BEGIN ON TIME. \nINSTRUCTORS SLOPPILY DRESSED. \nTHEY USE VULGAR EXPRESSIONS. \nMISSPELLED WORDS. \n\n\nINCOMPLETE COVERAGE OF MATERIAL. \n\nFREQUENT STRAYING FROM THE \nTOPIC BEING TAUGHT. \n\nTOO MUCH NOISE AND LAUGHTER. \nINACCURATE INFORMATION. \n\n\nAfter listening to her many complaints, the village instructors \ninvited the nurse to give a class to show them how to do it better. \nThey suggested a class on \"The Human Body and How It Works.\" \n\n\nSo the visiting nurse presented a class on \"Anatomy and Physiology.\" It was \ncarefully timed: 40 minutes of lecture with 10 minutes for questions at the end. \nShe briefly and expertly covered each of the body systems, naming the major \norgans and stating their functions. When she finished, she asked one of the health \nworkers if he had understood. He slowly shook his head. \"I didn't understand \nbeans!\" She called on student after student to see what they had learned. But \nwith the exception of two who had studied in secondary school, her lecture had \ngone completely over their heads. One of the village instructors had made a list of \nover 60 words she had used, which no one understood. He asked her to explain \nsome of the words. But each time she tried, she used 2 or 3 more words that \nnobody understood. \n\n\nThe students then asked if the nurse would be willing to give the class over \nagain, but more simply. The nurse admitted she didn't think she could. She asked \none of the village instructors to do it for her. \n\nThe next day, one of the local instructors led a discussion about \"The Body \nand How it Works\" (not \"Anatomy and Physiology\"). Rather than lecturing, he \nstarted by holding up a box. He challenged the students to ask as many questions \nas they could in order to find out whether the box contained something living or \nnot. They asked questions like: \n\n\nDOES IT GROW? OOES IT MOVE BY ITSELF ? DOES IT PEE AND SHIT ? \n\nDOES IT BREATHE ? DOES IT NEED WATER AND FOOD ? CAN IT MAKE BABIES OR SEEDS? \n\n\nThe instructor wrote the questions on the \nblackboard and then opened the box. Out jumped \na frog! \n\n\nNext, the instructor asked how we, as people, also do each of the things listed \non the blackboard. He started with what the class knew about the body, and \nbuilt on that, asking questions like: \n\n\nWHAT BECOMES OF THE FOOD WE EAT? \n\nWHAT HAPPENS TO US WHEN WE DON'T GET ENOUGH FOOD ? \n\n\nHelping Health Workers Learn (2005) \n\n\n2-17 \n\n\nAt one point, he asked two of the students to run fast around the building, and \nhad the group observe them and take their pulse. Then he asked. \n\nWHY DO WE SWEAT, BREATHE HAR DJ AND HAVE A FAST PULSE \n\nWHEN WE RUN OR DO HARD WORK ? \n\nWHAT IS THE PURPOSE OF THE HEART AND LUNGS? \n\nAfter the group had given their ideas (which were \nmostly correct), he asked: \n\nWHY DO PEOPLE WHO ARE VERY PALE GET TIRED MORE QUICKLY? \n\nWHAT IS THE PURPOSE OF BLOOD 1 \n\nHe spoke in the people's language, using the village names for different parts of \nthe body: 'guts' for intestines and 'belly' for abdomen. \n\nIn this way, the students themselves were able to piece together many of the \ndifferent systems of the body and their functions. It was like solving a mystery or \nputting together a puzzle. The students loved it. And everyone understood. The \nclass was noisy and went overtime, but no one objected— this time not even the \nnurse! \n\nOf course, some of the body systems were forgotten, and others were barely \nmentioned. \n\n\"There is a lot more to the body than we have talked about today,\" explained \nthe group leader at the close of the class. \"But we will talk about other parts \nof the body and how they work when we need to, to understand about particular \nhealth problems as they come up.\" (See p. 5-1 1 . ) \n\nBy the time the visiting nurse left, she had changed her mind— and said so. She \nhad seen that, in spite of certain inaccuracies and shortcomings of the teaching, \nthe students had learned more and taken a more active part in the classes taught \nby their fellow villagers! \n\n\nNot all the credit is due, of course, to the fact that the instructors were \nvillagers themselves. Much of the difference was in the teaching methods they \n\nused. But the technique of building on the students' own knowledge and \nexperience is often easier for a local person who shares a common background. \n\nIn Project Piaxtla in Mexico, we (the authors) and other outsiders used to do \nmost of the teaching for the health worker training courses. Then, several years \nago, the local health team (made up entirely of experienced village health \nworkers) took charge of the training. The first year that the course was taught by \nthe village team only, 3 students were present who had taken previous courses \ntaught by outsiders. When asked which course they thought better and more \nappropriate, all 3 agreed, \"This one, taught by the village health workers.\" Their \nreasons: \n\n\nUNDERSTAND. \n\nTHE INSTRUCTORS SEEM TO KNOW JUST HOW SLOW \nOR FAST TO CO TO BE SURE WE UNDERSTAND BUT \nDON'T GET BORED. \n\nWE FEEL MORE COMFORTABLE WITH THE TEACHERS WHO \nARE OUR OWN PEOPLE. IT MAKES LEARNING EASIER . IF \nTHEY CAN UNDERSTAND SOMETHING , WE KNOW WE CAN, TOO? \n\n\n2-18 \n\n\nHelping Health Workers Learn (2005) \n\n\n'TRAINING ORGANIZERS' OR 'BACK-UP PERSONS' \n\n\nSupportive back-up (supervision) can be as important for instructors as for \nhealth workers. This is true for instructors who are doctors and nurses, as well as \nfor village-level instructors. We all can benefit when someone with more \nexperience, or a different perspective, observes our teaching and makes helpful \nsuggestions. \n\nThe person who provides this sort of support and suggestions can be called a \n'back-up person', 'advisor', or 'training organizer'. Since her main goal is to help \npeople meet their needs, the training adviser should not only be an experienced \nhealth worker, but should also sympathize and identify with the poor. \n\nThe role of the training organizer in a health worker training program in \nBangladesh has been described as follows:* \n\n\"The 'Training Organizer' will sit in the class, quietly and discreetly at the \nback, and then review the class with the teacher afterwards, with emphasis on \npoints like: \n\n• Did the message get across \n\nclearly? \n\n• Did the trainees have an \n\nactive or passive role in \nthe class? \n\n• Were visual aids used \n\neffectively? \n\n• How many of the trainees \n\nfell asleep before the end \nof the class? \n\n\"The 'Training Organizer' \nwill review some of the above \npoints with the trainees as well \nas the teacher.\" \n\n\nvou covered All \n\nthe IMPORTANT POINTS,, \n\nBut two st uoent s \nPELL ASLEEP. \n\n\nVillage health workers can make excellent instructors. But at first they often \nlack basic teaching skills and experience in course planning. It is here that the \ntraining organizer can help. But it is essential that he or she be willing to stay in \nthe background and let the community-based instructors assume full \nresponsibility. Once again: \n\n\nAdvise, don't boss! \n\n\nTo emphasize the secondary role of this advisor, 'training assistant' might be a \nbetter term than 'training organizer'. To move into this back-up role is a natural step \nfor the outside professional or foreigner who has been active as an instructor early \nin the program. It allows the outside person to begin phasing herself out, to pass \nteaching and organizing responsibilities to local workers. In time, outstanding local \ninstructors (who started off as community health workers) may likewise be able to \ntake over the role of 'training assistant'. In this way, the outsider moves one more \nstep into the background. The sooner she is not needed, the more successful she \nhas been. \n\n\n* From a personal communication with Martin Schweiger, Medical Adviser/ Administrator, Rangput \nDinajpur Rehabilitation Service Program, Lalmanirhat-Rangpur, Bangladesh. \n\n\nHelping Health Workers Learn (2005) \n\n\nPlanning a Training \nProgram \n\n\n3-1 \n\n\nCHAPTER \n\n\nThe primary aim of this book is to look at ways of learning, not to discuss the \ndetails of a training program. But the way a training course is planned, and by \nwhom, can greatly affect how teaching and learning take place. \n\nMany approaches are possible. But two things are of key importance: \n\n1 ) Each training program should be designed according to the special needs and \ncircumstances of the area it serves. 2) Each course should be adapted to the \nexperiences and needs of each new group of students. \n\nWe have reasons for placing this chapter on planning after those on approaches \nto learning and selection of health workers, instructors, and advisers. The \neducational approach and the persons involved can affect how course content is \ndecided. For if a 'community-strengthening' approach is taken, some of the \ncourse planning is best done by the participants. \n\nTHE TRAINING COURSE AS PART OF A LARGER \nLEARNING PROCESS \n\n\nIn this chapter we focus on training courses for health workers. But keep in \nmind that 'training' takes place in many ways and on many levels. \n\nThe training course is— or should be— closely linked with a vital network of \ncontinuous learning and teaching that takes place in the community. The \ndiagram below shows some of the possibilities. \n\n\nTHE NETWORK OF LEARNING FOR COMMUNITY HEALTH \n\n\nE veryone \nhelps the \ninstructors \nlearn \n\nCOMMUNITY \n\nHealth workers \nhelp parents \nlearn \n\n\nInstructors \nhelp \nhealth \nworkers \nlearn \n\n\nA \n\n\nf. \n\n\nif A \n'TRAINING^ \nCOURSE j \n\n\n-Health workers — \nhelp instructors \n\n\nlearn \n\n\nHealth workers \nhelp children \nlearn \n\n\nChildren \n\nhelp \n\nparents \n\nlearn \n\n\nHealth workers \nhelp workers\\ \nearn \n\n\nParents help Parents \nhealth workers help \nlearn children \n\nlearn \n\n\nChildren \nhelp children \nlearn \n\n\nEveryone \nhelps student \nhealth workers \nlearn \n\n\nHealth workers \nhelp \n\n\nWorkers help \nhealth workers \nlearn \n\n\nMidwives help \nhealth workers \nlearn \n\n\n3-2 \n\n\nHelping Health Workers Learn (2005) \n\n\nTHE IMPORTANCE OF HAVING STUDENTS TAKE PART \nIN THE PLANNING \n\nThe ability to plan effectively— to analyze and organize what needs to be done— \nis basic to the self-reliance of every individual, family, and community. Planning \nskills are especially important for health workers who are to become leaders, \nteachers, and organizers in their communities. \n\nThis does not mean that a training program must include special classes on \n'planning and management'. Instead, it points to the value of including the \nstudent group in the planning process. \n\n\nLESS APPROPRIATE \n\n\nMORE APPROPRIATE \n\n\nSome of the most important skills are best learned through practice \nin applying them to real situations, rather than by studying them as separate topics. \n\n\nThere are several good reasons for including the student health workers in \nplanning the content and organization of their own training: \n\n• Through guided practice the students learn firsthand about analyzing, \nplanning, and organizing relevant activities. \n\n• Students become more deeply involved in the teaching-learning process. \n\n• They become— and feel— more equal to their instructors. This will help them \nwhen they begin to plan and teach in their communities. They will be more \nable to relate to their own people as equals, and to share responsibilities \nwith others. \n\n• Students can help adapt the content of the training program to the problems, \nneeds, and resources within their particular communities. This helps make \neach training session a new, special, exciting, and more relevant experience— \nfor the instructors as well as the students. \n\n• The flexibility and shared responsibility of this approach are basic to \nachieving community health and fairer distribution of control. \n\n\nHelping Health Workers Learn (2005) \n\n\n33 \n\n\nA COMMON PROBLEM: PLANNING THINGS BACKWARDS \n\n\n• Why are so many health worker training \ncourses taught by persons who have no \ncommunity experience? \n\n• Why do so many instructors give more \nclass time to the study of anatomy and \nfilling out forms than to child diarrhea, \nnutrition, and teaching methods? \n\n• Why do so many courses fail to prepare \nhealth workers to solve many of the \nbasic problems they will face? \n\n\nThe answers to these questions lie in the fact that training programs too often \nare planned backwards. The time and place are fixed, instructors chosen, and \ncourse content decided before planners consider the special difficulties, resources, \ncustoms, and strengths of the people involved. As a result, what is taught does \nnot match either the community's needs or the students' abilities. \n\nMany training programs today teach too much of what matters little— and too \nlittle of what matters most. To make things worse, the way they teach is often as \nunrelated to people's needs as is the subject matter. \n\nIf training is to be appropriate (adapted to people's needs, resources, customs, \nand abilities), things need to be done the other way around: \n\n1st: Invite the people from the communities that the program will affect to \n\ndetermine and make known their needs. \n\n2nd: Let the people's needs, resources, and abilities determine what should be \ntaught, and to whom. \n\n3rd: Let what should be taught, how, and to whom, determine who should \n\nteach, where, for how long, and in what way. \n\n\nThis people-centered or 'decentralized' approach to planning can be relatively \neasy for small programs that are community based. But it may be extremely \ndifficult for a large, regional program. An appropriate approach may still be \npossible, however, if those in positions of central authority are willing to: \n\n\n• Permit planning and basic decisions to take \nplace at the community level. \n\n• Act not as a controlling body, but as a center \n\nfor communications, advice, support, and supply. \n\n\nthe decentralized \nor \n\n► \n\npeople-centered \n\napproach \n\n\n3-4 \n\n\nHelping Health Workers Learn (2005) \n\n\nTHE DECENTRALIZED APPROACH TO PLANNING \n\n(the solid arrows show the main direction of flow) \n\n\nThe central ministry or program The communities provide most \n\nprovides most of the supplies, of the advice, planning, and \n\nsupport, and coordination. control. \n\n\nWhen groups are very large, central planning-and-control very easily becomes \nrigid, bureaucratic, change resistant, and corrupt. Planning-and-control has more \nchance of being appropriate, flexible, and responsive to human needs when it \ntakes place in groups that are small enough for everyone to know each other. \n\n\nDECIDING HOW MUCH TO PLAN IN ADVANCE \nAND HOW MUCH TO PLAN DURING THE COURSE \n\n\nAs we have noted, it is advisable to leave some of the planning of a training \ncourse until after it begins. This allows the course content to be planned or \nmodified according to the students' interests, experiences, needs, and capabilities. \n\nClearly, however, some planning must be done in advance. Someone has to \nmake decisions about why, when, where, with whom, and for whom the training \nwill take place. Resources and needs must also be considered. And certain \npreparations need to be made. \n\nOn the next four pages (3-5 to 3-8) we present an outline of IMPORTANT \nCONSIDERATIONS FOR OVERALL COURSE PLANNING. It includes: \n\n\nSection A: Planning to be done before the training course begins \nSection B: Continued planning after the training course begins \nSection C: Planning and programming after the course is completed \n\n\nHelping Health Workers Learn (2005) \n\n\n3-5 \n\n\nIMPORTANT CONSIDERATIONS FOR OVE RALL COURSE PLANNING \n\n\nA. Planning to be done before the training \ncourse begins: \n\n1. FIRST CONSIDERATIONS— \n\nPURPOSES AND QUESTIONS \n\n• Whose needs will the training program be primarily \ndesigned to meet? \n\n• Will it only extend the existing health system, or \nwill it help to change it? \n\n• How much will it prepare the health worker to \nunderstand and deal with the social (economic, \ncultural, political) causes of ill health? \n\n• Will it make the poor more dependent, or help \nthem to be more self-reliant? Will it promote or \nresist social change? \n\n• What are the general goals and objectives of the \nprogram? (To express goals in terms of numbers \nand dates is probably unwise at this stage. Why?) \n\n• Who is (or should be) involved in all these \ndecisions? \n\n\n2. OBSERVATION OF NEEDS AND RESOURCES \n\n(Talking with a few observant persons from the area \n\ncan often provide more useful information than a \n\ncensus or elaborate 'community diagnosis', at far \n\nlower cost, more quickly, and with less abuse.) \n\nInformation worth considering: \n\n• Common health problems: how frequent and how \nserious? \n\n• Causes of main problems: physical and social, \ncoming from inside and outside the community. \n\n• People's attitudes, traditions, and concerns. \n\n• Resources: human, physical, economic, from \ninside and outside the area. \n\n• Characteristics of possible health workers: age, \nexperience, education, interest, etc. \n\n• Possible choices of instructors and training \norganizers. \n\n• Possible sources of funding and assistance. (Which \nare more appropriate?) \n\n• Reports and experiences of other programs. \n\n• Obstacles: certain, likely, and possible. \n\n3. EARLY DECISIONS— \n\nWho? Where? How many? When? \n\n• Selection of health workers: by the community, \nby the health program, or by both? (How can \nselection of a health worker be a learning \nexperience for the community?) \n\n\n• Selection of instructors and advisers: \n\n♦ How much understanding and respect do they \nhave for village people? Do they treat them as \nequals? \n\n♦ How committed are they to working toward \nsocial change? \n\n♦ Do they have the necessary knowledge and skills \n(public health, education, group dynamics, \ncommunity organization, medicine, etc.) or are \nthey willing to learn? \n\n\n• Location: \n\n♦ Where will the training take place? Near or far? \nVillage or city? Why? \n\n♦ Where will everyone eat and sleep? I n hotels? \n\nIn special facilities? With village families? \n\n(How can these decisions influence what they will \nlearn?) \n\n• Numbers: How many students will take part in the \ntraining course? (Beyond 1 2 or 15, quality of \ntraining usually decreases. This must be weighed \nagainst the need to train more health workers.) \n\n• Timing: \n\n♦ How long will the training course last? \n\n♦ What time of year is best? \n\n(Consider how these decisions may affect who \ncan take part in the course.) \n\n♦ Will the training be done in one continuous \nstretch, or be divided Into short blocks so that \nstudents can return home (and practice what \nthey have learned) between sessions? \n\n(Whose needs and opinions should be considered \nin answering these questions?) \n\n• Funding: \n\n♦ From where? How much money should come \nfrom outside the local area? \n\n♦ What are the interests of possible funding \ngroups? \n\n♦ What are the advantages and disadvantages of \nasking communities to pay part of the cost of \ntraining their health worker? \n\n♦ How can costs be kept low? How much is \nneeded? \n\n• Follow-up and support: \n\n♦ What opportunities may there be for continued \nlearning or training after the course is over? \n\n♦ What kind of support or supervision will the \nhealth workers receive? \n\n(Why is it important to consider follow-up before \nthe training program begins?) \n\n\n3-6 \n\n\nHelping Health Workers Learn (2005) \n\n\n4. ANALYSIS OF PRIORITIES \n\n(deciding what is most important) \n\nProblems can be compared by considering the \nfollowing: \n\n• How common are they? \n\n• How serious are they? \n\n• How contagious are they? \n\n• How much concern do people feel about them? \n\n• How much do they affect other problems? \n\n• How much could a community health worker do \nabout them in terms of . . . \n\n♦ diagnosis and treatment? \n\n♦ referral, when needed? \n\n♦ prevention? \n\n♦ education of local people? \n\n♦ community action? \n\n• How easy or difficult will it be to teach a health \nworker to take safe, responsible action with \nrespect to the problem? \n\nThen group the problems according to their relative \nimportance, or priority, and decide which ones to \ninclude in the course. (Be sure to include common \nsocial problems that affect health— such as drinking, \noveruse and misuse of medicines, local forms of \nexploitation of the poor, and misuse of resources— \nas well as physical diseases.) \n\n5. RE-EXAMINING OBJECTIVES \n\n• In view of the information you have gathered and \nanalyzed, how can the training program be best \ndesigned . . . \n\n♦ so that it prepares health workers to help the \npeople in their villages solve their problems and \nneeds? \n\n♦ so that it is adapted to fit the particular \nstrengths and weaknesses of the students? \n\n6. ORGANIZING STUDY MATERIAL FOR \nAPPROPRIATE LEARNING \n\n• What general subject areas and specific topics \nmight be taught in order to prepare students to \nact upon the important problems and needs in \ntheir communities? \n\n• How many hours of organized study time will \nthere be during the course? \n\n• How much time is needed to adequately cover \neach topic? \n\n• How can the time available be best divided \namong the different topics, according to their \npriority? \n\n• Which topics are best approached through \nclassroom learning, through practice (in clinic, \ncommunity, or field), or a combination? \n\n(At this point, some program planners make a list \nfor each subject area, stating exactly what the \nhealth workers should know and be able to do. \nWhat are the strengths and weaknesses of this \napproach? See Chapter 5.) \n\n\n7. PLANNING FOR BALANCE \n\n• How can the subject matter be approached so as \n\nto maintain an appropriate balance between . . . \n\n♦ classwork and practical experience? \n\n♦ learning in the training center and learning in \nthe community? \n\n♦ preventive and curative health care? \n\n♦ physical and social causes of ill health? \n\n♦ the needs of the poor and the requirements of \nthose in positions of control? \n\n♦ caution and innovation? \n\n♦ health skills, teaching skills, and leadership \nskills? \n\n♦ work and play? \n\n\n8. PREPARING A ROUGH TIMETABLE OR \nCLASS SCHEDULE \n\n(without details, to be changed later) \n\n• How can different subjects and topics be arranged, \naccording to hours, days, and weeks, so that . . . \n\n♦ there is enough variety to keep the students \ninterested (for example, classwork alternating \nwith farm work, community action, and \nlearning of practical skills)? \n\n♦ related subjects are scheduled close together or \nin a logical order? \n\n♦ more difficult subjects come early in the day, \nand more fun subjects later (when people are \ntired)? \n\n♦ all key subject matter is included? \n\n♦ high-priority subjects are given more emphasis \nin the training course? \n\n♦ skills and knowledge needed for immediate use \nand practice are learned early (for example, \nlearning about medical history, physical exams, \npreventive advice, Road to Health charts)? \n\n• How can study time and free time be best arranged \nto meet students' and instructors' needs? \n\n• How can the schedule be kept open and flexible \nenough to allow for unplanned learning \nopportunities and special needs as they arise? \n\n(It helps to leave the last week of the course \nunscheduled, to allow for review and for making \nup 'displaced classes'.) \n\n• How can the schedule be presented in a clear, \nsimple form that can be easily seen and \nunderstood by students and instructors? \n\n\nWEEKLY PLAN \n\n— \n\nHelping Health Workers Learn (2005) \n\n\n3-7 \n\n\n9. PLANNING APPROPRIATE TEACHING \nMETHODS AND AIDS \n\n• What teaching approach is best suited to persons \nwho are more used to learning from experience \nthan from lectures and books? \n\n• What approaches to learning will help the health \nworker be an effective teacher in his community? \n\n• What attitudes on the part of the teacher will \nencourage the health worker to share knowledge \ngladly and treat others as equals? \n\n• What teaching methods might aid the health \nworker in helping community people to become \nmore confident and self-reliant? \n\n• What teaching aids can be used that will lead the \nhealth worker to make and invent teaching aids \nafter returning to his village? \n\n• What approach to learning will best prepare the \nhealth worker to help his people understand and \nwork together to solve their biggest problems? \n\n• What approach to health problems will enable the \nhealth worker to learn how to approach the \nsolving of other community problems? \n\n• What can be done to ensure that all learning is \nrelated to important needs? \n\n• How can classwork be made more friendly and \nfun? \n\n• How can tests and exams be presented so that \nstudents use them to help each other rather than \nto compete? How can tests and exams be used \nto judge the instructor as well as the students? \n\n\n10. GETTING READY AND \nOBTAINING SUPPLIES \n\n• What preparations are needed before the course \nbegins? (transportation, eating and sleeping \narrangements, study area, wash area, etc.) \n\n• What furnishings and teaching materials are \nneeded to begin? (benches, blackboard, etc.) \n\n• What can be done if some of these are not ready \non time? \n\n11. DETAILED PLANNING OF ACTIVITIES AND \nCLASSES FOR THE BEGINNING OF THE \nCOURSE \n\n• How many days of classes and activities should \nbe planned in detail before the course begins? \n\n• Why is it important that the details of all the \nclasses and activities not be planned in advance? \n\n\nB. Continued planning after the training \ncourse begins: \n\n12. INVOLVING STUDENTS IN PLANNING THE \nCOURSE CONTENT (based on their experience \nand the needs in their communities) \n\n• Why is it important that the students take part \nin planning the course? \n\n• How can the students' participation in planning \nhelp them to learn about . . . \n\n• examining and analyzing the needs in their \ncommunities? \n\n• recognizing both the strengths and the \nweaknesses of their people's customs? \n\n• ways to plan and organize a learning group? \n\n• the value of learning by doing, and of respecting \nand building on their own experiences? \n\n• shared decision making? \n\n13. REVISING THE PLAN OF STUDIES \n(COURSE CONTENT) ACCORDING TO \nSTUDENT SUGGESTIONS \n\n• To what extent do the priorities determined by \nthe students, according to problems and needs in \ntheir own villages, correspond to those already \nconsidered by the instructors and planners? (How \ndo you explain the similarities and differences?) \n\n• How important is it to revise the course plans in \norder to better meet the concerns and expressed \nneeds of the student group? \n\n\n14. PREPARING INDIVIDUAL CLASSES AND \nACTIVITIES \n\n• How detailed should class plans be? \n\n• How far in advance should a class or activity be \nplanned? Why? \n\n• Is it helpful to use a particular outline or formula \nfor preparing a class? If so, what should it include? \n\n• Can each class or activity be planned to include . . . \n\n♦ all of the basic points to be learned or \nconsidered? \n\n♦ active student participation and interaction? \n\n♦ use of appropriate learning aids? \n\n• opportunities for the students to explore \nquestions and discover answers for themselves? \n\n• practice in solving problems similar to those \nhealth workers will meet in their work? \n\n• a chance for students to summarize what they \nhave learned and to ask questions? \n\n• To what extent can students take part in the \npreparation of classes and of teaching aids? (Is \nthis important? Why?) \n\n\n3-8 \n\n\nHelping Health Workers Learn (2005) \n\n\n15. CONTINUED REVISION OF THE \n\nSCHEDULE— to make room for new ideas, \nlearning opportunities, needs, and problems \nas they arise \n\n• What are the advantages and disadvantages to \nkeeping the program open and flexible? (How \nmight this influence a health worker's ability \nto work toward, or tolerate, change in his or \nher community?) \n\n\n18. STARTING OVER \n\nThe whole process is repeated: \n\n\n1 \n\nPURPOSE \n\nI \n\nOBSERVATION \n\n\n16. EVALUATION DURING THE TRAINING \nPROGRAM —to consider how it might be \nimproved (see Chapter 9) \n\n• I n what ways can this be done? \n\n• Who should be involved? \n\n• What is the value of . . . \n\n♦ round-table discussions in which all students \nand staff have a chance to express their feelings \nabout the program and each other? \n\n♦ similar discussions with members of the \ncommunity where the training program takes \nplace? \n\n♦ tests and exams? \n\n♦ setting specific goals and seeing if they are met? \n\n• If evaluation studies (informal or formal, ongoing \nor final) are made, what can be done to help \nassure that results are useful and will be used? \n\n\nCE \n\nLU \n\n> \n\no \n\na \n\nz \n\nI— \n\nre \n\n- Good health \nis more than the \nabsence of disease. \nGood health means \nthe well-being of a \nwoman’s body, mind, \nand spirit. \n\n\nThis larger view helps us understand the underlying (root) \ncauses of women’s poor health. Improving women’s health \nincludes treating their health problems, but \nit also requires changing the \nconditions of their lives so they \ncan gain more power over their \nown health. \n\nWhen this happens, \neveryone — the woman, her \nfamily and community — benefits. \n\nA healthy woman has a chance to fulfill all \nof her potential. Plus, she will have healthier \nbabies, be better able to care for her family, and \ncan contribute more to her community. This kind of \nview also helps us see that a woman’s health problem \nis almost never her problem alone. Women’s health \nis a community issue. \n\nwww. Hesperian . o r g \n\n\n\nWhere Women Have No Doctor 2010 \n\n\n2 Women’s Health Is a Community Issue \n\n\nWomen \nAre More \nat Risk for \nDisease and \nPoor Health \n\n\n>■ Not getting enough \ngood food can keep \na girl from growing \nproperly, and can \nlead to serious health \nproblems. \n\n\n\neating for good health \n\n\nBecause a woman's body is different from a man’s, and \nbecause of the basic inequalities between men and women, \nwomen face a greater risk of disease and poor health. Here \nare some of the health problems that affect women most: \n\nPoor nutrition \n\nPoor nutrition is the most common and disabling health \nproblem among women in poor countries. Starting in \nchildhood, a girl is often given less food to eat than a boy. As \na result, she may grow more slowly and her bones may not \ndevelop properly (which may later cause difficulty during \nchildbirth). The problem worsens as she becomes a young \nwoman, because her need for good food increases as her \nworkload increases, and as she starts her monthly bleeding, \nbecomes pregnant, and breastfeeds. \n\nWithout enough good food, she may begin to suffer from \ngeneral poor health, including exhaustion, weakness, and \nanemia. If a woman who is already malnourished becomes \npregnant, she is more likely to have serious complications with \nchildbirth, such as heavy bleeding, infection, or a baby that is \nborn too small. \n\n\n\nThe health worker told me I \nshould drink more milk and eat \ngreen leafy vegetables. But I save \nall our milk for my husband and \nson, and we don’t have the money \nto buy vegetables. \n\n\n% \n\n\nA woman’s health cannot be isolated from her social status. In most of rural India, women drink \nless milk than their husbands and sons and they eat only after the men have been served. This \nusually leaves women with a limited diet, and it also tells about how she is valued. \n\n— CHETNA, Ahmedabad, India \n\n\nWhere Women Have No Doctor 2010 \n\n\nw. nespenan.org \n\n\n\nWomen Are More at Risk for Disease and Poor Health 3 \n\n\nReproductive health problems \n\nSexually transmitted infections (STIs), including HIV. A woman \nis physically more vulnerable than a man to infections like STIs \nand HIV. This is because a man’s semen stays inside her and the \ngerms it carries can pass through the lining of the vagina into her \nblood. And, since a woman often has no signs of infection, she \nmay not get treatment. \n\nBut the problem is really a social one. Women often have \nlittle control over decisions about sex and often cannot refuse \nunsafe sex. As a result, millions of women get an STI every \nyear, and more than 17 million are already infected with HIV. \nWithout treatment, STIs can cause disabling pain, severe pelvic \ninflammatory disease (PID), infertility, problems during pregnancy, \nand an increased risk of cervical cancer. Untreated, HIV becomes \nAIDS, which causes death. \n\nFrequent pregnancies. In many parts of the world, a third to half \nof young women become mothers before they are 20 years old. \nWithout family planning, many of these women will not have time \nto get strong again between births. This puts a woman at risk \nfor poor health and complications of pregnancy and childbirth. \nFrequent childbirth also means she is less able to control her own \nlife, to get an education, and to learn skills to support herself. \n\nComplications from pregnancy and birth. In the last 40 years, \nthe number of infant deaths has been greatly reduced. Yet \nthe number of women who die from pregnancy and birth has \nnot. Every minute, one woman dies from a problem related \nto pregnancy or childbirth. And for every woman who dies \nin childbirth, 20 more suffer from injury or infection. This \nmeans that overtime, about a quarter of all women living in \npoor countries will be seriously affected by complications from \npregnancy and birth. \n\nUnsafe abortion. When a woman tries to end a pregnancy by \nhaving an unsafe abortion, she risks her life. But every day about \n60,000 women and girls try to end their pregnancies in unsafe \nways because they have no way to get a safe abortion. Many \nare left unable to have children or with lasting pain, infection, and \nother health problems. \n\nFemale genital cutting. Female genital cutting, in which part or \nall of a girl’s outer genitals are cut off, can cause serious health \nproblems. These include pelvic and urine system infections, \nsexual and emotional problems, and difficulties during childbirth. \nYet despite these problems, it continues to be widely practiced. \nEvery year about 3 million girls are cut, mostly in Africa, and in \nsome parts of the Middle East and Asia. \n\n\n\nSTIs and other \ninfections of the \ngenitals \n\n\nV Because women \nmust often have \nunsafe sex against \ntheir will, STIs are a \nsocial issue. \n\n\n\n>- Every minute, one \nwoman dies from a \nproblem related to \npregnancy. \n\n\nV Every year 70,000 \nwomen die from \nunsafe abortions. \n\n\nWWW. \n\n\n\n4*hMA,y*L \n\nespenan.org \n\n\nWhere Women Have No Doctor 2010 \n\n\n\n4 Women’s Health Is a Community Issue \n\n\nV Men and women \nget many of the same \ndiseases , but women \ncan be affected \ndifferently. \n\n\n\nTB, 387 \n\nalcohol and other \ndrugs, 435 \n\n\nGeneral medical problems \n\nWomen are more likely than men to suffer from certain health \nproblems because of the work they do, because of poor \nnutrition, or from being too tired. A disease can also cause a \ndifferent kind of harm to a woman than a man. For example, a \nwoman who suffers from a disease which weakens her or makes \nher look ugly may be rejected by her husband. \n\nOnce they are sick, women are less likely to seek and receive \ntreatment until they are seriously ill. For example, tuberculosis (TB) \nis spreading among both men and women, but fewer women \nthan men get treatment. Almost 3000 women die every day from \nTB — at least Vk of whom did not receive proper treatment or \nnever even knew they had the disease. Other health problems \nthat in the past affected mostly men are now risks for women, \ntoo. For example, more women are suffering from problems \nrelated to smoking cigarettes or drinking too much alcohol. \n\n\n\nwork \n\n\nV A woman faces \nhealth risks from \nher work inside and \noutside of the home. \nWorking long hours , \nthe ‘double work day , \ncan make her body \ntoo tired to fight \ndisease. \n\n\nV Problems with \nmental health can be \nas serious as other \nhealth problems. \n\n\n\nmental health \n\n\nWork hazards \n\nWomen face health risks every day from their work. At \nhome, lung diseases from smoke or burns from cooking fires \nare so common that they are considered the main work-related \nhealth problem for women. Diseases spread through water \nare also common, \nbecause of the \namount of time \nwomen spend \nwashing clothes, \nhauling water, or \nstanding in water \nwhile farming. \n\nMillions of \n\nwho work outside the \nhome suffer health problems \ndue to unsafe conditions in the workplace. And \nwhen they come home from their jobs, they usually continue to \nwork at home, so they end up with twice as much work. This \nleads to exhaustion and an increased risk of illness. \n\nMental health problems \n\nWomen and men have about the same risk of developing \na mental health problem. Severe depression, however, \naffects many more women than men. It often affects women \nwho are poor, who have experienced loss or violence, or whose \ncommunities have been destroyed or undergone great change. \nBut women who suffer any kind of mental health problem are \nmuch less likely than men to get help. \n\n\n\nWhere Women Have No Doctor 20 1 0 \n\n\nwww. Hesperian. i \n\n\nr \n\n\nWomen Are More at Risk for Disease and Poor Health 5 \n\n\nViolence \n\n\nViolence is often overlooked as a health problem. But \nviolence can lead to serious injuries, mental health problems, \nphysical disabilities, and even death. Rape and sexual harassment \nare a constant threat to all women. Many girls are sexually \nabused by family members or friends. Many women are \nforced to have sex or are physically abused by their partners. \nIncreasingly violent and damaging rapes and sexual assaults have \nbecome common practices during wartime. \n\n\n\nEven though these kinds of violence \nagainst women and girls happen in \nalmost all parts of the world, most \nof it is not reported, because \nthe police and others often \nblame women rather than \nmen for the problem. The \nmen causing the violence \nare rarely punished. \n\n\n>- When women \nsuffer violence, it is \nusually from men \nthey know. But most \nviolence against \nwomen is not \nreported, and men \nare rarely punished. \n\n\n\nviolence, 3 1 3 \n\nrape and sexual \nassault, 327 \n\n\nHow women are forced into a life of poor health \n\n\nAlthough not all women suffer \nfrom the health problems \ndescribed above, most \nwill suffer from 3 of \nthem: poor nutrition, \npregnancies that are \ntoo close together, \nand overwork. Each of \nthese problems affects a \nwoman’s general health \nand wears her body out, \nmaking her more likely to \nget sick. Pregnancy also \nmakes certain medical \nproblems — like malaria, \nhepatitis, diabetes, and \nanemia — worse, just as they \nmake pregnancy more difficult. \n\nAll these things make a woman \nmuch more likely to suffer from \ngeneral poor health than a man. \n\n\n\n\n\n:/Wr^ \nAAvs-i) 'Ur/xlyJv \n\n\n\nToo-r. \n\nHEALTH \n\n\nWhere Women Have No Doctor 2010 \n\n\n6 Women’s Health Is a Community Issue \n\n\nCauses of \nPoor Health \nin Women \n\n\nIt is easy to name the direct causes of most of women’s health \nproblems. For example, we can say that STIs are caused by \ndifferent germs, poor nutrition comes from not eating enough \ngood food, and problems during pregnancy are often caused \nby a lack of prenatal (before birth) care. But beneath these \ndirect causes are 2 root causes — poverty and the low status of \nwomen — that contribute to many of women’s health problems. \n\n\nPoverty \n\nTwo out of three women around the world are poor. Women are not only \nmuch more likely than men to be poor, but are most often among the poorest of \nthe poor. \n\nMillions of women are caught in a cycle of poverty that begins even before \nthey are born. Babies born to women who did not get enough to eat during \npregnancy are likely to be small at birth and to develop slowly. In poor families, \ngirls are less likely than their brothers to get enough to eat, causing their growth \nto be further stunted. Girls are often given little or no education, so as women \nthey must work at unskilled jobs and receive less wages than men (even if they \ndo the same kind of work). At home, their daily work is unpaid. Exhaustion, \npoor nutrition, and lack of good care during pregnancy place the woman and her \nchildren at risk for poor health. \n\nPoverty forces her to live under conditions that can cause many physical and \nmental health problems. For example, poor women often: \n\n• live in bad housing, with little or no sanitation or \n\nclean water. n \n\n• do not have enough \ngood food, and must \nspend precious time \nand energy looking for \nfood they can afford. \n\n• are forced to accept \ndangerous work, or to \nwork very long hours. \n\n• cannot use medical care, \neven if it is free, because they \ncannot afford time off work or away from their families. \n\n• are so busy struggling to survive that they have little time or energy to take \ncare of their own needs, to plan for a better future, or to learn new skills. \n\n• are blamed for their poverty and made to feel less important than those with \nmore money. \n\nPoverty often forces women into relationships in which they must depend on \nmen for survival. If a woman depends on a man for her — or her children’s — \nsupport, she may have to do things to keep him happy that are dangerous to \nher health. For example, she may allow him to be violent or to have unsafe sex \nbecause she fears losing his economic support. \n\n\n\nwww.ll6Sp6riRn.orc \n\n\nWhere Women Have No Doctor 20 1 0 \n\n\nCauses of Poor Health in Women 7 \n\n\nLOW STATUS OF WOMEN \n\nStatus is the importance that a person has in \nthe family and community. Status affects how \na woman is treated, how she values herself, the \nkinds of activities she is allowed to do, and the \nkinds of decisions she is allowed to make. In most \ncommunities in the world, women have lower \nstatus than men. Women’s lower status leads \nto discrimination — -that is, being treated poorly or denied \nsomething simply because they are women. Discrimination \nmay take different forms in different communities, but it always \naffects a woman’s health. \n\nWanting sons rather than daughters. Many families value boys \nmore than girls because boys can contribute more to the family’s \nwealth, support their parents in old age, perform ceremonies \nafter their parents die, and carry on the family name. As a \nresult, girls are often breastfed for a shorter time, are given less \nfood and medical care, and receive little or no education. \n\n\n\n\nLack of legal rights or power to make decisions. In many \ncommunities, a woman cannot own or inherit property, earn \nmoney, or get credit. If she gets divorced, she may not be \nallowed to keep her children or her belongings. Even if a \nwoman has legal rights, her community’s traditions may allow \nher little control over her life. Often a woman cannot decide \nhow the family’s money is spent or when to get health care. \n\nShe cannot travel or participate in community decisions without \nher husband’s permission. \n\nWhen women are denied power in these ways, they must \ndepend on men to survive. As a result, they cannot easily \ndemand things that contribute to good health, like family \nplanning, safer sex, enough food, health care, and freedom from \nviolence. \n\n\n>- Because so much \nof the work that \nwomen do is not \nrecognized, they often \nlack legal protection \nin the workplace. \n\n\nHaving too many children, or having children too close \ntogether. Discrimination against women can also lead them to \nget pregnant more often, because bearing children may be the \nonly way that women can gain status for themselves or their \npartners. \n\nUnder all these conditions, women live less healthy lives and \nget less health care. They also often accept their low status, \nbecause they have been raised to value themselves less than \nmen. They may accept poor health as their lot in life and seek \nhelp only when health problems are severe or life-threatening. \n\n\n>- Women make up \nhalf of the world’s \npopulation, but work \n2 out of every 3 \nhours worked in the \nworld, receive only a \ntenth of the world's \nincome, and own only \na hundredth of the \nworld's property. \n\n\nwww. nespcr121n.org \n\n\nWhere Women Have No Doctor 2010 \n\n\n8 Women’s Health Is a Community Issue \n\n\nThe medical system does not meet women’s needs \n\nPoverty and discrimination in the family and community not \nonly lead to more health problems for women, they also make \nthe medical system less likely to provide the services women \nneed. Government policies and the global economy may add \nto this problem. \n\nIn poor countries, many people do not have access to health \nservices of any kind. (The box below explains one reason why \nthis problem has become worse in recent years.) And because \nof discrimination against women, the little money that does \nexist will probably not be spent on women’s health needs. So \na woman may not be able to get good care even if she can \nafford to pay for it. Some reproductive health services may be \nprovided, but to meet all of her health needs, she would have \nto travel to the capital city or perhaps even leave her country. \n\nIn many countries, the skills needed to care for women are \nconsidered ‘special’ and are provided only by doctors. Yet many \nof these services could be provided at lower cost by trained \ncommunity health workers. \n\n\nDebt and poor countries \n\nSince the 1 970s, when many poor countries were pressured to borrow money from \nbanks in rich countries, huge debts have meant that governments are still struggling \nto meet the basic needs of their people. Although there has been a lot of corruption, \nmany countries have started new schools, hospitals, clinics, and other projects. \n\nBut as the banks demand that their money be paid back, the poor countries \nhave been forced to change or “adjust” their economies in ways that make life \nharder for poor people. These countries are forced to use much of the wealth \nthe people produce to pay the banks, and to change their laws to make it easier \nfor foreign companies to make money by using the poor countries’ resources and \nlabor. Basic services like water, electricity, \ncommunications and pensions have been \nsold to profit-seeking, foreign companies. \n\nAs a result, people work harder than \never but still have trouble meeting their \nbasic needs. Governments now have less \nmoney for schools, health centers, \nhospitals, and programs that help \npeople get food and fuel at a fair \nprice. The health of all poor people \nsuffers from these changes, but the / \n\nhealth of poor women and children A/1 any public health centers lack even the most \n\nsuffers most of all. basic medicines, supplies and equipment. \n\n\n\nWWW. \n\n\nnespenan.org \n\n\nWhere Women Have No Doctor 20 1 0 \n\n\nMira's Story 9 \n\n\nMira’s Story \n\n\n\nWhen Mira was a little girl, she dreamed of living in a big \nhouse, with electricity and a tile floor Her husband would be \nhandsome and kind, and she would be able to do whatever \nshe wished. But Mira’s family was poor, and she was the \nyoungest of four daughters. Sometimes, when her father was \n\n\ndrinking, he would beat her mother; and weep at his misfortune \nof having so many girls. \n\nWhen Mira was 1 4, and old enough to be married, she cried when she \nlearned her dreams would never come true. It was already arranged: Mira f \nwould marry a man whom her father had chosen. He had some land, and / \n\nMira’s father thought the family would benefit from their marriage. Mira \nhad no choice in the matter \n\nWith the birth of Mira’s second child — a son — her husband stopped \ninsisting on sex so often. Mira was very glad for that. Although he did not hurt her, \nhe had warts all over his penis that disgusted her Over the next 20 years, she had \n6 more children, including a little girl who died at age 3, and a boy who died at birth. \n\nOne day, Mira was using the latrine and she noticed a bloody discharge coming \nfrom her vagina when it wasn’t time for her monthly bleeding. She had never had a \nhealth exam, but now Mira asked her husband if she might see a health worker. He \nreplied that he didn’t trust doctors, and besides, he didn’t have the money to spend \nevery time she felt worried about something. \n\nMira was 40 when she began to suffer constant pain low in her belly. The pain \nworried her, but she didn’t know who to talk to about it. Some months later, Mira \nfinally decided she had to go against her husband’s wishes and get medical help. She \nwas frightened for her life, and borrowed some money from a friend. \n\nAt the health center; Mira got some medicine for the vaginal discharge, although \nthe health worker did not examine her first. Mira returned home that night, \nexhausted and upset that she had defied her husband and spent her friend’s savings. \nAs weeks passed, Mira’s health continued to worsen, and she became discouraged, \nrealizing that something was still wrong. \n\nFinally, Mira became so weak that her husband believed she really was ill, and they \nbegged a ride to a hospital in the big city far away. After waiting several days, Mira \nwas seen at the hospital. Finally, she was told that she had advanced cancer of the \n\n\n\ncervix. The doctor said they could remove her womb, but \nthat the cancer had already spread. The one treatment \nk that might save her life was available only in another \n\n\npart of the country, and was very expensive. The \ndoctor asked, “Why didn’t you get regular Pap \ntests? If we had found this earlier, we could \n\n\nhave treated it easily.” But it was too late \nfor that. Mira went home, and in less than \n2 months, she died. \n\n\nWWW. \n\n\n\nWhere Women Have No Doctor 2010 \n\n\n\n10 Women’s Health Is a Community Issue \n\n\nWhy did Mira die? \n\n\nHere are some common answers to this question: \n\n\nA doctor may say... \n\n\nMira died of \nadvanced cervical \ncancer because \nshe did not get \ntreatment earlier. \n\n\n\nMira died because \nshe didn't know \nshe should have a \nvisual inspection \nof the cervix or a \nPap test done. \n\n\n\nOr a health worker.., \n\n\nMira died because her \nhusband exposed her to \ngenital warts and other \nSTIs. These put her at high \nrisk for developing cancer \nof the cervix. \n\n\n\n> For more \ninformation about \ncancer of the cervix, \nsee page 377. \n\n\nAll these answers are correct. Women who start having sex \nat a young age and are exposed to genital warts are at a greater \nrisk for cancer of the cervix. And if the cancer is found early \n(by having a visual inspection of the cervix or a Pap test), it can \nalmost always be cured. \n\nYet these answers show a very limited understanding of the \nproblem. Each of them blames one person — either Mira or \nher husband — and goes no further. Mira was at greater risk of \ndying of cervical cancer because she was a poor woman, living \nin a poor country. \n\n\n\nWWW. \n\n\nnespenan. \n\n\nrc \n\n\nWhere Women Have No Doctor 2010 \n\n\nMira's Story | | \n\n\nHow poverty and the low status of women worked \ntogether to cause Mira’s death \n\nMira and her family were poor; so she was forced to marry \nand start having sex when she was very young. As a woman, \nshe lacked power in her relationship with her husband. She had \nno control over when and how many children to have, or over \nher husband’s relationships with other women. Her family’s \npoverty meant that she suffered from poor nutrition her whole \nlife, which weakened her body and left her more at risk for \ndisease. \n\nAlthough Mira’s community lacked health services, the \nnearest health center did have some women’s health services, \nlike family planning and information about preventing HIV. But \nthe health workers had no information or training about other \nwomen's health problems, even such serious ones as cancer \nof the cervix. They did not know how to do a pelvic exam (to \nlook at the vagina, cervix and other reproductive parts) or a \nPap test. So even if Mira had gone for medical care sooner, the \nhealth worker would not have been able to help her \n\nAs a result, Mira had to travel a long distance at great cost to \nsee a doctor who could tell her what was wrong. By that time \nit was too late. \n\nFinally, Mira’s country was poor, with little money to \nspend on health care. Like the governments of many poor \ncountries, her government chose to focus on other important \nhealth services, but not on women’s health. What money her \ngovernment did spend on women’s health went to expensive \nhospitals in the big city instead of community health programs \nthat women like Mira can get to. This meant that the services \nto find and treat cervical cancer — and many other women's \nhealth problems — early were not available. \n\nPoverty and the low status of women worked against Mira \nat all 3 levels — in her family, in her community, and in her \ncountry — to create the health problem that caused her death. \n\n\n>- You can explore \nthe root causes of \nMira’s death or other \nhealth problems by \nusing the excercise \ncalled \"But Why?\" on \npage 26 . \n\n\n\nthat led to Mira’s death. They are the same links \nthat cause many of women's health problems. \n\n\n| 1 * iifjU — \n\nwww.il6Sp6ridn.org \n\n\nWhere Women Have No Doctor 20 1 0 \n\n\n1 2 Women’s Health Is a Community Issue \n\n\nWorking for \nChange \n\n\n> For other ideas of \nhow your partner can \nhelp , see page 1 4. \n\n\nIt does not have to be this way \n\nThe way societies are organized forces most women into \nlives of poverty and poor health. But societies could be \norganized in a way that favors health instead of disease. \n\nSince the causes of poor health exist at the family, community, \nand national levels, changes to improve women’s health must \nhappen at each of these different levels. \n\nWorking for change in your family \n\nYou can improve your health by learning about women’s \nhealth problems and by making changes in your own life and in \nyour family. Talk with your partner about what you each need to \nhave better health, including practicing safer sex and sharing the \nworkload fairly. You can also work to improve the health and \nfuture of your children. Here are some ideas: \n\n\nRaising our children for a better world \n\nHow we raise our children, from the moment they are born, will determine much \nof what they believe and how they act as adults. \n\nAs mothers, we teach our children every day of their lives: \n\n• When we feed our husbands and sons first, we teach our children that girls' and \nwomen’s hunger is less important. \n\n• When we send only our sons to school, we teach our children that girls do not \ndeserve the opportunities that come from an education. \n\n• When we teach our sons that it is manly to be violent, we raise violent men. \n\n• When we do not speak out against violence in our neighbor’s house, we teach \nour sons that it is acceptable for a man to beat his wife and children. \n\n\nAs mothers, we have the power to change who our children will become: \n\n• We can teach our sons to be kind and compassionate, so they will grow up to \nbe kind and compassionate husbands, fathers, and brothers. \n\n• We can teach our daughters to value themselves, so they will \nexpect the same from others. \n\nWe can teach our sons to share \nand take pride in household \nwork, so their sisters, wives and \ndaughters do not suffer the \nburden of overwork. \n\nWe can teach our daughters to be more \nindependent by finishing school or learning a skill. \n\nWe can teach our sons to respect all women and to \nbe responsible sexual partners. \n\n\n\n\nWe can raise our children for a better world. \n\n\nWhere Women Have No Doctor 20 1 0 \n\n\nwww.ll6Sp6riBn.org \n\n\nWorking for Change | 3 \n\n\nWorking for change in your community \n\nYou can improve your health and the health of other women \nin your community by sharing this book and by talking with \nthem about women’s health problems. \n\nTalking with others can be hard. Women often feel shame \n(for example, when talking about parts of the body) or fear \nabout what others will think. Yet talking with others is the only \nway to learn more about health problems and to discover their \ncauses. Often you will find that other women are worried \nabout the same things, and want to discuss them. \n\nGet a small group of women together to talk about health \nproblems in your community. Try inviting women who are \nfriends of your friends, neighbors, or women you work with. \nOnce you have identified a health problem that many women \nshare, it is often helpful to meet again and invite others to \ndiscuss it and learn more. When you meet, think about the \nroot causes of the health problem, and plan the changes you \ncan make in your families and community. For ways to work \nwith a group to plan and carry out actions for change, see \npages 26 to 3 I . \n\n\nV Because social \nconditions affect \nthem differently, \nwomen and men \nmay need to find \ndifferent solutions \nfor the same health \nproblems. \n\n\nMy back hurts so much these \ndays from having to carry \nwater all the way up the hill to \nmy house. The health worker \nsays I shouldn't carry heavy \nloads when Tm pregnant— \nthat's how Mari lost her \npregnancy. But how else would \n\n\nIt isn't a problem just \nfor women who are \npregnant! My back \nis always hurting \ntoo. I finally got my \nhusband to start \nhelping me carry \nwater every day. \n\n\n\nwww.n6Sp6ridn.org \n\n\nI was visiting my sister \nthe other day, and where \nshe lives they got the city \nto put in some water taps \nclose to the houses. It's \ngreat, she doesn't have \nto carry water very far at \nall. Everyone loves it. \n\n\nMaybe we could get enough \npeople together to convince \nthe city to do the same thing \nfor us. But we would need a \nlot of people. And we would \nneed to know who to talk to, \nand decide where we wanted \nthe water taps. \n\n\nWell, we could talk \nwith Jose. He's \na teacher and \neveryone respects \nhim. He could \n\n\nof women, you con leorn more \nabout 0 health problem and \nwhat can be done to solve it. \n\n\nWhere Women Have No Doctor 2010 \n\n\n\n14 Women’s Health Is a Community Issue \n\n\nThink about involving men as well as women in \ndiscussions about women’s health. It may seem difficult \nto talk about women’s health problems with men, \nbecause this kind of talk is considered taboo, or \n‘women's secrets’. But since men are often in positions \nof power, their help can be very important. Look for \nmen who are supportive of women, are good role \nmodels for boys, or who treat women as their equals. \n\n\nHOW MEN CAN HELP \n\nAny man can help improve women’s health by: \n\n• raising his children to respect women, and treating boys and girls as equals. \n\n• asking women what they think, and listening to them. A man can listen to his \npartner's and daughters’ concerns and needs, and see if together they can find a \nway to meet the needs of everyone in the family. \n\n• talking with his partner about how many children they each want to have, and \nthen taking equal responsibility for family planning. \n\n• encouraging his partner to go for regular health exams, and helping find the \nmoney and time for her to go. \n\n• taking turns caring for the children and doing house work. \n\n• being faithful to his partner or, if he cannot, being honest with her and practicing \nsafer sex when he is not with her. If a man ever gets an STI, he should tell all of \nhis sexual partners right away, so everyone can get treatment. \n\n• encouraging his partner to take a fair share of the food that there is to eat — \neven if nobody is getting very much. \n\n• encouraging all of his children to stay in school as long as they can. The longer \nthey can stay in school, the more choices they will have as adults, and the better \ntheir health will be. \n\nA man can also set a good example in his community by: \n\n• encouraging women in his community to come to meetings, and making sure \nthat they have a chance to speak. Or by encouraging women to hold their \nown, separate meetings, where men will not speak. \n\n• encouraging women to become involved in planning and running community \nprojects. \n\n• encouraging others to limit their use of alcohol and drugs — -these contribute \nnothing to the community and waste money and energy. Try to plan \ncelebrations that do not involve alcohol. \n\n• not tolerating any kind of violence against women. \n\n• teaching children how to care for their physical, mental, and sexual health and \nhowto prevent common illnesses. \n\n• working to change the image that a strong man is one who has sex with many \n\nwomen. A strong man is a strong partner. \n\n\n\nWWW. \n\n\nnespenan.org \n\n\nWhere Women Have No Doctor 2010 \n\n\nWorking for Change | 5 \n\n\nHere are some other activities that can help improve health in a \ncommunity: \n\n• Share information. Find ways to spread information about \nthe common health problems in your community, so that \neveryone will know about them. \n\n• Form support groups. Women who share common \nproblems — such as women who have survived rape or \nabuse, breastfeeding mothers, women with disabilities, or \nsex workers — can form groups to support each other and \nwork together to overcome their problems. \n\n\nIn Zimbabwe, the Musasa Project was created to help women who suffered from \nviolence, particularly violence in the home and sexual assault. Musasa found that \nwomen who were beaten by their partners were not protected by the law. Many \npeople said that men should have power over women because that was the way it \nhad always been, or because it was part of their community’s beliefs. These people \nalso said that regular beatings reminded women of their ‘place’. \n\nMusasa’s goal is to change this attitude \nthrough public education and by counseling \nthose who have survived violence. In \nthis way, women, men, teachers, students, \npolice, and health workers are learning \nthat violence is an abuse of power. Musasa \nplans to set up a house where women and \nchildren can stay when they are in danger. \n\n\n\n\nstarting a support \ngroup \n\n\n• Work toward more independence. Projects that help \nwomen earn money and improve their working conditions \nalso help women start to make their own decisions and \ngain self-esteem. \n\n\nIn a tiny Mayan village in \nGuatemala, a group of women \nformed a weaving group. They \nsold their weavings through a \ncooperative store for women’s \ncrafts in the capital city. The \nwomen now earn more income \nthan most of the men in their \narea. As a result, women have \ngained new status in their families \nand communities and have more \nopportunities in their lives. \n\n\n\nwww. nespenan.org \n\n\nWhere Women Have No Doctor 2010 \n\n\n\n\n\n16 Women’s Health Is a Community Issue \n\n\n\ncommunity sanitation \n\n\n• Develop community projects. For example, try to find \nways for every family in the community to get enough \nto eat, or to improve community sanitation and access to \nclean water. \n\n\nThe Green Belt movement in Kenya has involved many women in planting and \nprotecting trees, which prevent soil erosion and provide fuel. The women’s success \nat protecting the environment and providing fuel for their families has built their \nconfidence and helped them earn a living. \n\nAs one Green Belt member said, “Our forests were \nrunning out because of our constant need for firewood. \n\nWe meet weekly to collect seeds, to do potting \nand fencing, and tend the trees in \nour nursery. We also talk to \ngroups and schools about the \nenvironment. In this way, we \nare both helping ourselves and \nbettering the environment.” \n\n\n\nMany women’s \nhealth problems \ncould be \nprevented or \ntreated early \nif more health \nworkers were \ntrained to care \nfor women’s \nhealth. \n\n\n\nSimple and low-cost community efforts can make a difference \n\nWhen you first look at a problem, it often seems very hard \nto make changes. But, in fact, communities can make many \nimprovements that do not cost too much. For example, here \nare some of the suggestions this book contains for preventing or \nhelping solve women’s health problems: \n\n• Start a community stove project. Women often suffer \nfrom lung infections, burns, and back problems. Low-cost \ncook stoves that are safer, use less fuel, and produce less \nsmoke can prevent many of these problems (see page 394). \n\n• Establish an emergency transportation system. Many \nwomen die from complications of pregnancy, childbirth, \nand unsafe abortion. These deaths could often be \nprevented by reaching medical care quickly (see page 101). \n\n• Low-cost cancer screening can prevent many women from \ndying from cervical and breast cancer. Cancers are much \neasier to treat if they are found early (see page 375). \n\n• Make family planning services and good prenatal care \naccessible to all women. Doing so can prevent many deaths \ndue to complications of pregnancy, childbirth and unsafe \nabortion. \n\n• Train health workers to care for women’s health. They \nshould be trained in pelvic exams, Pap tests and visual \ninspection, manual vacuum aspiration (MVA), breast exams, \nand counseling. They should also learn howto use medicines \nfor women’s health. \n\n\nWhere Women Flave No Doctor 20 1 0 \n\n\nnespenan.org \n\n\n\n\nWorking for Change | 7 \n\n\nWorking for change in your country \n\nYou can improve your health, and the health of many other \nwomen in your country, by working together with other groups \nin different parts of the country. By working together, you can \nmake important changes in the way your government treats \nwomen and women’s health. For example, community groups \ncan pressure the government to punish men who rape or \nabuse women, or to make safe abortion available. Or you can \nget laws passed to allow women to own or inherit property — \nso that women are not forced to depend on men. \n\n\nMany women and men are struggling to get their governments to: \n\n• equip rural clinics and train health workers to treat common women’s health \nproblems. This way, rural women will not be forced to go to urban hospitals \nfor care. \n\n• pay for people — especially women — from poor areas to get health training. \nThat way there will not be such a shortage of trained health workers. \n\n• keep companies from damaging the environment and advertising products that \nharm people’s health. \n\n• force companies to \nprovide fair working \nconditions and \ndecent wages for \nwomen and men. \n\n• make it easier for \npeople to grow \nfood for their \ncommunities, not \nfor export. \n\n• distribute unused \nland to those who \nhave been forced \nfrom their land. \n\n\n\nGaining power over our own health \n\nJust as ‘women’s health’ means more than maternal health, it \nalso means more than access to health care. To be truly healthy, \nwomen need the chance to make the decisions necessary \nfor good health. And they need access to a fair share of the \nresources in their communities and in the world. \n\nBy joining other women and men in the struggle for health, \nwe can demand the chance to live healthy, full, and joyful lives — \nfree of disease, pain, and fear. \n\n* I lTtA.4 Slit «r \n\n\nWWW. \n\n\nWhere Women Have No Doctor 20 1 0 \n\n\n\n18 Solving Health Problems \n\n\nChapter 2 \n\nIn this chapter: \n\n\nJuanita’s Story 20 \n\nWhat is the problem? 20 \n\nSome illnesses are hard to tell apart 2 1 \n\nWhat is causing the problem? 2 1 \n\nWhat Is the Best Treatment 22 \n\nIs a treatment helpful or harmful? 22 \n\nRisks and benefits 24 \n\nWorking for Change 26 \n\nLooking for the root causes of health problems 26 \n\nOrganizing to solve community health problems 28 \n\nTo the Health Worker 30 \n\nHelping women help themselves 30 \n\n\nWWW. \n\n\nHesperian. \n\n\nr \n\n\nWhere Women Have No Doctor 2010 \n\n\n19 \n\n\n\nWhenever a woman has signs of a health problem, she needs \ninformation in order to solve it. She needs to know what the \nproblem is, its cause, what can be done to treat it, and how to \nprevent it from happening again. \n\nIn this chapter we tell the story of one woman, Juanita, and \nhow she solved her health problem. Although the details apply \nonly to Juanita, the way she thinks about her problem and works \nto solve it can apply to all health problems. You can use this \nmethod to solve a health problem yourself or to make decisions \nabout getting good medical care. \n\nJuanita discovered that a lasting solution to her health \nproblem involved looking beyond her own situation. She also \nhad to identify the root causes of the problem in her community \nand country, and work to change them. Like Juanita, you and \nyour community can use this method to identify all the causes \nof women’s poor health — and to plan ways to make your \ncommunity a healthier place for women. \n\n\n>- Some problems \nmust be treated with \nskilled medical care. \nBut most health \nproblems can be \ntreated at home or \ncan be prevented by \nhealthy living. \n\n\nwww. nespcr121n.org \n\n\nWhere Women Have No Doctor 2010 \n\n\n) \n\n\n20 Solving Health Problems \n\n\nJuanita’s \n\nStory \n\n\n\n\n\n\n\nStep I : Start with \ndoubt. This means \nadmitting you do not \nknow the answer yet. \n\n\nJuanita lives in a small village in the mountains of western \nHonduras where she and her husband grow corn on a small \nplot of land. Their land does not produce enough to feed their \n3 children, so several times each year Juanita’s husband, Raul, \ngoes off to the coast with other men from the village to work \non the banana plantations. \n\nAbout 3 weeks after the last time her \nhusband returned home from the coast, Juanita \nbegan to notice more discharge than usual from \nher vagina. Then she started having pain when \npassing urine. Juanita knew that something was \nwrong, but she had no idea what it was. \n\nJuanita decided to ask her friend Suyapa for \nhelp. Suyapa suggested drinking teas made from \ncorn silk, because this had helped her when she \nhad had pain passing urine. So Juanita tried the \nteas — but the pain and discharge did not go \naway. Suyapa then recommended the remedy \nher friend Marfa del Carmen had used for pains \nafter childbirth. The local midwife had given Marfa a cotton \ncloth filled with plant medicines to wrap around her belly. When \nJuanita tried the remedy and it didn't work, she thought putting \nthe medicines inside her vagina might be better. But nothing \nhelped, and her signs kept on bothering her. \n\nFinally Juanita decided to go see the health worker, Don \nPedro. She felt shy about having a man examine her, but by this \ntime she was scared that something serious was wrong. \n\nWhat is the problem? \n\nDon Pedro told Juanita that in order to help her; he \nneeded to learn as much about the illness as possible. \n\nSo he asked Juanita these questions: \n\n\nStep 2: Find out as \nmuch as possible about \nthe problem. Ask \nquestions like these: \n\n\n\n\n\nWhen did you first notice \nthe problem? \n\nWhat signs made you suspect \nthat something was wrong? \n\nHow often do you have these \nsigns? What are they like? \n\nHave you ever had these signs \nbefore , or has anyone in your \nfamily or community had them \nbefore? \n\nDoes anything make the signs \nbetter or worse? \n\n\n\nWhere Women Have No Doctor 2010 \n\n\nwww. nesperiaii.orcj \n\n\n\nJuanita’s Story 21 \n\n\nSome illnesses are hard to tell apart \n\nAfter listening carefully to Juanita describe her pain and \ndischarge, Don Pedro explained that signs often tell us the \ngeneral kind of health problem someone has. But sometimes \nseveral different illnesses can cause the same signs. For \nexample, a change in the amount, color, or smell of a \nwoman’s vaginal discharge could be caused by: \n\n• a sexually transmitted infection (STI). \n\n• an infection of the vagina that is not an STI. \n\n• pelvic inflammatory disease (PID), which is an infection \nof the womb and tubes, often caused by an STI. \n\n• cancer of the cervix. \n\n\nStep 3 :Think about all \nthe different illnesses \nthat could be causing \nthe signs. \n\n\nTo get a better idea about which of these problems was \ncausing Juanita’s signs, Don Pedro needed to know whether \nJuanita and her husband used condoms, and whether either \nof them had had other sex partners. Juanita admitted that \nshe suspects her husband has sex with other women, since \nhe is gone for months at a time to work. But they had never \ndiscussed it, so she did not know for sure. The last time her \nhusband came home, however; he had complained of some \npain when passing urine. He blamed it on the foods he ate \nat the coast. \n\n\nStep 4: Look for clues that \ncan tell you which answer \nis most likely. \n\n\nWith this added information, Don Pedro said he \nsuspected Juanita had an STI, probably gonorrhea or \nchlamydia. Because it is difficult to tell these infections \napart, it is better to treat both of them. \n\n\nStep 5: Decide which \nanswer is probably \nthe right one. \n\n\nWhat is causing the problem? \n\nInfectious diseases are those that are spread from one person to another. They \ncan be spread through touching infected people or objects, or through the air or \nwater. The germs Don Pedro thinks are causing Juanita’s illness are spread through \nsexual contact. But not all diseases spread from person to person. \n\nNon-infectious diseases (not spread between people), may be caused by: \n\n• something that goes wrong in the body, such as weak bones from aging. \n\n• something that harms the body from the outside, such as lung problems from \nbreathing a lot of dust or smoke. \n\n• something the body lacks, such as enough good food. \n\nBut illnesses rarely have just one cause. (To learn more about identifying other \ncauses, see page 26.) Different things contribute to whether a person is healthy \nor sick, including a person’s beliefs and cultural traditions, conditions in the home \nand surrounding environment, and the ways in which land, wealth and power are \ndistributed. \n\n\nwww. nespenan.org \n\n\nWhere Women Have No Doctor 2010 \n\n\n\n\n\n22 Solving Health Problems \n\n\nWhat Is \nthe Best \nTreatment? \n\n\nIS A TREATMENT HELPFUL OR HARMFUL? \n\nAlthough Don Pedro was certain that medicines would solve \nthe problem, Juanita wanted more information before deciding \non a treatment. She knew, for example, that home remedies \nhad often helped her mother and grandmother when they \nwere ill. Why, then, did the remedies she had tried fail to work? \nHere is Don Pedro's explanation: \n\n\n\nEvery community has developed \\ \nremedies for solving health \nproblems. Home remedies and \nmodern medicine can both be \nhelpful if practiced carefully and \ncorrectly. But remember that \nboth home remedies and modern \nmedicines can be helpful, can be \nharmless, and can also be harmful. \n\n\n\nIn Juanita’s case, she had used all 3 kinds of remedies: \n\nCorn silk tea would have been very \nhelpful if Juanita had an infection of the \nurine system. This is because corn silk \ntea makes a person pass urine more and \nso flushes germs out of the body. But \nthese teas probably did not help Juanita \nbecause her infection was not in the \nurine system. \n\n\nWrapping plant medicines around \nthe belly is a harmless remedy. \n\nIt will not make a health problem \nworse, because the medicines \nstay outside the body, but it will \nnot help, either \n\n\n\nPutting plant medicines into the \nvagina is harmful and should \nnever be done. Plant medicines \ncan irritate the vagina and cause \ndangerous infections. \n\n\nWhere Women Have No Doctor 20 1 0 \n\n\n\nWhat Is the Best Treatment? 23 \n\n\nDon Pedro told Juanita that she could learn about a particular \ntreatment and how well it works by talking to many different \npeople who have used it. Here are some questions to ask: \n\n• Why do you use this method? \n\n• When do you use it? \n\n• How do you use it? \n\n• What happens when you use it? \n\n• How often does it help the problem? \n\n• Do things ever go wrong? \n\nThink carefully about what different people say about \ntreatments they have used. Then, when you try a remedy \nyourself, pay attention to what happens to your signs to see \nif the remedy helps you. Be careful about trying too many \nremedies at once. \n\n\nTo decide if a treatment will be helpful, harmless, or harmful, learn all you can \n\nabout it first. If you are still unsure whether a treatment is harmless or harmful, \n\nconsider these things: \n\n1. The more remedies there are for any one illness, the less likely it is that any \nof them works. \n\n2 . Foul or disgusting remedies are not likely to help — and are often harmful. \n\n3 . Remedies that use animal or human waste do no good, and often cause \ndangerous infections. Never use them. \n\n4 . The more a remedy resembles the sickness it is said to cure, the more likely \nthat its benefits come only from the power of belief. For example, a red \nplant will not necessarily stop bleeding. \n\n5 . Methods that deny people food, exercise, or rest usually make them weaker, \nnot stronger. \n\n6 . Methods that blame people for their problems usually add to their suffering \nand pain. \n\n\ntoo. \n\n\nThis helped \nMaria del \nCarmen, so it \nmay help you, \n\n\n\nWWW. \n\n\n\nWhere Women Plave No Doctor 20 1 0 \n\n\n24 Solving Health Problems \n\n\nWhen Juanita felt satisfied that modern \nmedicines were the best treatment for \nher health problem, Don Pedro gave \nJuanita some pills called doxycycline and \nciprofloxacin and told her to come back \nin a week, after she had taken them all. He \nexplained that her husband, who was away again, must be \ntreated with the medicines when he comes back, and that they \nmust begin to practice safer sex. \n\nWhen Juanita returned to see Don Pedro the next week, \nshe told him that she had taken all the pills he gave her but \nher signs had not gone away. She also said her discharge \nwas getting worse and becoming yellow in color. So Don \nPedro asked Valeria, a health worker with more training, \nfor help. \n\n\nStep 7: See if there is some \nimprovement. If there are \nno results, start over again. \n\n\nStep 6: Decide on the \nbest treatment. Always \nremember to think \nabout possible risks and \nbenefits (see below). \n\n\n\n\nValeria agreed that Juanita had an STI. But because the \nmedicines had not helped, Valeria suspected that Juanita may \nhave a form of gonorrhea that is resistant to ciprofloxacin. \nValeria explained that many resistant forms of gonorrhea \nhad come from foreign soldiers at the military base on the \ncoast, who have been infecting the local women when they \nhad sex. Valeria recommended that Juanita go to the city \nwhere she could get a more complete exam and be \ntested for gonorrhea, syphilis (another STI), and cancer. \nShe could also get newer, more effective medicines, if \nneeded. \n\n\nRisks and benefits \n\nJuanita went home to think about what to do. She would \nhave to spend most of her family’s savings to pay for a trip \nto the city and the medicine. Since she would be gone at \nleast two days (the trip is almost 6 hours each way by bus \nand walking), and her husband was still away at the coast, she \nwould also have to find someone to watch her children while \nshe was gone. \n\nJuanita was afraid that her husband would be angry if he \ncame back and found out that she had spent so much money \nto see a doctor. But she was also scared that if she did not go \nshe would get worse. Valeria told her that without treatment \nshe could pass the infection on to a new baby if she became \npregnant. With time she would probably become unable to \nhave more children, would develop severe pain in her lower \nbelly, and would have problems with her urine system and \nmonthly bleeding. Her husband could also develop many \nserious health problems. \n\n\nWhere Women Have No Doctor 20 1 0 \n\n\nwww. nesperian. or S \n\n\n\n\nWhat Is the Best Treatment? 25 \n\n\nJuanita felt so uncertain about what to do that she went \nto see Valeria again. When Juanita explained her fears, Valeria \nsuggested thinking about the problem this way: \n\n\n\nEvery treatment has risks and benefits. A risk is the chance \nthat something may cause harm. A benefit is the good that \nsomething may bring. The best choice is to do something that \nwill cause the greatest benefit and the smallest risk. \n\nIt may help to think about scales you use to weigh food \nin the market. Some things weigh more than others, and \nmany small things can weigh more than one big thing. The \nsame is true for risks and benefits. If the risks ‘weigh’ more \nthan the benefits, then the action is not worth doing. \n\n\n\nSo Juanita went to the city for treatment, where the doctors \nsaid it was true that she had gonorrhea and probably chlamydia, \nbut no signs of other STIs or \nproblems. They explained that \nthe medicine she had taken no longer \nworks in her country. They gave Juanita a \nnewer medicine for both her and her husband. \n\nwww.n6Sp6ridn.org \n\n\nWhere Women Have No Doctor 20 1 0 \n\n\n26 Solving Health Problems \n\n\nWorking for \nChange \n\n\nWhen Juanita had taken the medicine and was feeling better, \nit was tempting to think that her health problem had been \nsolved. But she knew this was not true. When her husband \nreturned from the coast, she would get infected again if he did \nnot take the medicine and use condoms. She discussed the \nproblem with Suyapa and other women whose husbands work \nat the coast, and together they decided to ask Valeria for advice. \n\nLooking for the root causes of health \n\nPROBLEMS \n\n\nValeria agreed that Juanita’s health problem was not yet \nsolved, because many of the conditions that created the \nproblem still existed. She suggested playing a game called \n“But why. . . . ?” to help everyone identify all the conditions \nthat created the problem. \n\nValeria gathered the women in a circle, and asked them to try \nand answer her questions: \n\n\nStep 8: Look for the root \ncauses of the problem. \n\n\n\n\nWhy did Juanita get sick? \n\nBUT WHY did she get \ngonorrhea and chlamydia? \n\n\nQ: BUT WHY did her husband \nhave gonorrhea and \nchlamydia? \n\nQ: BUT WHY did he have \nsex with other people? \n\n\nQ: BUT WHY was he \naway from his \nwife for so long? \n\n\n\nFrom gonorrhea and chlamydia. \n\nBecause she was infected by her husband. \n\nBecause he had sex with other people. \n\n\n\nA: Because men are taught that they do not \n\nneed to control their desire , and he was \naway from his wife for a long time. \n\nA: Because he does not have enough land to \n\nfeed his family and must work on the coast \nfor months at a time. \n\n\nQ: BUT WHY does he \nhave so little land? \n\n\nQ: Why else did \n\nJuanita get \ninfected? \n\n\nBUT WHY \nwon't \nJuanita's \nhusband use \ncondoms? \n\n\nBecause most of the land is owned by big \nlandowners. (A long discussion follows \nfrom this answer.) \n\n\nBecause her \nhusband won't use \ncondoms. \n\n\n\n\nAnd so on. \n\n\nWhere Women Have No Doctor 2010 \n\n\nwww. nesperian.org \n\n\n\nWorking for Change 27 \n\n\nWhen the women had named a long list of causes, \n\nValeria suggested putting the causes in groups. This way \nit is easier to see the different kinds of conditions that \ncause health problems: \n\nPhysical causes: germs or parasites, or something that \ngoes wrong in the body or that the body lacks \n\nEnvironmental causes: conditions in the physical surroundings \nthat harm the body, such as cooking smoke, lack of clean water, \nor crowded living conditions \n\nSocial causes: the way people relate to or treat each other, \nincluding their attitudes, customs, and beliefs \n\nPolitical and economic causes: causes having to do with \npower — who has control and how — and money, land, and \nresources — who has them and who does not \n\nWhen the women put the causes of Juanita’s problem into \nthese groups, they came up with the following list: \n\n\nStep 9: It may help to \ngroup the causes together \nto think about what can \nbe done to address them. \n\n\nThis is a \nnice list, \nbut what \ncan we do \nabout these \nthings? \n\n\n\n^PHYS]CAL_^ \n\n. gonorrhea ijerms \n\n° d co 3 - r es ista rit \ngerms \n\n° Wtxoen's bodies <3 re \nmore susceptible \nto STIs than \nme its bodies, \nespecidy when \nweakened by \nmany pregnancies \n\n\nPolitical and \n\nJXONOMlC \n\noiown is isolated, \n50 men must \nOp away -to work \n\no -foreign soldiers \n\nat the coast \n\nSpread drug' \nresistant germ? \nopo medicines -for \n\ndrug -resistant \n\ngonorrhea or \nlaboratory for \ntesting in the \n\n\notovth is \nisolated/ -far \na way -from \n\nthe cify \n\no road is in \npoor Condition \n\n\n^OCIaL^ \n\nc-men often \nhave other \nsex partners \n\n»men won't use \ncondoms becdost, \n\"it's not manly\" \n\n• lack of educatioi \nabout 5 T|> \n\n\n\nwww. nespcri2tn.org \n\n\nWhere Women Have No Doctor 2010 \n\n\n\n28 Solving Health Problems \n\n\nOrganizing to solve community health problems \n\n\nStep 1 0: Decide which \ncauses you and your \ncommunity can change. \n\n\nThe next step, Valeria told the women, is to look at the \ndifferent causes and decide which ones you and others in \nthe community can change. Then think about what actions \nmust be done to make the changes happen. \n\n\nStep 1 1 : Decide what \nactions can make those \nchanges happen. \n\n\nAfter a lot of discussion, the women decided they would \nprobably not be able to change the fact that the men had \nto go away for work — or even keep them from having sex \nwith other women. But they thought they might get their \nhusbands to use condoms if the men knew more about \n\n\nSTIs, and if condoms were not so expensive. The actions \nthey decided to take were: \n\n\nLet's ask Don Pedro to talk \nwith the men about STIs , \nsince they respect him and \nlisten to him. \n\n\nLet's all meet together \nto practice talking with \nour husbands about \nusing condoms. \n\n\n\n\n\nI'll see if the \nhealth center \ncan give out \nfree condoms. \n\n\nOther members of the group suggested these actions: \n\n• Organize a community group to talk about health problems, \nand include STIs in the topics discussed. \n\n• While women are washing clothes at the river, talk to them \nabout STIs and how to prevent them. \n\n• Talk to their sons about STIs before they leave the village to \ngo to the coast. \n\n\nStep 1 2: Make a plan for \ncarrying out the actions. \n\n\nThe last step, said Valeria, is to make a plan to carry out \neach of these ideas for action. The plan, she said, should \nanswer each of these questions: \n\n• What are we going to do? What steps will we take? \n\n\n\nCause: Men do not use condoms* \n\nAction: Help me/i I earn about tow STjs are sp read. \n\nWl^/^ho: Don lldro Will talk do The. men about THs and \ntow condoms prevent the spread of STI s. \n\nWhen: When the men return Tom the coast \nWhat materials do we need ? Condoms. \n\nWho is responsible? Juanita will ask Don ftdro . \n\nHow will we evaluate? If men b*jin to use condoms. \n\n\nWhere Women Have No Doctor 2010 \n\n\nWhen are we going to do \nthese things? \n\nWho will we do them with? \n\n• Who is responsible \nfor making sure \nthat the plan is \ncarried out? \n\n* How will we \nknow if the plan is \nworking? \n\nwww. nesperiaii.org \n\n\n\n\n\n\nWorking for Change 29 \n\n\nTo help you use this method of solving health problems \nyourself, here is a chart with a list of all of the steps. On the \nleft are the steps and on the right are the parts of Juanita’s \nstory that go with each step. Any time you have a health \nproblem you can use this chart to help you remember this \nmethod for thinking about and taking action to solve the problem. \n\n\nThe Steps \n\nJuanita’s Story \n\n1 . Start with doubt. \n\n1. Don Pedro did not know what caused the problem. He \n\n\nneeded more information. \n\n2. Find out as much as possible \n\n2. Don Pedro asked Juanita questions to find out what could \n\nabout the problem. \n\nhave caused the problem. \n\nAsk questions. \n\n\n3. Think about all the different \n\n3. Don Pedro thought about all the illnesses with these \n\nillnesses that could be causing \n\nsigns : an STI, another kind of vaginal infection, or cancer. \n\nthe signs. \n\n\n4. Look for clues that can tell you \n\n4. Don Pedro tried to find out if an STI could have caused \n\nwhich answer is most likely. \n\nJuanita's illness. \n\n5. Decide which answer is \n\n5. Don Pedro decided Juanita probably had an STI. \n\nprobably the right one. \n\n\n6. Decide on the best treatment. \n\n6. Don Pedro did not know which germs caused Juanita's \n\n\ninfection, so he chose a treatment that works for several \n\n\nSTIs. \n\n1. If there are no results, \n\n1. Juanita took the pills but did not improve and developed \n\nstart over again. \n\nnew signs. So Don Pedro asked Valeria for help. \n\n8. Look for the root causes \n\n8. Juanita and her friends thought about the reasons why \n\nof the problem. \n\nthere was this kind of sickness in their community, \n\n\nsuch as poverty, unequal land ownership, the ways that \n\n\nmen and women were expected to act, and lack of \n\n\ninformation. \n\n9. Put the causes into groups to \n\n9. The women put the causes into physical, environmental, \n\nthink about what can be done. \n\nsocial, political, and economic groups. \n\n1 0. Decide which causes you and \n\n10. They decided to work on the “social\" causes. They think \n\nyour community can change. \n\nthey can get their partners to use condoms. \n\n1 1. Decide what actions can \n\n1 1. The women decided to practice how to talk to their \n\nmake those changes happen. \n\npartners about using condoms, to see if the health \n\n\ncenter will give out free condoms, and to ask Don Pedro \n\n\nto talk with their partners about STIs. \n\n12. Make a plan for carrying out \n\n12. They made a plan for each action they decided to take. \n\nthe actions. \n\n\n\nWhere Women Have No Doctor 2010 \n\n\n30 Solving Health Problems \n\n\nTo the \nHealth \nWorker \n\n\nV Share your \nknowledge with \nother women, other \nhealth workers, and \nwith the people who \nmake decisions in the \ncommunity. \n\n\nHelping women help themselves \n\nIn this chapter Don Pedro and Valeria played an important \nrole in helping the women in Juanita's community solve a health \nproblem. The reason that Don Pedro and Valeria were so \neffective was that they did not tell Juanita and her friends what \nto do. Rather, Don Pedro and Valeria helped the women learn \nhow to help themselves. \n\nYou, too, can help the women in your community by \nfollowing Don Pedro’s and Valeria’s example. You can: \n\n• Share your knowledge. To help themselves, women need \ninformation. Many health problems can be prevented if \npeople know how. But remember that you do not have to \nhave all of the answers to help people. Many times there \nare no easy answers. It is fine to admit when you do not \nknow something. The people you work with will be glad \nfor your honesty. \n\n\n\n• Treat women with respect. Each person should be \ntreated as someone who is capable of understanding her \nhealth problems and of making good decisions about her \ntreatment. Never blame a woman for her problem or for \npast decisions she has made. \n\n\n\nWhat we have \ndiscussed is \nprivate. I will not \ntell anyone else. \n\n\nKeep health problems \nprivate. Health problems \nshould not be discussed \nwhere others can hear. \nNever tell anyone else about \na problem someone has \nunless the person with the \nproblem says it is OK. \n\n\nRemember that listening is more important than \ngiving advice. A woman often needs someone who \nwill listen to her without judgment. By listening, you \nlet her know you care and that she is important. And \nas she gets a chance to talk, she may find that she \nalready knows some of the answers to her problem. \n\n\nWhere Women Have No Doctor 20 1 0 \n\n\ni Ait ~- \n\nwww.nesperian.org \n\n\nTo the Health Worker 3 I \n\n\nSolve problems with others, not for them. Even when \na woman’s problems are very large and cannot be solved \ncompletely, she usually has some choices she can make. As \na health worker, you can help her realize she has \nchoices, and help her find the information she \nneeds to make her own decisions. \n\nLearn from the people you help. \n\nLearning how others solve their own \nproblems can help you to help others \nbetter (and sometimes yourself, too). \n\n\n\nYou learn \nfrom those \nyou help, \n\nand \n\nthose you \nhelp learn \nfrom you. \n\n\n• Respect your people’s traditions and ideas. Modern \nscience does not have all the answers. And many modern \nmedicines come from studying plant medicines and \ntraditional ways of healing. So it is important to respect and \nuse what is good in both methods — and to realize that both \nmethods can cause harm when used in the wrong way. \n\n\n• Find out what people really want to learn about. It is easy \nto fall into the trap of giving information without finding out \nif it will be helpful. This often happens with health workers \nwho give prepared talks. But if you find out exactly what \npeople want to know, they will get knowledge that is useful \nto them. This also helps them build on their own knowledge. \n\n\nIron is found in \nhemoglobin , mioglobin } \nand different enzymes. \nDuring their fertile \nyears women need \n18 mg. daily to fill \nthe needs created \nby menstruation , \npregnancy , and \nbreastfeeding. \n\n\n\n\nA/hy do so many^\\ \nwomen bleed to \ndeath during birth? \n\nOne reason is \nanemia. Many women \ndo not eat enough \nfoods rich in iron , \nlike meat. \n\n\nBut meat \ncosts so \nmuch. What \nother ways \ncan we get \nenough \niron? \n\n\n\n• Plan with people, not for people. When you plan your \nwork, be sure to talk first with women and men in your \ncommunity. Find out how they view the problem you are \nworking to solve. Together, talk about what they think \ncauses the problem and how they would like to solve it. \nWorking together brings the best results! \n\n\nWWW. \n\n\nnespenan.org \n\n\nWhere Women Have No Doctor 2010 \n\n\n32 The Medical System \n\n\nChapter 3 \n\nIn this chapter: \n\n\nThe Medical System 34 \n\nImportant health services 34 \n\nHow to Get Better Care 36 \n\nKnow what to expect 36 \n\nBring a friend or family member 37 \n\nIf You Need to Go to the Hospital 38 \n\nWorking for Change 40 \n\n\nLore \n\n\nWhere Women Have No Doctor 2010 \n\n\nwww. Hesperian \n\n\n33 \n\n\n\nMost areas of the world have several different kinds of health \ncare. For example, there are community health workers, \nmidwives and traditional healers, doctors and nurses. They \nmight work in their own homes, in clinics or health centers, or \nin hospitals. They may be in private practice (charge money for \ntheir services), or they may be supported by the community, the \ngovernment, a church, or another organization. Sometimes they \nare well trained and equipped — and sometimes they are not. \nTogether they are called the medical system. \n\nMost people use some combination of modern medicine and \ntraditional remedies to treat their health problems themselves. \nThis is often all they need to do. But sometimes they need to \nseek care from the medical system. \n\nUnfortunately, many women have problems getting good \nhealth care. They may not have enough money to visit a clinic \nor buy medicine. Or maybe there are no health workers in \ntheir community. Even if women can go to a clinic, it can be difficult \nto talk with health workers about their problems. Sometimes \nthe clinic or hospital does not offer the services they need. \n\n\nThis chapter gives some ideas about how women can get \nbetter health advice and better medical care. It also suggests \nways that women can work together to change the medical \nsystem so that it better responds to their needs. \n\n\nWWW. \n\n\nnespenan.org \n\n\n>* When trained \npromoters give basic \nhealth care in the \ncommunity, everyone \ngets better care for \nless money. \n\n\n\nSolving Health \nProblems \n\n\nWhere Women Have No Doctor 2010 \n\n\n\n34 The Medical System \n\n\nThe Medical \nSystem \n\n\n\n\n\n\n\n\nhealth promoters \nand nurses \n\n\n\ndoctors and \nnurses \n\n\nInODOQO \n\n00 \n\nOOOQQO \n\nna \n\n1 ao non o \n\n00 \n\nonoooo \n\nan, \n\n] HOSPITAL | \n\n\nFFlfl \n\nnl \n\n\nhealth promoter \n\n\ndoctors, nurses, \nand specialists \n\n\nNot all communities have all levels of medical services. However, whatever \nthe combination of services available, women ( and any other sick people) \nwill receive better care if there are good links between them. \n\n\nImportant health services \n\nThe medical system offers many different kinds of services. \nSome services, like surgery, x-rays or ultrasounds (see page 37) \nare usually only available in hospitals. But the following services \nthat women need should be offered at low cost at the \ncommunity level: \n\n• health information so that everyone can make better \ndecisions about their health, treat health problems correctly, \nand prevent illness. \n\n• immunizations or vaccinations that can prevent many \ndiseases, including tetanus, measles, diphtheria, whooping \ncough, polio, tuberculosis, rubella, and hepatitis. \n\n• care during pregnancy (prenatal care) that can help a \nwoman find and treat problems affecting her or her unborn \nbaby before they become serious. \n\n• family planning services and supplies. Family planning can \nsave lives by helping women control how many children they \nhave, and the amount of time between births. \n\n• health exams to help find and treat problems such as weak \nblood (anemia), high blood pressure, and sexually transmitted \ninfections (STIs), including HIV. \n\nTests can give more information about possible causes of \nhealth problems. Some tests, like Pap tests for example, require \nsome training but no expensive equipment. These tests should \nbe offered at the community level. Some health centers have \nlaboratories with the equipment needed to get the results of \ndifferent tests. However, often a woman will need to go to a \nhospital to be tested. \n\nOther services are only available in hospitals. If a woman has \na serious illness, complications from childbirth or abortion, or if \nshe needs an operation, she will probably have to go to a hospital. \n\n\nWWW. \n\n\nnespenan.or \n\n\nWhere Women Have No Doctor 2010 \n\n\nThe Medical System 35 \n\n\nNo matter where you go for health care, you should be treated with respect. \n\nAll people who care for your health should do their best to provide you with: \n\n1. Access. Everyone who needs medical care should be able to have it. It \nshould not matter where you live, how much money you have, what your \nreligion is, how much status you have in the community, the color of your \nskin, your political beliefs, or what health problem you have. \n\n2. Information. You should be told about your problem and about what the \ndifferent possible treatments mean for you. The person caring for you \nshould make sure you understand what you need to do to get better, and \nhowto prevent the problem from happening again. \n\n3. Choice. You should be able to choose whether or not you are treated, \nand how. Also, you should be able to choose where to go for treatment. \n\n4. Safety. You should be given the information you need to avoid harmful \nside effects or results of treatment. You should also be told how to \nprevent dangerous health problems in the future. \n\n5. Respect. You should always be treated with respect and courtesy. \n\n6. Privacy. Things that you say to a doctor, nurse or other health care worker \nshould not be overheard by others or repeated to anyone else. Exams \nshould be given in a way that other people cannot see your body. If there \nare other people who need to be in the room, you should be told who \nthey are and why they are there. You have the right to tell them to leave if \nyou do not want them there. \n\n\n7. Comfort. You should be made as comfortable as \npossible during an exam. You should also have a \ngood place to wait and not have to wait too long. \n\n8. Follow-up care. If you need more care, you \nshould be able to go back to the same \nperson, or be given a written record of \nthe care you have received to take to \na new doctor, nurse, or health worker. \n\n\nCan I come back \nif I don’t get \nbetter soon? \n\n\n\nwww.nespcrisin.org \n\n\nWhere Women Have No Doctor 2010 \n\n\n36 The Medical System \n\n\nHow to \nGet Better \nCare \n\n\n\nrisks and benefits of \ntreatment \n\n\n>- It often helps to \nthink of the questions \nyou want to ask \nbefore you go for \nmedical care. \n\n\nT here are many decisions to make when you have a health \nproblem. One decision is whether to see a health worker, \nand what kind of health worker you think you need. If there \nis more than one way to treat a problem, you will need to \nconsider the risks and benefits of each kind of treatment \nbefore you make a decision. You will be able to make the best \ndecisions — and get the best care — if you can take an active role \nin working with your doctor, nurse, or health worker to solve \nyour health problem. \n\nKnow what to expect \n\nYou will be best able to take an active role in your health \nif you are prepared and know what to expect when you seek \nmedical care. \n\nQuestions about your health \n\nIt is best to learn as much as you can about your health \nproblem before you use the medical system. Reading this book \nmay help you understand your health problem and the possible \ncauses. For help thinking about health problems, see “Solving \nHealth Problems.” \n\nThe doctor; nurse, or health worker who sees you should \nask about the problem you are having now and about your \npast health. Try to give complete information, even if you \nfeel uncomfortable, so that the person asking the questions \ncan learn as much as possible about your health. Always tell \nabout any medication you are taking, including aspirin or family \nplanning methods. \n\nYou should also have a chance to ask any questions you \nmay have. It is very important to ask as many questions as you \nneed to make a good decision about how to solve your health \nproblem. If these questions have not already been answered, \nyou may want to ask: \n\n\n\nMany doctors and nurses \nmay not be used to giving \ngood information, or they may \nbe busy and not take the time \nto answer your questions. Be \nrespectful, but firm! They \nshould answer your questions \nuntil you understand. If \nyou do not understand, it is \nnot because you are stupid, \nbut because they are not \nexplaining well. \n\n\n\n• What will the treatment do? \nAre there any dangers? \n\n• Will I be cared? Or will the \nproblem come back? \n\n• How much will the tests and \ntreatment cost? \n\n\n\nWhere Women Have No Doctor 20 1 0 \n\n\nnespenan.org \n\n\nHow to Get Better Care 37 \n\n\nThe exam \n\nIn order to know what is wrong with you and how serious \nyour problem is, you may need an examination. Most exams \ninclude looking at, listening to, and feeling the part of your body \nwhere the problem is. For most problems you need to undress \nonly that part of your body. If you would feel more comfortable, \nask a friend or female health care worker to be in the room with \nyou during the exam. \n\n\n\npelvic exam \n\n\nTests \n\nTests can give more information about a health problem. \nMany tests are done by taking a small amount of urine, stool, or \ncoughed-up mucus and sending it to a laboratory. Or, a needle \nis used to take a small amount of blood from your finger or \narm. Other common tests include: \n\n• taking some fluid from your vagina to test for sexually \ntransmitted infections (STIs). \n\n• scraping cells from the opening of your womb ( cervix ) to \ntest for cancer. (This is called a Pap test. See page 378.) \n\n\n\nultrasound machine \n\n\n• taking tissue from a growth to test for cancer (biopsy). \n\n\n• using X-rays or ultrasound to see inside your body. X-rays \nmay be used to find broken bones, severe lung infections, \nand some cancers. Try not to be X-rayed during pregnancy. \nUltrasound can be used during pregnancy to see the baby \ninside your womb. Neither of these tests causes any pain. \n\nBefore you have any test, discuss the cost. Ask the doctor, \nnurse, or health worker to explain what he or she will learn \nfrom the test, and what would happen if the test was not done. \n\n\n>- X-rays are safe if \nthey are used properly. \nA lead apron should \nbe used to protect \nyour reproductive \norgans. \n\n\nBring a friend or family member \n\nMany people feel worried about seeking medical \ncare — even for illnesses that are not serious. And \nwhen a person is sick, it can be even harder for them \nto demand the care they need. If another person can \ngo along, it can help. \n\nA friend can: \n\n• watch the woman’s children. \n\n• help think of questions to ask, remind the woman to \nask them, and make sure they are answered. \n\n• answer questions if the woman is too sick to talk. \n\n• keep the woman company while she waits. \n\n• stay with the woman while she is being examined, \nto support her and make sure the doctor acts in a \nrespectful way. \n\n\nI am her mother. \n\nI can answer some \nof your questions. \n\n\n\nIf a woman is very sick, \nsomeone who can give \ninformation should go with her. \n\n\nWWW. \n\n\nnespenan.org \n\n\nWhere Women Have No Doctor 2010 \n\n\n38 The Medical System \n\n\nIf you need to have an operation or you have a serious illness, \nfirst find out if it is possible to be treated without having to stay \nin a hospital. If a hospital is the only place you can get the care \nyou need, this advice may help: \n\n• Bring someone with you who can help you get the \nattention you need and help you make decisions. \n\n• Different people may examine you. Each one should write \ndown what he or she did on a card that stays with you. \n\nThis way the next person who cares for you will know \nwhat has already been done. \n\n• Before anyone begins a test or treatment, it is very \nimportant to ask what they are going to do and why. This \nway you can decide if you want them to do it and help \nprevent mistakes. \n\n• Try to make friends with the staff at a hospital. They can \nhelp you get better care. \n\n• If you need to have some kind of operation, ask if it is \npossible to have an injection to stop pain only in the area \nbeing operated on (local anesthetic). It is safer and you \nwill get better more quickly than if you are given medicine \nto make you sleep during the surgery (general anesthetic). \n\n• Ask what medicines you are being given and why. \n\n• Ask for a copy of your records when you leave. \n\nCommon operations for women \n\nAn operation is sometimes the only answer to a serious health problem. \n\nDuring many operations, a doctor makes a cut in the skin in order to fix problems \ninside the body or to change the way the body functions. Here are some of the \noperations women commonly have: \n\n• Emptying the womb by either scraping or suctioning (D and C, or MVA, see \npage 244). Sometimes the lining of the womb must be removed — either \nduring or after an abortion or miscarriage, or to find the cause of abnormal \nbleeding from the vagina. \n\n• Birth by operation (cesarean section or c-section). When complications \nmake it dangerous for a woman or her baby to go through normal labor and \nbirth, a cut is made in a woman’s belly so her baby can be born. C-sections \ncan be necessary, but too often they are done for the benefit of the doctor, \nnot the woman. See the chapter on “Pregnancy.” \n\n• Sterilization. During this operation, a woman’s fallopian tubes are cut and the \nends tied. This prevents her eggs from reaching the womb, so a man’s sperm \nwill not be able to make her pregnant (see page 223). \n\n• Removing the womb (hysterectomy). A hysterectomy is a serious operation, \nso it should be done only when there is no better way to solve your health \nproblem (see page 38 1 ). Ask if you can have your ovaries left in. \n\n\nIf You Need \nto Go to the \nHospital \n\n\nOperations are \nsometimes done \nwhen they are \nnot necessary , or \nwhen a medicine \ncould have worked \njust as well. Get \nanother medical \nopinion if you are \nnot sure. \n\n\n\nWWW. \n\n\nnesperiaii.org \n\n\nWhere Women Have No Doctor 2010 \n\n\nIf You Need to Go to the Hospital 39 \n\n\nBlood transfusions \n\n\nA blood transfusion may be given in an emergency, when you have lost a lot of \nblood. It can save your life. But if the blood has not been tested properly, it can \ncarry diseases, such as hepatitis or HIV, that are spread through the blood. Avoid \nblood transfusions except in cases of life or death emergencies. \n\n\nIf you must have an operation that you know about ahead of time, see if it is \npossible to have some of your own blood taken in advance and stored at the \nhospital. Then if you need it, you will get your own blood back. If you cannot have \nyour own blood stored, ask a friend or relative to come with you to the \nhospital. Be sure she has been tested recently for hepatitis and HIV, \nand that neither she nor her partner has had a new sex partner in \nthe last 3 months. Her blood must also be tested to make sure that \nit will work in your body. \n\nIf you must receive blood from an unknown person \nand the hospital does not test its blood for HIV, there \nis a risk that you might become infected. After the \ntransfusion, protect your partner by practicing safer \nsex for 3 months and then try to get tested for HIV. \n\nFor more information, see the chapters on “HIV” and \n“Sexual Health.” \n\n\n\nAfter you have an operation \n\nBefore you leave the hospital, ask: \n\n• What should I do to keep the \ncut clean? \n\n• What should I do about pain? \n\n• How long should I rest? \n\n• When can I have sex again? (If you \nfeel too shy to ask this, perhaps \nthe doctor or health worker can \ntalk to your partner.) \n\n• Do I need to see a doctor again? \n\nIf so, when? \n\n\nEat soft, mild foods that are easy to digest. \n\n\n[})) \n\n\n\n\nY \" \n\n\n\n\n\n\n\n\n\nTo keep your lungs healthy \nand prevent pneumonia, \nmove around if you can. While \nin bed, take deep breaths and \ntry to sit up often. \n\n\nRest as much as you can. If you are at home, ask your family to \ntake care of your daily chores. A few days spent taking care of \nyourself can help you get better faster. \n\nWatch for signs of infection: yellow discharge (pus), a bad smell, \nfever, hot skin near where you were cut, or more pain. See a \nhealth worker if you have any of these signs. \n\nIf your operation was in the abdomen, try not to strain the area \nthat was cut. Press against it gently with a folded cloth, blanket, \nor pillow whenever you move or cough. \n\nwww. nespenan.org \n\n\nWhere Women Have No Doctor 2010 \n\n\n40 The Medical System \n\n\nWorking \nfor Change \n\n\nM illions of people throughout the world suffer and die from \nillnesses that could have been prevented or treated if they had \naccess to good medical care. And even where health services \ndo exist, there are many barriers that keep women, especially \npoor women, from using them. \n\nBut together, health workers and groups of women can \nchange the medical system. They can make it a resource — \nrather than a barrier — for women as they try to solve their \nhealth problems. The medical system will not change on its own, \nthough. It will change only when people demand it, and when \nthey offer creative ways to bring the health care that people \nneed within the reach of all. \n\nA good place to begin changing the medical system is by \ndiscussing the health care problems that affect people in your \ncommunity — including lack of access to good care — with other \nwomen and men. \n\n\nI live very far away. \n\nIf there were a health \nworker close by, it would \nsave my family the \n2 weeks wages I spend \nevery time I have to come. \n\n\n\nThese city^\\ \ndoctors look A \ndown on us. \n\nI would feel \nbetter if \npeople from \nthe village \nhelped run \nthe clinic. \n\n\nI wish they \nexplained what \nwas wrong. This \nis the 4th time \nthis year Tve \nhad pain when I \npassed urine. Why \ndoes this keep \nhappening? \n\n\nI wish they\\ \ncould give \nus Pap \ntests here. \nTve heard \nthey are \nimportant , \nbut I can't \nafford to go \nto the city. J \n\n\n(iwishthey didn't run out of \nfamily planning supplies. I got \npregnant last year because the \nI clinic ran out , and I can't afford \nto buy a lot all at once when they \nV do have them. \n\n\nn want there to be \n\nseparate rooms \nwhere we could be \nexamined without \neveryone listening. \n\n\n\nr ; ^ \n\n| I would like the clinic \nI to be open in the \n\nevenings , after I have \n( finished my work. \n\n\nI don't like \nhaving a man \nexamine me. I \nwish there were \nwomen health \nworkers. \n\n\n\nWhere Women Have No Doctor 2010 \n\n\nThere is always \nsuch a long wait. \nIf someone asked \nright away what \neach person \nneeded then the \nreally sick people \ncould be treated \nsooner. \n\n\nwww. nesperiaii.org \n\n\nWorking for Change 4 1 \n\n\nWomen can also work together to: \n\n• help every member of the community to learn about \nwomen’s health problems. For example, you can organize \na campaign to explain how important it is that women get \ngood prenatal care. If women and their families know about \nwomen’s health needs, women will be more likely to use \nthe health services that already exist.They will also be more \nlikely to demand that new ones — such as better treatment \nand screening for cervical and breast cancer — be made \navailable. \n\n\n\n• see how existing health resources can be improved. For \nexample, if there is already a community midwife, how can \nshe get training in new skills? \n\n• find new ways to make health care available. It is important \nto think about what health services you want to have, and \nnot just what you have now. So, if there is no health worker \nnow, how can one be trained and supported? If there is \nalready a clinic, could it offer new services like workshops \nor counseling ? \n\n• share the knowledge each woman has about health care. \nWomen already do much of the ‘health work’ in the \ncommunity. For example, it is usually women who care for \nthe sick, teach children to stay healthy, prepare food, keep \nthe home and community clean and safe, and help other \nwomen have babies. Through this work, they have learned \nmany skills that they can use to care for each other and \nevery member of the community. \n\n\nWWW. \n\n\nnespenan.org \n\n\nWhere Women Have No Doctor 2010 \n\n\n42 Understanding Our Bodies \n\n\nChapter 4 \n\nIn this chapter: \n\nA Woman’s Reproductive System 44 \n\nThe reproductive parts on the outside 44 \n\nThe breasts 45 \n\nThe reproductive parts on the inside 45 \n\nA Man’s Reproductive System 46 \n\nHaving a baby — will it be a boy or a girl? 46 \n\nHow a Woman’s Body Changes 47 \n\nHormones 47 \n\nMonthly Bleeding 48 \n\nThe monthly cycle (menstrual cycle) 48 \n\nProblems with monthly bleeding 50 \n\n\nThis chapter is about the parts of the body that make up a woman’s or a \nman's sexual and reproductive system. This information will help you to use \nthe rest of this book. \n\n\nWhere Women Have No Doctor 20 1 0 \n\n\nwww. nesperiaii.org \n\n\n43 \n\n\nUnderstanding Our Bodies \n\n\n\nEvery woman \nchanges from a \ngirl into a woman.. \n\n\nPuberty \n\n\n\n...and then from \na woman into an \nolder woman. \n\n\nReproductive \n\nyears \n\n\n\n\n\nhip bones \n\n\nIn many ways, a woman’s body \nis no different from a man’s. For \nexample, women and men both \nhave hearts, kidneys, lungs, and \nother parts that are the same. But \none way they are very different is \nin their sexual or reproductive parts. \n\nThese are the parts that allow a \nman and a woman to make a baby. \n\nMany of women’s health problems \naffect these parts of the body. \n\nSometimes talking about the sexual parts of our bodies \ncan be difficult, especially if you are shy, or do not know what \ndifferent parts of the body are called. In many places, the \nreproductive parts of the body are considered ‘private’. \n\n\nYou can feel your hip bones just \nbelow your waist They are part \nof the pelvis. The pelvic area is \n\neverything between the hips. \nThis is where a woman's \nreproductive parts are. \n\n\n\n>• No one should \nfeel ashamed of \nany part of his or \nher body. \n\n\nBut knowing how our bodies work means we can take \nbetter care of them. We can recognize problems and their \ncauses and make better decisions about what to do about them. \nThe more we know, the more we will be able to decide for \nourselves if the advice that others give us is helpful or harmful. \n\n\nSince different communities sometimes have their own \nwords for parts of the body, in this book we often use medical \nor scientific names. This way, women from many different \nregions of the world will be able to understand the words. \n\n\nWWW. \n\n\nWhere Women Have No Doctor 2010 \n\n\n\n44 Understanding Our Bodies \n\n\nA Woman’s \n\nReproductive \n\nSystem \n\n\nA woman has sexual parts both outside and inside her body. \nThey are called the reproductive organs, or genitals. The outside \nparts are called the vulva. Sometimes people may use the word \nvagina for the whole area. But the vagina is the part that begins \nas an opening in the vulva and leads inside to the womb. The \nvagina is sometimes called the ‘birth canal’. \n\n\n\nThe drawing below shows \nwhat the vulva looks like and \nwhat the different parts are \ncalled. But every woman’s \nbody is different. There are \ndifferences in the size, shape, \nand color of the parts, especially \nof the outer and inner folds. \n\n\nT HE REPRODUCTIVE PARTS ON THE OUTSIDE \n\n\nVulva: All the sexual parts \nyou can see between your legs. \n\n\nOuter folds: The fatty lips \nthat close up when the legs \nare together. They protect \nthe inner parts. \n\nInner folds: These \nflaps of skin are soft, \nwithout hair, and are \nsensitive to touch. \n\nDuring sex, the inner \nlips swell and turn \ndarker. \n\nVaginal opening: The ' \n\nopening of the vagina. \n\nHymen: The thin piece of \nskin just inside the vaginal opening. \n\nA hymen may stretch or tear and \nbleed a little because of hard work, \nsports or other activities. This can also \nhappen when a woman has sex for \nthe first time. All hymens are different. \nSome women do not have a hymen \nat all. \n\n\n\nAnus: The opening of \nthe intestine, where waste \n( stool j leaves the body. \nThe anus connects to the \nrectum (the lower part of \nthe intestine). \n\n\nMons: The hairy, fatty \npart of the vulva. \n\n\nClitoris: The clitoris is \nsmall and shaped like \na fower bud. It is the \npart of the vulva that is \nmost sensitive to touch. \nRubbing it, and the area \naround it, can make a \nwoman sexually excited \nand cause climax. \n\nUrinary opening: \n\nThe outer opening of \nthe urethra. The urethra \nis a short tube that carries \nurine from where it is \nstored in the bladder to \nthe outside of the body. \n\n\nwww.nespenan.orc \n\n\nWhere Women Have No Doctor 2010 \n\n\nA Woman’s Reproductive System 45 \n\n\nT HE BREASTS \n\nBreasts come in all shapes and sizes. They start to grow \nwhen a girl is between 10 and 15 years old, when she changes \nfrom a girl to a woman (puberty). They make milk for babies \nafter pregnancy. When they are touched during sexual relations, \na woman’s body responds by making her vagina wet and ready \nfor sex. \n\nInside the breasts: \n\nGlands make the milk. \n\nDucts carry the milk to the nipple. \n\nSinuses store the milk until the baby drinks it. \n\nThe nipple is where milk comes out \n' of the breast. Sometimes they stick out. \nSometimes they are fat. \n\nThe areola is the dark and bumpy skin around \nthe nipple. The bumps make an oil that keeps the \nnipples clean and soft. \n\n\n\n\nThe reproductive parts on the inside \n\n\nOvaries: The ovaries \nrelease one egg into a \nwoman’s fallopian tubes \neach month. When a man’s \nsperm joins the egg , it can \ndevelop into a baby. A \nwoman has 2 ovaries, one \non each side of the \nwomb. Each ovary is \nabout the size of an \nalmond or grape. \n\nCervix: This is the \nopening or ‘mouth’ \nof the womb, where \nit opens into the \nvagina. Sperm can \nenter the womb \nthrough the small \nhole in the cervix, but \nit protects the womb \nfrom other things, like \na man’s penis. During \nchildbirth, the cervix \nopens to let the baby \ncome out. \n\n\nFallopian tubes: The fallopian tubes connect the womb \nwith the ovaries. When an ovary releases an egg, it \ntravels through the fallopian tubes into the womb. \n\n\nWomb (uterus): The \nwomb is a hollow muscle. \nMonthly bleeding comes \nfrom the womb. The \nbaby grows here during \npregnancy. \n\n\nVagina or birth \ncanal: The vagina \nleads from the vulva \nto the womb. The \nvagina is made of a \nspecial kind of skin \nthat stretches easily \nduring sex and \nwhen giving birth. \nThe vagina makes \na fluid or wetness \n(discharge) that \nhelps it keep itself \nclean and prevents \ninfection. \n\n\n\nwww. nesperian.org \n\n\nWhere Women Have No Doctor 2010 \n\n\n46 Understanding Our Bodies \n\n\nA Man’s \n\nReproductive \n\nSystem \n\n\nA man’s sexual parts are easier to see than a woman’s \nbecause they are mostly outside the body. The testicles \n(balls) make the main hormone in a man’s body, called \ntestosterone. When a boy goes through puberty, his body \nbegins to make more testosterone. It causes the changes \nthat make a boy look like a man. \n\n\n\nThe testicles also make a \nman’s sperm. A man begins \nto produce sperm during \npuberty, and makes more \nevery day of his life. \n\nSperm travel from the \ntesticles through a tube in the \npenis where they mix with \na liquid produced by special \n\nglands. \n\nThis mixture of liquid and \nsperm is called semen. The \nsemen comes out of the penis \nwhen a man climaxes during \nsex. Each drop of semen has \nthousands of sperm which are \ntoo small to see. \n\n\n\nHaving a baby — will it be a boy or a girl? \n\n\nAbout half of a man’s sperm will \nproduce a baby boy and the other half \nwill produce a girl. Only one sperm \nwill join with the woman’s egg. If it is a \nboy sperm, the baby will be a boy. If it \nis a girl sperm, the baby will be a girl. \n\nBecause most communities value \nmen more than women, some families \nwould rather have boys than girls. \n\nThis is unfair because girls should be \nvalued just as much as boys. It is \nalso unfair because in some places \na woman is blamed if she does not \nhave any sons. But it is the man’s \nsperm that makes a baby either a \nboy or a girl! \n\n\n\nWhere Women Have No Doctor 20 1 0 \n\n\nwww. nesperia.n.orc \n\n\nHow a Woman's Body Changes 47 \n\n\n\nA woman’s body goes though many important changes during \nher life — at puberty, during pregnancy and breastfeeding, and \nwhen she stops being able to have a baby ( menopause ). \n\nIn addition, during the years she can have a baby, her body \nchanges every month — before, during, and after the time of \nher monthly bleeding. The parts of the body where many of \nthese changes happen are the vagina, womb, ovaries, fallopian \ntubes, and the breasts, also called the reproductive system. Many \nof the changes are caused by special chemicals called hormones. \n\n\nHow a \nWoman’s \nBody \nChanges \n\n\n\npuberty, 54 \nmonthly bleeding, 48 \nmenopause, 124 \n\n\nHormones \n\nHormones are chemicals the body makes that control how and when the body \ngrows. A little while before a girl’s monthly bleeding first starts, her body begins \nto produce more estrogen and progesterone, the main female hormones. These \nhormones cause the changes in her body known as puberty. \n\nDuring the years when she can have a baby, hormones cause a woman’s body \nto prepare for possible pregnancy each month. They also tell her ovaries when to \nrelease an egg (one egg every month). So hormones determine when a woman \ncan get pregnant. Many family planning methods work to prevent pregnancy by \ncontrolling the hormones in a woman’s body (see page 207). Hormones also \ncause changes during pregnancy and breastfeeding. For example, hormones keep \na pregnant woman from having her monthly bleeding, and after childbirth they also \ntell the breasts to make milk. \n\nWhen a woman is near the end of her reproductive years, her body slowly \nstops producing estrogen and progesterone. Her ovaries stop releasing eggs, her \nbody stops preparing for a pregnancy, and her monthly bleeding stops forever. This \nis called menopause. \n\nThe amount and kind of hormones produced by a woman’s body can also affect \nher moods, sexual feelings, weight, body temperature, hunger, and bone strength. \n\n\nwww.n6Sp6riRn.org \n\n\nWhere Women Have No Doctor 20 1 0 \n\n\n48 Understanding Our Bodies \n\n\nMonthly \n\nBleeding \n\n\nAround the world, \n\n\nAbout once each month during her reproductive years, a \nwoman has a few days when a bloody fluid leaves her womb \nand passes through her vagina and out of her body. This is \ncalled ‘monthly bleeding’, the ‘monthly period' or ‘menstruation’. \nIt is a healthy process and is part of the way the body gets \nready for pregnancy. \n\n\nwomen have many \n\n\n\nMost women think of their monthly bleeding as a normal \npart of their lives. But often they do not know why it happens \nor why it sometimes changes. \n\n\nT HE MONTHLY CYCLE (MENSTRUAL CYCLE) \n\nThe monthly cycle is different for each woman. It begins \non the first day of a woman’s monthly bleeding. Most women \nbleed every 28 days. But some bleed as often as every \n20 days or as little as every 45 days. \n\nThe amount of the hormones estrogen and progesterone \nproduced in the ovaries changes throughout the monthly \ncycle. During the first half of the cycle, the ovaries make \nmostly estrogen, which causes a thick lining of blood and \ntissue to grow in the womb. The body makes the lining so a \nbaby would have a soft nest to grow in if the woman became \npregnant that month. \n\n\nWWW. \n\n\nHesperian. \n\n\nr \n\n\nWhere Women Have No Doctor 2010 \n\n\nMonthly Bleeding 49 \n\n\nAbout 1 4 days before the end of the cycle, when the soft \nlining is ready, an egg is released from one of the ovaries. This \nis called ovulation. The egg then travels down a tube into the \nwomb. At this time a woman is fertile and she can become \npregnant. If the woman has had sex recently, the man's sperm \nmay join with her egg. This is called fertilization and is the \nbeginning of pregnancy. \n\nDuring the last 14 days of the cycle — until her next monthly \nbleeding starts — a woman also produces progesterone. \nProgesterone causes the lining of the womb to prepare for \npregnancy. \n\nMost months, the egg is not fertilized, so the lining inside \nthe womb is not needed. The ovaries stop producing estrogen \nand progesterone, and the lining begins to break down. When \nthe lining inside the womb leaves the body during the monthly \nbleeding, the egg comes out too. This is the start of a new \nmonthly cycle. After the monthly bleeding, the ovaries start to \nmake more estrogen again, and another lining begins to grow. \n\n\n>- A woman may \nfind that the time \nbetween each \nmonthly bleeding \nchanges as she grows \nolder, after she gives \nbirth, or because of \nstress. \n\n\n\njfl-r \n\nwww.il6Sp6ri2in.org \n\n\nWhere Women Have No Doctor 20 1 0 \n\n\n50 Understanding Our Bodies \n\n\n\nabnormal bleeding, 359 \ngrowing older, 1 23 \n\n\n\nPressing hard on the \ntender place between \nyour thumb and first \nfnger can ease many \nkinds of pain. For \nother places where \npressure can ease pain \nfrom monthly bleeding, \nsee page 546. \n\n\nProblems with monthly bleeding \n\nIf you have problems with your monthly bleeding, try to talk \nwith your mother, sisters or friends. You may find that they have \nthem too and they may be able to help you. \n\nChanges in bleeding \n\nSometimes the ovary does not release an egg. When this \nhappens, the body makes less progesterone, which can cause \nchanges in how often and how much a woman bleeds. Girls \nwhose monthly bleeding has just begun — or women who have \nrecently stopped breastfeeding — may only bleed every few \nmonths, or have very little bleeding, or too much bleeding. \n\nTheir cycles usually become more regular with time. \n\nWomen who use hormonal family planning methods \nsometimes have bleeding in the middle of the month. See \npages 207 to 215 for more information about changes in \nbleeding caused by hormonal family planning methods. \n\nOlder women who have not yet gone through menopause \nmay have heavier bleeding or bleed more often than when \nthey were younger As they get closer to menopause, they \nmay stop having monthly bleeding for a few months and then \nhave it again. \n\n\nPain with monthly bleeding \n\nDuring monthly bleeding the womb squeezes in order to \npush out the lining. The squeezing can cause pain in the lower \nbelly or lower back, sometimes called cramps. The pain may \nbegin before bleeding starts or just after it starts. \n\n\nWhat to do: \n\n\n• Rub your lower belly. This helps the tight muscles relax. \n\n• Fill a plastic bottle or some other container with hot water \nand place it on your lower belly or lower back. Or use a \nthick cloth you have soaked in hot water \n\n• Drink tea made from raspberry leaves, ginger, or \nchamomile. Women in your community may know of other \nteas or remedies that work for this kind of pain. \n\n• Keep doing your daily work. \n\n• Try to exercise and walk. \n\n• Take a mild pain medicine. Ibuprofen works very well for \nthe pain that comes with monthly bleeding (see page 482). \n\n• If you also have heavy bleeding and nothing else works, \ntaking a low-dose birth control pill for 6 to 1 2 months may \nhelp (see page 208). \n\n\nWWW. \n\n\nHesperian. \n\n\nr \n\n\nWhere Women Have No Doctor 2010 \n\n\nMonthly Bleeding 5 I \n\n\nPre-menstrual syndrome (PMS) \n\nSome women and girls feel uncomfortable a few days before \ntheir monthly bleeding begins. They may have one or more of \na group of signs that are known as pre-menstrual syndrome \n(PMS). Women who have PMS may notice: \n\n• sore breasts \n\n• a full feeling in the lower belly \n\n• constipation (when you cannot pass stool) \n\n• feeling extra tired \n\n• sore muscles, especially in the lower back or belly \n\n• a change in the wetness of the vagina \n\n• oiliness or spots (pimples) on the face \n\n• feelings that are especially strong or harder to control \n\nMany women have at least one of these signs each month \nand some women may have all of them. A woman may have \ndifferent signs from one month to the next. For many women, \nthe days before their monthly bleeding starts are a time of \nunrest. But some women say they feel more creative and \nbetter able to get things done. \n\n\n\nWhat to do: \n\nWhat helps with PMS is different for each woman. To find \nout what will help, a woman should try different things and \nnotice what makes her feel better. First, try following the \nsuggestions for pain with monthly bleeding (see page 50). \n\n\nThese ideas may also help: \n\n• Eat less salt. Salt makes your body keep extra water \ninside, which makes the full feeling in \nyour lower belly worse. \n\n• Try to avoid caffeine (found \nin coffee, tea and some soft \ndrinks like cola). \n\n• Try eating whole grains, \npeanuts, fresh fish, meat \nand milk, or other foods \nthat are high in protein. \n\nWhen your body uses \nthese foods, it also gets \nrid of any extra water, \nso your belly feels less \nfull and tight. \n\n• Try plant medicines. Ask \nthe older women in your \ncommunity which ones work. \n\nwww. nesperian . o r g \n\n\n\nExercise can \nsometimes \nhelp with the \nsigns of PMS. \n\n\nWhere Women Have No Doctor 2010 \n\n\n52 Health Concerns of Girls \n\n\nChapter 5 \n\nIn this chapter: \n\n\nChanges in Your Body (Puberty) 54 \n\nMonthly bleeding (period, menstruation) 55 \n\nChanges that Can Lead to a Better Life 56 \n\nDeciding about Boyfriends and Sex 59 \n\nProtecting yourself if you are ready for sex 6 1 \n\nPressured or Forced Sex 62 \n\nPressure to have sex with a boyfriend 62 \n\nIf someone in your family tries to have sex with you 63 \n\nYoung girls and older men 63 \n\nTrading girls for money or other needs 64 \n\nIf you get pregnant and did not plan to 64 \n\nGetting Help from Adults 65 \n\n\nWWW. \n\n\n1 *r \n\nnesperian. \n\n\nr \n\n\nWhere Women Have No Doctor 2010 \n\n\n53 \n\n\n\nSometime between the ages of 1 0 and 1 5, a girl’s body begins \nto grow and change into an adult body. These can be exciting \nand difficult years. A young woman may not feel exactly like a \ngirl or a woman — her body is somewhere in between and is \ndoing new things she is not used to. What can make it harder \nis when no one talks about the changes, and so a girl may not \nknow what to expect. This chapter describes these changes, tells \nhow a girl can stay healthy as she grows, and gives information to \nhelp her make the right decisions for a healthy life. \n\n\nEating for healthy growth \n\n\nOne of the most important things a girl can \ndo to stay healthy is to eat well. Her body \nneeds to get enough protein, vitamins, and \nminerals during her years of growth. A girl \nneeds at least as much food as a boy. Getting \nenough to eat leads to less sickness and more \nsuccess in school, healthier pregnancies, safer \nbirths, and a healthier old age. \n\n\n\nGirls who get enough to \neat do better in school. \n\n\nGirls also need the right kinds of food. \n\nWhen a girl begins her monthly bleeding she \n\nwill lose some blood each month. To prevent weak blood (anemia), she will \nneed to replace the lost blood by eating foods with iron in them. Also, girls and \nwomen both need foods with calcium to help their bones grow strong. For more \ninformation on eating well, see page I 65. \n\n\nwww.il6Sp6ridn.org \n\n\nWhere Women Have No Doctor 20 1 0 \n\n\n54 Health Concerns of Girls \n\n\nChanges in \nYour Body \n(Puberty) \n\n\nAll girls go through changes in their bodies, but the changes \nhappen differently for each girl. So do not worry if your \nbody does not look exactly like your sister’s or friend’s. \n\nGrowing. Your first change will probably be that you grow \nfast. You may be taller than all of the boys your age for a \nwhile. You will usually stop growing I to 3 years after your \nmonthly bleeding starts. \n\nBody changes. Besides growing fast, your body will begin \nto change. There are natural chemicals in the body called \nhormones that tell your body to grow and that make these \nchanges happen. \n\n\nHow a girl’s body changes in puberty \n\n\n\n• You grow taller and rounder. \n\n• Your face gets oily and pimples \nor spots may grow. \n\n• You sweat more. \n\n• Hair grows under your arms \nand on your genitals. \n\n• Your breasts grow as they \nbecome able to make milk. As \nthey get larger, it is common \nfor the nipples to hurt \nsometimes. One breast may \nbegin to grow before the other, \nbut the smaller breast almost \nalways catches up. \n\n• Wetness (discharge) starts to \ncome out of your vagina. \n\n• Your monthly bleeding starts \n\n(menstruation). \n\n\n\nunderstanding our \nbodies \n\n\nV Changes of \npuberty do not all \nhappen at the same \ntime or in the same \norder. \n\n\nInside your body. There are other changes that you cannot \nsee. The womb (uterus), tubes, ovaries, and vagina grow and \nchange position. \n\nWhat you feel. As you go through these changes you become \nmore aware of your body. You may also become more \ninterested in boys, and in your friends. There may be times \nwhen your feelings are hard to control. In the days before \nmonthly bleeding, it is even more common to have strong \nfeelings of all kinds — -joy, anger, and worry, for example. \n\n\nWhere Women Have No Doctor 2010 \n\n\nwww. nesperia.ii.orc \n\n\nChanges in Your Body (Puberty) 55 \n\n\nMonthly bleeding (period, menstruation) \n\nMonthly bleeding is a sign that your body can become \npregnant. No girl can know exactly when she will get her first \nmonthly bleeding. It usually happens after her breasts and the \nhair on her body start to grow. Several months before her first \nmonthly bleeding, she may notice some wetness coming from \nthe vagina. It may stain her underclothes. This is normal. \n\nSome girls are happy when they have their first monthly \nbleeding, especially if they know what to expect. Girls who \nwere never told about it often worry when the bleeding starts. \nIt is something that happens to all women, and you can feel \naccepting and even proud of it. Do not let anyone make you \nthink it is something dirty or shameful. \n\n\nCaring for yourself during your monthly bleeding \n\nStaying clean. Many girls prefer to make pads of folded cloth \nor wads of cotton to catch the blood as it leaves the vagina. \nThey stay in place with a belt, pin, or underwear The pads \nshould be changed several times each day, and washed well \nwith soap and water if they are to be used again. \n\nSome women put something inside the vagina that they \nbuy or make from cotton, cloth, or a sponge. These are called \ntampons. If you use tampons, be sure to change them at least \n3 times each day. Leaving one in longer may cause a serious \ninfection. \n\nWash your outside genitals with water each day to remove \nany blood that is left. Use a mild soap if you can. \n\nActivities. You can continue all your regular activities. \n\n\n\nill — \n\nwww.n6Sp6riRIl.org \n\n\n\n\n\nmonthly bleeding \n\n\nWhere Women Have No Doctor 2010 \n\n\n56 Health Concerns of Girls \n\n\nChanges \nthat Can \nLead to a \nBetter Life \n\n\n\nlow status of women \n\n\nr he way a woman sees herself forms as she grows. It is \nimportant that a girl learn to feel good about herself when she \nis young, so that she will be able to develop fully and help make \nher community a better place. A girl is much more likely to \nlearn this when her family and community show her that they \nvalue her. \n\nIn many places girls are raised to believe they are less \nimportant than boys. They are taught to feel shame about their \nbodies and about being female, and they learn to accept less \neducation, less food, more abuse, and more work than their \nbrothers. This not only hurts their health directly, but it makes \nthem feel bad about themselves and less able to make the right \ndecisions for a healthier life in the future. When girls are raised \nin this way, it shows that their communities do not value them \nas much as boys. \n\nBut if a girl's community recognizes the value of each \nperson — whether the person is male or female — she will grow \nup feeling she can make a better life for herself and for her \nfamily and neighbors. \n\n\nThe way a community treats females also affects how \nfamilies treat their girl children. For example, if a community \nbelieves that girls should learn skills, a family that lives there is \nmore likely to want their daughter to go to school for as long \nas she can. But in a community where women are allowed to \ndo only ‘women’s work’ and are not allowed to participate in \nany public meetings, families are much less likely to believe that \ntheir daughters should be educated. \n\nThere are many ways to help girls feel better about \nthemselves and to help their families and communities \nunderstand that girls’ lives can be different. On the next few \npages are some ideas. \n\n\n\nWhere Women Have No Doctor 20 1 0 \n\n\nWWW. \n\n\n\nChanges that Can Lead to a Better Life 57 \n\n\nWays girls can work for a better life \n\nFind someone to talk to who you think will listen and \nunderstand — a friend, a sister, or another female relative. Talk \nabout your fears and problems. Together, you can talk about \nstrong women in your community, your goals, and dreams for \nthe future. \n\nDo things that you and your friends think are important. \n\nIf you see a problem in your community, get together with \nyour friends to do something to change it. You will all \nfeel proud when you see that your efforts can make your \ncommunity better. \n\n\nTry to plan your future. The first thing you \ncan do to plan for your future is to set \ngoals. A goal is something you would \nlike to happen. For most girls this \nis not easy. Many feel their lives \nare controlled by their families \nor the traditions of their \ncommunities. But you can \nstart to help yourself by \nknowing what you want. \n\nNext, try to talk to \na woman or man \nwho works at \nsomething you \nwould like to \ndo. It could be \nsomeone you \nadmire, \nor a \nleader \n\n\n\n\nin your \n\ncommunity. Ask \nif you can spend time \nwith that person to learn \nmore about their work. \n\n\nSometimes girls feel frustrated because their dreams and hopes for their future \nmay conflict with the beliefs in their community and family about what a woman \nshould do. It is important to explain your dreams and hopes carefully to adults and \nto listen to their concerns also. See page 65 for ideas about how to communicate \nwith your family. \n\n\nwww.il6Sp6ridn.org \n\n\nWhere Women Have No Doctor 20 1 0 \n\n\n58 Health Concerns of Girls \n\n\nDecisions for a better future \n\nThere are important decisions that you can make with your \nfamily to create new possibilities for your future. \n\n\n\nEducation and training. Education can help you feel proud of \nyourself, earn a better living, and live a \nhappier and healthier life. For many \ngirls, education opens the door to \na better future. Even if you cannot \ngo to school, there are other ways \nto learn to read and develop skills. \n\nFor example you can study \nat home, join a literacy \nprogram, or learn a trade \nfrom a skilled person \n(apprenticeship). When \nyou have new skills, you \nhave something special \nto give to your community, \nand you can better support yourself and your family. \nLearning new skills can help you have more choices in your life. \n\n\n\nWaiting to get married. Talk with your family about waiting \nto get married until you feel ready and until you find the right \npartner. Many girls are able to finish school and find work \nbefore starting families. This can help you learn more about \nyourself and what you want. If you wait, you may even find a \npartner who feels the same way about life as you do. \n\nWaiting to have children. It is \n\neasier to raise a happy and healthy \nchild when you wait until you and \nyour partner feel ready to start \na family. If you are thinking \nabout having a baby, these \nare some things to think about: \n\nWill you be able to continue your \neducation? How will you fulfill the child’s physical needs — food, \nclothes, shelter; etc? Are you ready to provide the emotional \nsupport a baby needs to grow up into a healthy child? Will your \npartner commit himself to helping with child raising? How will \nyour family help you? \n\nParents and girls can work together to organize ways for girls to learn about how \nthe body works, sexuality and prevention of early pregnancy. This can be done at \nhome, and programs can be held in schools, community meeting places, or places \nof worship. \n\n\n\nWWW. \n\n\nnespenan.org \n\n\nWhere Women Have No Doctor 2010 \n\n\nDeciding about Boyfriends and Sex 59 \n\n\nMost young people 0r \n\nbegin to have loving or f% \n\nsexual feelings as they /kw \n\nget older. Thinking about Syj \n\ntouching or being touched in \n\nby someone in a sexual ft j \n\nway is not unusual. (Girls \nmay even think about \nanother girl or woman in this way.) \n\nBut people often have these feelings \nbefore they are ready to act on them \n\nYoung women have sex for many c \nreasons. Some do it because they wj \nhave a baby. Others do it because it \nthem feel good or wanted. Some wc \nfeel they have very little choice because \n\nit is their duty as a wife or girlfriend. Some trade sex for money \nor for other things they need to survive, such as food, or clothes \nfor their children, or a place to live. \n\nOthers have sex because they think it will make someone \nlove them more. Sometimes a friend or a boyfriend can make a \ngirl feel that she should have sex when she is not ready. \n\nNo one should have sex when she does not want to. Only \nhave sex when you decide you are ready. Sex can be enjoyed \nby both people, but it is difficult to enjoy something when you \nfeel fear or shame, or have not given consent. \n\nIf you are ready for a sexual relationship, always protect \nyourself against pregnancy and disease. For more information \non how, see the chapters on “Family Planning,” “Sexually \nTransmitted Infections,” “HIV,” and “Sexual Health.” \n\n\n\nDeciding \nabout \nBoyfriends \nand Sex \n\n\nV Only hove sex \nwhen you decide that \nyou are ready and \nknow how to protect \nyourself from harm. \nSex can be enjoyed \nby both people, but \nnot if there is fear or \nshame. \n\n\nHealth risks of early pregnancy \n\nMost girls' bodies are not ready for a safe and healthy birth. Young women \nare more likely to develop eclampsia (which causes seizures, “fits”) during \npregnancy. Because their bodies may still be too small for a baby to come out, \nmothers under age 1 7 are more likely to have long, difficult labors, and blocked \nbirths. Without medical help, a woman with any of these problems can die. \nBlocked births can also damage the vagina, causing urine and stool to leak (see \npage 370). Babies born to girls younger than 17 are more likely to be born too \nsmall or too soon. If you are already pregnant, try to see a trained midwife or \nhealth worker as soon as possible to find out how to have the safest birth. For \nmore information, see page 72. \n\n\ni lit — \n\nwww.n6Sp6ridn.org \n\n\nWhere Women Have No Doctor 20 1 0 \n\n\n60 Health Concerns of Girls \n\n\nWhat girls should know about having sex \n\nYou can get pregnant the first time you have sex. \n\nYou can get pregnant any time you have sex without a \nfamily planning method (even if it is only once). \n\nYou can get pregnant even if the man thinks he did not let \nhis seed (sperm) come out. \n\nYou can get an STI or HIV if you do not use a condom \nwhen you have sex with an infected person. And you \ncannot tell by looking at a person if he is infected. \n\nIt is easier for a girl to get a sexually transmitted infection \n(STI) or HIV from a boy or man than it is for her to give \nthese diseases to him. This is because of the way sex \nworks — because she is the ‘receiver’. It is also harder to \nknow if a girl has an infection, because it is inside her body. \n\n\n\nAlways use a condom for protection against STIs and HIV. But the most \ncertain way to avoid pregnancy, STIs, and HIV is to not have sex. \n\n\n\n\npressure to have sex \n\n\nHaving a relationship with no sex \n\nBuilding a loving relationship takes time, caring, respect, and \ntrust from both sides. Sex is not the only way of showing \nsomeone that you care. Having sex does not mean that you \nwill fall in love. \n\nYou can spend personal time together without having sex. \nBy talking and sharing experiences you can learn something \nmore important about each other — how you view life, \ndecisions you would make together, what kind of partner and \nparent you would each make, and how you feel about each \nother’s plans for life. Touching each other (without sexual \nintercourse ) can be satisfying by itself, and is not dangerous as \nlong as it does not lead you to lose control and to have sex \nwhen you are not ready. \n\nTalk to your boyfriend. If you are sure he is right for you, \nbut you are not sure you want to have sex, talk about ways to \nwait. You may find that he is not ready for sex, either. If you \nrespect each other, you will be able to decide together. \n\nTalk to your friends. You may find that some girl friends are \nfacing the same difficult choices. You can help each other find \nways to have good relationships without sex. But think twice \nabout advice from a friend who is already having sex. A friend \nmay try to convince you to do something she is doing to make \nherself feel better about doing it. This is called ‘peer pressure’. \n\n\nwww.nesperian.or \n\n\nWhere Women Have No Doctor 20 1 0 \n\n\nDeciding about Boyfriends and Sex £ I \n\n\nProtecting yourself if you are ready for sex \n\nWhen you decide you are ready for a sexual relationship, you \nmust protect yourself against pregnancy and disease. There are \n\nmany ways to make sex safer. This \nmeans you have to plan before \nyou have sex. \n\nTalk to your boyfriend \nbefore you have sex. Let \n\nhim know how important \nit is to protect yourself. If \nyou find it hard to discuss, \nperhaps you can first \npretend you are talking \nabout another couple. \n\nIf he really cares about you, he will want \nto protect you. If he Is pushing for sex, he \nmay care only about himself \n\n\n\nMany communities have people \nwho are trained to provide condoms \nand other family planning methods. \n\nTalk to them or ask a health worker \nwhere to get a method of protection. \n\nIf you feel embarassed to ask, find \nsomeone you trust to help you. \n\nSome family planning clinics have \nspecial services for teenagers and \nmay have trained teenagers as \npeer counselors who can give you \ninformation. \n\nSince you cannot tell by looking \nif a man has a sexually transmitted \ninfection or HIV, sex is safer only if you \nuse a condom every time. If a man has \na discharge coming from his penis or a \nsore somewhere on it, he has an infection \nand will almost certainly give it to you! \n\nIf you had sex and notice a new \ndischarge from your vagina, sores on your \ngenitals, or pain in your lower belly, you \ncould have an STI. See the chapter on \n“Sexually Transmitted Infections.” \n\n\n\n\nfamily planning \n\n\n\nsafer sex \n\n\n\nSTIs \n\n\n1 hTAi Shi i t «- \n\nwww. nesperian.org \n\n\nWhere Women Have No Doctor 2010 \n\n\n62 Health Concerns of Girls \n\n\nPressured \nor Forced \nSex \n\n\n\nIf someone has \nforced you to have \nsex when you do not \nwant it, it is rape. \n\n\n\nrape \n\n\nPressure to have sex with a boyfriend \n(‘date rape’) \n\nAll over the world, young girls and women are forced to \nhave sex when they do not want to. Often it is done by \nboyfriends who claim to love them. In some places this is \ncalled ‘date rape’. The force may not only be physical. \n\nYou can feel pressure from words or feelings. He \nmay threaten you or say “please” or somehow \nmake you feel guilty or ashamed if \nyou do not have sex. This is still \nwrong. No one should be made \nto have sex when they do not \n^ want to have it. \n\nPrevention: \n\n• If he wants to have sex and you do not, you can tell him \nyou are flattered by his desire for you but that you are \nnot ready. If you are afraid of being alone with the person, \nbring someone with you, or ask someone else to talk \nwith him. \n\n• Say “NO” loudly if you are \n\npushed to have sex. Keep \nsaying “NO” if you have to. \n\nAlso say no with your body. \n\nIf you say “NO,” but give in \nwith your body, he will think \nthat you really mean “yes.” \n\n• Move away if you are touched \nin any way that you do not \nlike. Your feelings are warning \nyou that something worse may \n\nhappen. Make a lot of noise \nand be ready to run if you \nhave to. \n\n• Do not drink alcohol or take drugs. Alcohol and drugs \nmake you less able to use your judgement and control what \nhappens to you. \n\n• Go out in groups. In many places, young couples court or \ndate in groups. You can still get to know a boy, but you are \nless likely to be pushed into having sex because you will not \nbe alone. \n\n• Go only to safe places where others can see you. \n\n• Plan ahead. Decide how much touching will be too much \nfor you. Do not get caught by your feelings and let things \nhappen to you. \n\natAi&til- \n\nwww.nespenan.org \n\n\n\nWhere Women Have No Doctor 2010 \n\n\nPressured or Forced Sex 63 \n\n\nIf someone in your family tries to have sex \n\nWITH YOU (INCEST) \n\nIt is never right for someone to touch you if you do not want \nto be touched. Family members, such as your cousin, uncle, \nbrother, or father should not touch your genitals or any other \npart of your body in a sexual way. If this happens, you need to \nget help. Even if the man says he will hurt you if you tell, you \nneed to tell an adult you trust as soon as possible. Sometimes \nit is best to tell someone outside your family such as a woman \nteacher or religious leader in your community. \n\n\n\nrape \n\n\nYoung girls and older men \n\nSome girls are attracted to older men. Going with an older \nman may seem very exciting, especially if he is well known or \nimportant in your community, or if he \nhas money and can buy things. In some \nplaces a man who buys his girlfriend many \npresents is called a ‘Sugar Daddy'. Often \na girl who goes with an older man ends \nup feeling she was used for sex or treated \nbadly, especially if the man is married or \nhas other women. \n\nSometimes an older man can make a \nyoung woman feel more pressured to have \nsex than boys her own age can, especially if \nhe has power over her. \n\n\n\nDon’t let Mr. Chifeve push you into it, \nTarisai. Remember Alice? He got her \npregnant and she had to leave school. I \nwill help you tell Mama and Baba. \n\n\n\n\nIn many communities, more young women and girls are getting infected with \nHIV than any other group of people. There is more risk for girls who have sex \nwith older men, because older men have usually had more chances to become \ninfected with HIV. But it can happen with a man of any age. \n\n\nwww.n6Sp6riRn.org \n\n\nWhere Women Have No Doctor 20 1 0 \n\n\n\n64 Health Concerns of Girls \n\n\n\nsex workers \n\n\nTrading girls for money or other needs \n\nSometimes a poor family will give a young daughter to an \nolder man to pay a family debt. Or they may trade her for \nmoney or something the family needs. \n\n\n\nSometimes the girls are taken \naway to another town or city. They \nthink they are going to work in \nfactories, or as maids, but they are \noften forced to have sex for money. \n\nIf you think that you or another \ngirl in your community is going to be \nsold into marriage, or sent away to \nwork, try to get help from another \nadult. Perhaps an older aunt or \nuncle, or a woman teacher can help. \n\n\n\nsafe abortion \n\n\nIf you get pregnant and did not plan to \n\n\nYou may be pregnant if you had \nsex and your monthly bleeding is \nlate, your breasts hurt, you pass urine \noften or you feel like vomiting. See \na health worker or midwife as soon \nas you can to find out for sure if you \nare pregnant. \n\n\n\nMany young girls get pregnant when they did not want to. \nSome of them are able to get the support they need from \n\n\nfamily and friends. For others, it is \n\n\n\nTalk to someone older who you trust. \n\nYour life is too valuable to lose. \n\n\nnot so easy. \n\nIf you are feeling trapped \nby a pregnancy you did not \nplan and you want to end \nthe pregnancy, please be \ncareful in the decisions you \nmake. All over the world, \ngirls and women die from \ntrying to end pregnancies \nin dangerous ways. There \nare safe ways to end a \npregnancy. \n\n\nWhere Women Have No Doctor 20 1 0 \n\n\nnespenan.org \n\n\n\n\nGetting Help from Adults 65 \n\n\nr alking with your mother or father can be hard sometimes. \nYour parents may want you to live by tradition, but you feel that \ntimes are changing. You may feel that your parents do not listen \nor try to understand you. Or you may be afraid they will get \nangry. \n\nYour family can love you without agreeing with everything \nyou say. They may get angry because they care — not because \nthey do not like you. Try to talk with them respectfully and help \nthem to understand you better. \n\n\nIdeas for better communication \n\n• Choose a good time to talk, when your \nparents are not busy, tired, or worried \nabout something else. \n\n• Share your concerns, worries and goals \nwith them. Ask what they would do in \n\n\n• Give them something to read or show \nthem a picture to get them started talking. \nYou can read a part of this book together \nif it is related to your problem. \n\n• If you get angry, try not to shout. You can make your parents angry and they \nmay think you do not respect them. \n\n• If you have tried these things and you still cannot talk to your parents, find \nanother older person you can talk to. It could be a teacher, the mother of a \nfriend, an aunt, an older sister; grandmother, someone in your place of worship, \nor a health worker. \n\n\nHow mothers can help their daughters \n\nYou may have grown up in a time when girls were not \nallowed to have an education, plan their families, or make \ndecisions about their lives. Life can be different for your \ndaughter. If you listen to her, share your own experiences, and \ngive her useful information, you can help her make her own \ngood decisions. You can help her to see the good things about \nbeing a girl and a woman. \n\nwww. nespenan.org \n\n\n\n\nGetting \nHelp From \nAdults \n\n\nWhere Women Have No Doctor 2010 \n\n\n\n66 Pregnancy and Childbirth \n\n\nChapter 6 \n\n\nIn this chapter: \n\nStaying Healthy during Pregnancy 68 \n\nCommon Problems during Pregnancy 69 \n\nRisks and Danger Signs during Pregnancy 72 \n\nPrenatal Care (Check-ups during Pregnancy) 76 \n\nPreparing for Labor and Birth 78 \n\nGiving Birth 80 \n\nSigns that labor is near 80 \n\nThe 3 stages of labor 80 \n\nDanger signs during labor 85 \n\nDifficult Births 88 \n\nDanger Signs for the Baby at Birth 94 \n\nCaring for the Mother and Baby after Birth 95 \n\nWomen with Extra Needs 98 \n\nTo the Father 1 00 \n\nWorking for Change 1 0 1 \n\n\nMost women in the world today do not get prenatal care or trained \nhelp during birth. They usually have their babies at home with the help of \na local midwife or a family member. This chapter has information for both \nthe pregnant woman and her helpers, about care during pregnancy, and care \nboth during and after the birth. \n\nFor more complete information about caring for women in pregnancy and \nhelping them with both normal and difficult births, see Hesperian’s A Book for \nMidwives (for how to order it, see the last page of this book). \n\n\nWhere Women Have No Doctor 20 1 0 \n\n\n1 ^iiObU- Read about the \n‘Danger signs during \npregnancy’, starting \non page 73, to learn \nwhen it is important \nto see a health \nworker, \n\n\n\nSTIs \n\n\n>- If there is malaria \nwhere you live, sleep \nunder a bed net to \navoid being bitten by \nmosquitos. \n\n\nIf you take good care of yourself while pregnant, you are more \nlikely to have a safe pregnancy and birth and a healthy baby. \n\n• Try to eat enough nutritious foods. Good nutrition gives \nstrength, prevents infection, builds a healthy baby, and helps \nprevent too much bleeding during birth. Remember that \nyou are feeding both yourself and your baby. Use iodized \nsalt so your baby will not suffer from mental slowness. \n\n• Sleep and rest more. If you work \n\nstanding up, try to sit or lie down Do your \nseveral times during the day. daily work... \n\n\n• Go for prenatal (before-birth) check-ups to make sure \nthere are no problems, and to find problems before \nthey become serious. If you have never had a tetanus \nimmunization, get one as soon as you can. Get at least 2 \nbefore the end of the pregnancy (see page 161). \n\n• Keep clean. Bathe or wash regularly and clean your teeth \nevery day. \n\n• Practice squeezing exercises, so your vagina will be stronger \nafter the birth (see page 371). \n\n• Try to get daily exercise. If you sit down at work, try to \nwalk a little every day. But try not to tire yourself. \n\n• Get treatment if you think you have a sexually transmitted \ninfection (STI) or other infection. \n\n• Get tested for HIV. Prevent HIV infection during pregnancy \nby using condoms when you have sexual intercourse. \n\n• Avoid taking modern or plant medicines, unless a \nhealth worker who knows you are pregnant says it is OK. \n\n• Do not drink alcohol or smoke or chew tobacco during \npregnancy. They are bad for the mother and can harm the \ndeveloping baby. \n\n• Avoid pesticides, herbicides, or factory chemicals. They \ncan harm the developing baby. Do not touch or work near \nthem, or breathe in their fumes. Never store food or water \nin their containers. \n\n• Stay away from a child with a rash all over its body. It may \n\nbe caused by German Measles, which can harm the baby. \n\nwww.nesperian.org \n\n\n\n\nWhere Women Have No Doctor 20 1 0 \n\n\nCommon Problems during Pregnancy 69 \n\n\nWhen you are pregnant your body changes and you may \nhave some of the following common problems. But remember, \nmost of these problems are normal in pregnancy. \n\nSick stomach (nausea) \n\n\nCommon \n\nProblems \n\nduring \n\nPregnancy \n\n\nAlthough it is often called ‘morning sickness’, during \npregnancy you may feel sick to your stomach at any time during \nthe day or even all day long. It usually goes away by the end of \nthe 3rd or 4th month. \n\nWhat to do: \n\n• Drink a cup of ginger or cinnamon tea \n2 or 3 times a day, before meals. \n\n• Eat small meals often, and avoid foods \nthat are oily or hard to digest. \n\n• Lick a lemon. \n\n• Ask the midwives in your community for \ngood local plant medicines or remedies. \n\n\nTo help with morning sickness... \n\n\n\n...try eating a biscuit, a tortilla, a piece of \nbread, a chapati, or a little rice or porridge \nwhen you wake up in the morning. \n\n\nIMPORTANT \n\n\nSee a health worker if you vomit so much that you \ncannot keep any food down , or if you are losing weight. Also watch \nfor signs of dehydration (see page 298). \n\n\nHeartburn or indigestion \n\nHeartburn causes a burning feeling in the throat and chest. \n\nIt is most common in later pregnancy, after eating or when lying \ndown. \n\nWhat to do: \n\n• Eat several small meals instead of one large meal. \n\n• Avoid spicy or oily foods. \n\n• Drink plenty of water and other clear liquids. \n\n• Try not to lie down right after eating. \n\n• Sleep with your head higher than your stomach. \n\n• Take a cup of milk or yogurt, some bicarbonate of soda \nin a glass of water, or calcium carbonate (antacid). \n\nDischarge from the vagina \n\n\n\nDuring pregnancy, it is normal to have more white discharge \nthan usual from the vagina. But if the discharge itches, burns, or \nhas a bad smell, you may have an infection of the genitals, which \nshould be treated. If the discharge is bloody or has mucus in it, \nor if there is a lot and it looks like water, see a health worker \nYou may be starting labor too early. \n\n\nWWW. \n\n\nnespenan.org \n\n\n\ninfections of the \ngenitals \n\n\nWhere Women Have No Doctor 2010 \n\n\n\n\n70 Pregnancy and Childbirth \n\n\nSwollen veins (varicose veins) \n\nBlue swollen veins in the legs and around the vagina are \ncalled varicose veins. They are caused by the weight of the \ngrowing baby. They can become quite large and painful. \n\n\n\nWhat to do: \n\n• Try not to stand up for too long. If you have to stand, walk \nin place or move your feet and legs. When you are sitting \ndown, put your feet up as often as possible. \n\n• Be sure to walk every day. If you have a disability and \ncannot walk, ask someone in your family to help move and \nexercise your legs. \n\n• If the problem is severe, wrap your legs with cloths. \nBegin wrapping at the ankles and work up to just \nbelow the knee. The bandage should be tighter \naround the ankle and looser further up the leg. \nTake off the bandages at night. \n\n\nWomen with swollen \nveins should try to \nput their feet up \nwhen they can, and \nwrap their legs if the \nswelling is very bad. \n\n\nConstipation (difficulty passing stool) \n\nPregnancy makes the bowels work more slowly. This can make \nthe stool harder; so it is more difficult to pass. \n\nWhat to do ( these things also help prevent constipation): \n\n• Drink at least 8 glasses of liquid every day. \n\n• Get regular exercise. \n\n• If you are taking iron tablets, try taking only one a day with \nfruit or vegetable juice. Or skip a few days. \n\n• Eat plenty of fruits, vegetables, and foods with fiber — like \nwhole grains and cassava (manioc) root. \n\n\n•t. \n\n\n\n• Do not take laxatives. They only solve the problem for a \nshort while and then you need to take more. \n\nPiles (hemorrhoids) \n\nHemorrhoids are swollen veins around the anus. They often \nitch, burn, or bleed. Constipation makes them worse. \n\nWhat to do: \n\n• Sit in a basin or pan of cool water to relieve the pain. \n\n\nIf you have \n\nhemorrhoids, sitting in \ncool water can help \nwith the pain. \n\n\nFollow the advice above for preventing constipation. \n\nSoak some clean cloth in witch hazel \n(a liquid plant medicine) if you can \nfind it, and put it on the painful area. \n\nKneel with your buttocks \nin the air. This can help \nrelieve the pain. \n\n\n\nWhere Women Have No Doctor 20 1 0 \n\n\nwww. nesperia.n.orc \n\n\nCommon Problems during Pregnancy 71 \n\n\nLeg cramps \n\n\nPregnant women often get foot or leg cramps — especially \nat night, or when they stretch or point their toes down. Leg \ncramps may be caused by not enough calcium in the diet. \n\nWhat to do: \n\n• Eat plenty of foods that contain calcium, such as milk, \ncheese, sesame seeds, and green leafy vegetables. \n\n\n\nfoods with calcium \n\n\nIf your foot or leg cramps: \n\n\nPush \ndown on \nyour heel. \n\n\n\n...and \nf point \nyour toe \nupward... \n\n\n...then \ngently \nstroke your \nleg to help \nit relax. \n\n\n\nDO NOT \npoint your \ntoe down. \n\nIt can make \nthe cramps \nworse. \n\n\nLow-back pain \n\nLow-back pain is caused by the weight of the growing baby. \n\n\n\nWhat to do: \n\n• Ask someone to rub or massage your back. \n\n• Ask your family for help with some of the heavy work. \n\n• Take care to stand and sit with your back straight. \n\n• Sleep on your side with a pillow or rolled up cloth between \nyour knees. \n\n• Do the ‘angry cat’ exercise for a few minutes, 2 times each \nday, and whenever your back hurts. \n\n\n\nlifting and carrying \nheavy loads \n\n\n\nSwelling of the feet and legs \n\n\nSome swelling of the feet is normal during pregnancy — \nespecially for women who must stand all day. \n\n\nWhat to do: \n\n• Put your feet up as often as you can during the day. \n\n• When resting, lie on your left side. \n\n• If your feet are very swollen, or they are swollen already \nwhen you wake up in the morning, or your hands and face \nalso swell, these are signs of danger during pregnancy. See \npage 74. \n\n\n\nswelling of the hands \nand face \n\n\nWWW. \n\n\nnesperian . o r g \n\n\nWhere Women Have No Doctor 20 1 0 \n\n\n72 Pregnancy and Childbirth \n\n\nRisks and \n\nDanger \n\nSigns \n\nduring \n\nPregnancy \n\n\nhealth center \n\nm \n\n\na \n\n\nhospital \n\nill \n\ni I \n\nfill \n\n\nA woman who is likely \nto have a dangerous \nbirth should plan \nto have her baby in \na health center or \nhospital. \n\n\nWomen who have extra risks \n\nWomen with any of the following problems can have more \ndangerous pregnancies and births. They should plan to go to \na health center or hospital for birth, and they may need more \nprenatal care during pregnancy. \n\n• Weak blood ( anemia ) makes a woman more likely to bleed \nheavily (hemorrhage) during birth, become ill after childbirth, \nor even die. For more on anemia, see the next page. \n\n• Sugar sickness ( diabetes ) often causes very serious \nproblems for the mother and the baby. The baby can die \nbefore birth or sometimes grows very large and gets stuck \nin the pelvis. \n\n• High blood pressure can lead to severe headaches, seizures, \nand even death. \n\n• Older mothers who have had many babies often have long, \ndifficult labors, and heavy bleeding after the birth. \n\n• Mothers under the age of 1 7 are more likely to have \neclampsia (which causes seizures), long, difficult labors, babies \nborn too early (premature), and blocked births, which may \ndamage the bladder, vagina, and womb (see page 370). \n\n• Mothers who had problems with past pregnancies — such \nas seizures, birth by operation, heavy bleeding, a too-early \nor too-small baby, or a baby born dead — are more likely to \nhave problems in another pregnancy or birth. \n\n• Women with disabilities, especially women with a loss of \nfeeling in the body or difficulty walking, can have problems \nduring both pregnancy and birth (see page 145.) \n\n• Women with HIV can take medicines to prevent passing \nHIV to their babies (see page 520). \n\n\nOther women who should try to give birth \nat a health center or hospital \n\nSome women — who have none of the extra risks listed above — are still likely to \nhave dangerous births. These women should also try to give birth at a health center \nor hospital: \n\n• A woman with a baby in the wrong position for birth at the end of pregnancy \n\n(see page 75) can have a long, difficult labor. The mother, the baby, or both may die, \n\n• Women carrying twins often have one baby in the wrong position for birth. Also, \nthese mothers are more likely to bleed after birth. \n\n• Women who have their genitals cut can have severe tearing of the genitals during \nthe birth (see page 464). This can cause great pain, heavy blood loss, and infection. \n\n\nWhere Women Have No Doctor 20 1 0 \n\n\nwww.ll6Sp6riRn.orc \n\n\nRisks and Danger Signs during Pregnancy 73 \n\n\nDanger signs during pregnancy \n\nIn addition to the problems just listed, these danger signs may occur during \npregnancy. A woman with any of these signs may be in serious danger and should \nsee a health worker. See the next few pages for more about them. \n\n• feeling very weak • bleeding from • swelling of hands and face, \n\nor tired the vagina or bad headache and blurred \n\n• pain in the belly • fever eyesight \n\n\nFeeling very weak or tired (anemia) \n\nIf you feel very weak or tired, you could be anemic \n(see page 1 72). Women who are very anemic are much \nmore likely to have heavy bleeding after the baby is born. \n\nWhat to do: \n\n\nEat foods rich in iron — meat, fish, chicken, eggs, beans, peas, \nand leafy green vegetables. \n\nTake 325 mg of iron 2 times a day, and I mg of folic \nacid once a day, until the baby is born. If you take \niron tablets with fruits like oranges, mangoes, or \npapayas, your body uses the iron better \n\n\n\nPain in the lower belly (abdomen) \n\n1. Strong, constant pain in the first 3 months may be caused \nby a pregnancy that is growing outside the womb in the tube \n(a tubal pregnancy). As the tube stretches, it causes pain. If \nthe pregnancy grows large enough, the tube will burst and \nbleed. This is very dangerous. You will bleed inside your \nabdomen and may die. \n\nSigns of tubal pregnancy (ectopic pregnancy): \n\n• missed monthly bleeding, and \n\n• pain in the lower abdomen on one side, or \n\n• slight bleeding from the vagina, or \n\n• feeling dizzy, weak, or faint \n\nWhat to do: \n\nGo to the nearest hospital. \n\n2. Strong pain that comes and goes (cramping) in the first \n\n6 months could mean you are losing the pregnancy (having \na miscarriage ). See page 234. \n\n\n\n3. Strong, constant pain in late pregnancy. This could mean \nthe afterbirth ( placenta ) is coming off the wall of the womb. \n\nThis is very dangerous. You could die if you do not get \nhelp. Go to the nearest hospital. \n\n4. Pain that comes and goes in the 7th or 8th month could \nmean you are going into labor too early (see page 75). \n\nwww. nesperian . o r g \n\n\n\nfoods rich in iron \n\n\ntubal pregnancy \n\n\n\nV Strong pain in \nthe abdomen does \nnot always mean \nsomething is wrong \nwith a pregnancy. For \ninformation about \nother possible causes , \nsee pages 353 to \n357. \n\n\n\nTRANSPORT! \n\n\nWhere Women Have No Doctor 2010 \n\n\n74 Pregnancy and Childbirth \n\n\n\nmiscarriage \n\n\n\nTRANSPORT! \n\n\nBleeding from the vagina \n\n1. Bleeding early in pregnancy. Light bleeding from the vagina \nfor a few days during the first 3 months of pregnancy can \nbe normal. But if you have pain with the light bleeding, it \ncould mean a pregnancy is developing outside the womb, \nwhich is very dangerous (see page 73). If the bleeding gets \nheavier and stronger than a normal monthly bleeding, you \nare probably losing the pregnancy (having a miscarriage). \n\n2. Bleeding later in pregnancy. Bleeding after the first \n\n3 months can mean there is something wrong with the \nafterbirth (placenta). Both you and the baby are in danger. \n\nWhat to do: \n\n• Go to the nearest hospital. \n\n• On the way, lie down with your feet up. \n\n• Do not put anything in your vagina. \n\n\n\n166 \n\nfoods rich in protein \n\n\nFever \n\nHigh fever, especially along with shivering, body aches and \nsevere headache, can be caused by malaria. Treatment for \nmalaria depends on where you live. See Where There Is No \nDoctor for more information. \n\nSwelling of the hands and face or severe \nheadache and blurred vision (eclampsia) \n\nSome swelling in the legs and ankles is normal in pregnancy. \nBut swelling of the hands and face can be a sign of eclampsia, \nespecially if you also have headaches, blurred vision, or pains in \nyour abdomen. Eclampsia can cause seizures, and both you and \nthe baby can die. \n\nWhat to do: \n\n• Find someone who can check your blood pressure. \n\nGo to a health center or hospital if necessary. \n\n• Rest as often as possible, lying down on your left side. \n\n• Try to eat more foods with a lot of protein every day. \n\n• Plan to have the birth in a health center or hospital. \n\n\nDanger signs of eclampsia \n\n\n\n• swollen hands and face \n\n• dizziness \n\n• blood pressure 140/90 or \n\n• severe headache \n\n• severe pain high in \n\nhigher (see page 532) \n\n• blurred vision \n\nthe stomach \n\n\n\n\nTRANSPORT! \n\n\nIMPORTANT \n\n\nIf a woman has any. of the danger signs of eclampsia , \nshe needs medical help fast If she is already having seizures, see page 87. \n\n\nnespenan.org \n\n\nWhere Women Have No Doctor 2010 \n\n\n\n\nRisks and Danger Signs during Pregnancy 75 \n\n\nBaby in the wrong position when labor starts \n\nIf the baby is buttocks first (breech) when labor starts, the \nbirth can be more difficult. If the baby is lying sideways when \nlabor starts, the baby cannot be born without an operation. \n\n(Turn the page to learn howto check the baby’s position.) \n\n\n>■ If the baby's head \nis down , the birth is \nmore likely to go well. \n\n\nPositions that cause difficult or dangerous births \n\n\n\nBaby with buttocks \nfirst (breech) \n\nIf the baby's head \n\nis up, the birth may \nbe more difficult. \n\nIt may be safer for \nthe mother to give \nbirth in a hospital. \n\n\n\nBaby lying sideways \n\nIf the baby is lying \nsideways , the mother \nshould give birth in a \nhospital. She and the \nbaby are in danger. A \nbaby that stays sideways \ncannot be born without \nan operation. \n\n\nDuring the last month of \npregnancy, it may be possible \nto change the baby’s position \nby lying in this position for \n1 0 minutes, 2 times a day: \n\n\n\nLie on the foor with pillows under \nthe hips. Try to get the hips higher \nthan the \nhead. \n\n\nDo this exercise every day with an empty stomach, until \nthe baby changes to a head-down position and then stop. The \nbaby’s position should be checked each week. \n\n• If labor starts and the baby is still sideways, the mother \nmust go to a health center or hospital where the baby’s \nposition can be changed, or where she can have an \noperation. Without medical help, the mother and her baby \nwill almost certainly die. \n\n\nIf labor starts and the baby is still buttocks first, see page 90. \n\n\nIMPORTANT \n\n\nDO NOT try to change the baby's position by hand \nyourself unless you have been trained to do it and have done it before \nsuccessfully. You can tear the womb and harm both the mother and the baby. \n\n\n\nTRANSPORT! \n\n\nIf labor starts too early (before the 8th or 9th month) \n\nSome babies born too early might not live. A woman may be able to slow or \nstop labor by lying in bed with her hips raised, and resting until the labor stops (see \nthe picture above). If she can go to a hospital, they may be able to stop the labor. \nEven if they cannot stop the labor, they can sometimes keep the baby alive. (Also \nsee page 94 for how to care for a baby born too early.) \n\n\nwww.n6Sp6riRn.org \n\n\nWhere Women Have No Doctor 20 1 0 \n\n\n\n\n76 Pregnancy and Childbirth \n\n\nPrenatal \n\nCare \n\n(Check-ups \n\nduring \n\nPregnancy) \n\n\n>■ Prenatal \ncheck-ups can help \nyou decide the best \nplace to have your \nbaby: at home, or at \na health center or \nhospital. \n\n\nP renatal check-ups are important to find and take care of \nproblems early — before they become dangerous. Good \nprenatal care is not difficult to give and does not require very \nexpensive equipment. It can save many lives. \n\nIf you are pregnant, try to have at least 3 check-ups: \n\n1. As soon as you think you are pregnant. \n\n2 . Around the 6th month of pregnancy. \n\n3 . A month before the baby is due. \n\nA midwife or health worker will ask about past pregnancies \nand births, including any problems, such as a lot of bleeding or \nbabies that died. This information can help you both prepare for \nsimilar problems in this pregnancy. A midwife may also be able to: \n\n• make sure a woman is eating well enough and suggest ways \nfor her to eat better food, if necessary. \n\n• give iron and folic acid tablets, which help prevent anemia \nand birth defects. \n\n• examine the mother, to make sure she is healthy and that \nthe baby is growing well. \n\n• give vaccinations to prevent tetanus, a disease that can kill \nboth mothers and babies (see page 161). \n\n• give medicine to prevent malaria if it is common in the area. \n\n• give tests for HIV (see page 288) and syphilis, along with \nother sexually transmitted infections (see page 261). \n\n• give medicines to prevent a woman’s HIV from spreading to \nher baby. \n\n\nA birth attendant \n\nCheck the eyelids \nand finger nails for \nsigns of anemia \n(see page 1 72). \n\n\n\nWhat to expect at a prenatal check-up \n\nor midwife should do these things at a prenatal check-up: \n\n• Check the growth of the baby in the \nwomb. Normally the womb will grow \n2 fingers each month. At 4 Vi months \nit is usually at the level of the navel. If \nthe womb seems too small or too big \nor grows too fast, it may mean there is \nCheck the hands a problem, \n\nand face for swelling \n(see page 74). \n\n\n\nCheck weight, \nurine, and \nblood pressure \n(see page 532). \n\n\n\nwww. nesperian.org \n\n\nWhere Women Have No Doctor 2010 \n\n\nPrenatal Care (Check-ups during Pregnancy) 77 \n\n\nTo check whether the baby is healthy a midwife may listen \nfor the baby’s heartbeat It may be possible to hear it by \nputting one ear against the woman’s abdomen, but often you \ncannot tell the baby’s heartbeat apart from the mother’s. It is \neasier with a fetoscope. Another sign the baby is healthy is if \nthe mother feels the baby move every day, and if she has felt it \nmove on the day of the check-up. \n\n\n\nChecking the baby’s position \n\nDuring pregnancy, it is common for a baby to change position several times in \nthe womb. By the end of the pregnancy, the baby should be lying in the womb \nwith its head down. This is the best position for birth. To make sure the baby is \nhead down, feel for the head like this: \n\n( \n\n\nWith the thumb \nand 2 fingers, \npush in here, __ \njust above the \npubic bone. \n\n\n\nHave the mother \nbreathe out all \nthe way. Using \nboth hands, feel \nthe baby. \n\n\nThe baby’s bottom is \nlarger and wider... \n\n...and its head is \nharder and \nmore round. \n\n\n2 . Push gently from side to side, \nfirst with one hand, then with the \nother. At the same time, feel what \nhappens to the baby’s body with \nthe other hand as you push. \n\n\nIf the baby’s \nbuttocks are pushed \ngently sideways, the \nbaby’s whole body \nwill also move. \n\nBut if the head \nis pushed gently \nsideways, it will bend \nat the neck and the \nback will not move. \n\n\n\nWith the \nother hand, \nfeel the top of \nthe womb. \n\n\nSo bottom up \nfeels larger \nhigh up... \n\n\n\n\n...and \nbottom \ndown feels \nlarger low \ndown. \n\n\n3 . Just before birth, a baby will move \nlower in the womb to get ready for \nbirth. So, late in pregnancy, you may \nnot be able to feel the baby’s head \nmove. \n\n\nIf the baby is still high \nin the womb, you can \nmove the head a little. \n\nBut if it has already \nmoved lower, you \ncannot move it. \n\nA woman’s first baby \nsometimes moves lower about 2 weeks before \nlabor begins. Second or later babies often do \nnot do this until labor starts. \n\n\n\n1 Ai ?T «- \n\nwww. nesperian.org \n\n\nWhere Women Have No Doctor 2010 \n\n\n78 Pregnancy and Childbirth \n\n\nPreparing \nfor Labor \nand Birth \n\n\n>- If you do not have \na new razor blade, \nyou can use rust- free \nscissors or a knife \nif you boil them for \n20 minutes just before \ncutting the cord. \n\n\nThings to have ready before birth \n\n\nA pregnant woman should have these things ready \nby the seventh month of pregnancy: \n\n\nalcohol \n\n\n\n\nclean string \n\n\nnew razor blade \n\n\n\nclean cloths \n\n\ntwo bowls, one for \nwashing, one for \nholding the afterbirth \n\n\nThese are some additional supplies a midwife or birth attendant may have: \n\n\ni TL^=j) \n\nflashlight \n\n\n\n\nsterile \ngloves or \nplastic \nbags \n\n\n\nm \n\n\n\nseveral \ninjections of \nergonovine, \nergometrine, \nor oxytocin \n\n\n\n\nHIV medicines \nfor mother and \nbaby if mother \nhas HIV \n\n\nblunt-tipped scissors for \ncutting the cord before the \nbaby is born all the way \n\n\n\n\nsterile syringe \nand needles \n\n\n\nsterile needle and gut \nthread for sewing tears \nin the birth opening \n\n\n\ntetracycline or \nerythromycin ointment \nfor the baby’s eyes \n\n\n\nsuction bulb for \nsucking mucus out \nof the baby’s nose \nand mouth \n\n\nThis is also the time to: \n\n• plan transportation \nin case you need to \ngo to the hospital. \n\n\n\nWhere Women Have No Doctor 2010 \n\n\nclean the \nbirth place \n\n\n\nwww. nesperia.il. ore \n\n\nPreparing for Labor and Birth 79 \n\n\nHelping a woman give birth \n\nIf you are pregnant, read this information to know what to \nexpect during labor and after the baby is born. It will also make \nyou better able to help other women during birth. \n\nIf you are helping a woman give birth, reassure the mother \nso that she will not be afraid. Remember that most babies are \nborn without problems. Stay calm and cheerful, and let her \nknow that you trust her ability to give birth. \n\n\n• Keep your nails clean and cut short. \n\n• Wash your hands with soap and clean water. Let them dry \nin the air. \n\n• Know which women have extra risks and learn the ‘Danger \nSigns during Pregnancy’ (see page 73). Make sure the \nmother gives birth in a health center or hospital if she has \nany of these risks or danger signs. \n\n• Learn the ‘Danger Signs during Labor’ (page 85). Take the \nwoman to a hospital if she has any of these signs. \n\n• Treat her with kindness and respect. \n\n\nIMPORTANT \n\n\nProtect yourself \nfrom HIV and hepatitis by wearing \nclean gloves during a birth. If you \ndo not have gloves, use washed \nplastic bags. \n\n\n\nDO NOT \n\n• Do not put your fingers or anything else in the woman's \nvagina. Checking how much the womb has opened does \nnot help the baby to be born, and may cause a dangerous \ninfection. \n\n• Do not give any medicine to speed up labor or to make \nlabor stronger. These medicines can kill the mother and the \nbaby. (Medicines that cause the womb to contract should \nonly be used to stop bleeding after the baby is born.) \n\n• Do not tell her to push before she is ready. When it is time \nfor the baby to be born, she will feel like she has to pass \nstool and will start pushing on her own. \n\n• Do not push on the outside of her womb to make the \nbaby come out faster. This can tear her womb or cause the \nplacenta to separate from the womb too soon. Both the \nmother and the baby can die. \n\n\n\npreventing infection \n\n\n>- For safe childbirth \npractice the 3 cleans: \n\nI. Clean hands \n\n\n\n2 . Clean place to \ngive birth \n\n\n\n3 . Clean tool to \ncut the cord \n\n\n\nWWW. \n\n\nWhere Women Have No Doctor 20 1 0 \n\n\n\n\n80 Pregnancy and Childbirth \n\n\nGiving \n\nBirth \n\n\nSigns that labor is near \n\nThese 3 signs show that labor is starting or will start soon. \nThey may not all happen, and they can happen in any order. \n\n1 . Clear or pink-colored mucus comes out of the vagina. \n\nDuring pregnancy, the opening to the womb ( cervix ) is \nplugged with thick mucus. This protects the baby and \nwomb from infection. When the cervix starts to open, it \nreleases this plug of mucus and also a little blood. \n\n2. Clear water comes out of the vagina. The bag of waters \ncan break just before labor begins, or at any time during \nlabor. \n\n3. Pains (contractions) begin. At first contractions may come \n1 0 or 20 minutes apart or more. Real labor does not \nbegin until contractions become regular (have about the \nsame amount of time between each one). \n\nWhen any one of these signs occurs, it is time to get ready for \nthe birth. Here is a list of things you can do: \n\n• Let your midwife know that \nlabor is starting. \n\n• Make sure that the supplies \nfor the birth are ready. \n\n• Wash yourself, especially \nyour genitals. \n\n• Continue to eat \nsmall meals and \ndrink whenever \nyou are thirsty. \n\n• Rest while \nyou can. \n\nThe 3 stages of labor \n\nEvery birth has these 3 parts. \n\nStage I begins when contractions start to open the cervix and \nends when the cervix is fully open. When it is the mother’s \nfirst birth, this stage usually lasts 10 to 20 hours or more. In \nlater births, it often lasts from 7 to 1 0 hours. It can vary a lot. \n\nStage 2 begins when the cervix is open and ends when the \nbaby is born. This stage is usually easier than Stage I, and \nshould not take more than about 2 hours. \n\nStage 3 begins when the baby is born and ends when the \nplacenta comes out. \n\n\n\nWhere Women Have No Doctor 20 1 0 \n\n\n.rdllticAi&.it'l- \n\nwww. nesperia.il. i \n\n\nr \n\n\nThe 3 stages of labor 8 1 \n\n\nStage I: The cervix opens \n\n\nTo make sure that labor is going well, check: \n\n1. How long has the woman been having contractions and \nhow often do they come? At first, they may come every \n\n1 0 or 20 minutes and last for a minute or less. After some \ntime they will come more quickly — about every 2 to 5 \nminutes — and each one will last longer, about a minute and \na half, until the baby is born. If she has had a contraction \nevery 1 0 minutes or faster for more than 1 2 hours and the \nbaby is not ready to be born, see Too long labor', page 86. \n\n2. Have her waters broken? If they have, ask when. If it has \n\nbeen more than a day, see ‘Waters break and labor does \nnot start in a few hours’, page 85. If the waters are green \nor brown, see ‘Green or brown waters’, page 86. \n\n3. Is the baby in a head-down position? Feel the mother's \nabdomen (see page 77). If the baby is sideways or breech, \nyou must take her to a health center or hospital. \n\n\n\ntoo long labor, 86 \n\n\nwaters break and \nlabor does not start, 85 \n\ngreen or brown \nwaters, 86 \n\nchecking the baby’s \nposition, 77 \n\n\nYou can also help the mother by reassuring her that \nshe is doing well and by encouraging her to: \n\n• stay active. \n\n• eat light foods, not heavy or \noily foods. \n\n• drink as much sweet liquid and \nwarm tea as she wants. \n\n• pass urine often. \n\n• take deep, slow breaths during \ncontractions, and to breathe \nnormally between them. \n\n• not push until she feels a strong \nneed to push (see page 82). \n\n\n\nWalking helps the womb \nopen. It can also make \nthe pain less and help \nthe mother feel calmer. \n\n\nDuring labor, let the woman choose the most comfortable positions. For many \nyears, doctors and some midwives asked women to lie on their backs, but this \nis often a difficult position for going through labor and giving birth. Encourage a \nwoman in labor to try different positions. Most women find it easier to push the \nbaby out when they are kneeling, squatting or sitting propped up. \n\n\n\nWhere Women Flave No Doctor 20 1 0 \n\n\n82 Pregnancy and Childbirth \n\n\nStage 2: Pushing the baby out \n\n\nSigns that it is time to push (this means the cervix is fully open): \n\n• The mother feels a strong need to push. It may feel like \nneeding to pass stool. \n\n• During contractions, you can see the mother's bottom \nbulging and you may see the baby’s head at the opening \nof the vagina. At first, the baby’s head moves back inside \nbetween contractions. \n\nWhat to do: \n\n\n\ntoo-long labor \n\n\n• Stay with the mother all the time and reassure her that she \nand the baby are doing well. \n\n• Each contraction will come with a very strong urge to \npush. When the mother feels like pushing, have her take a \ndeep breath and push as if she were passing stool, but with \nall her strength. Many women find it helpful to moan or \ngroan in a deep voice with the pushes. \n\n• Make sure that everything is going well and is ready for \nthe birth. If the woman has been pushing for more than \n2 hours, see Too-long labor,’ page 86. \n\n\n\nBirth of the head \n\nWhen the baby’s head stays at the opening of the vagina, \neven between contractions, it is time for the head to be born: \n\n1 . Tell the mother not to push hard, but to \ngive little grunts or little pushes. \n\n2. Allow the head to come out slowly, \nbetween contractions. This will help to \nprevent the mother’s skin from tearing. \n\n3. After the head is born, wipe the baby’s \nmouth and nose with a clean cloth. \n\n\n\n\n\nVj|l/ \n\nNow push hard. \n\nNow do not push hard. \n\nThe head usually comes \n\n...then the baby turns so \n\nout face down... \n\nthe shoulders can be born. \n\n\nBirth of the shoulders \n\nTo help the shoulders come out: \n\n1 . Gently hold the baby’s head and guide it toward the \nmother’s back (away from her abdomen). This lets the front \nshoulder be born first. Never pull or twist the head. \n\n2. The rest of the baby will then come out easily. Be ready! \nHold the baby so it does not fall. \n\nnespenan.org \n\n\nWhere Women Have No Doctor 2010 \n\n\nThe 3 stages of labor 83 \n\n\nCare of the baby at birth \n\nA healthy baby will start breathing, move its arms and legs, and \nstart crying right away. To care for the baby: \n\n\n• Wipe its mouth and nose with a clean cloth. To help the \nmucus drain, keep the baby’s head lower than its body. If \nthere is a lot of fluid or mucus, remove it with a suction bulb \n(see page 86). \n\n• Give the baby to the mother right away. Put a \nclean cloth around both of them. Do this as soon \nas possible so the baby stays warm. \n\n• Put the baby to the mother's breast \nimmediately. When the baby sucks, the mother’s \nwomb tightens and stops the bleeding. This will \nalso help the placenta come out more quickly. \n\n• Tie and cut the cord only when it turns white and stops \npulsing. To prevent tetanus, a serious disease that kills many \nbabies, cut the cord close to the baby’s body. \n\n\n\nTo cut the cord: \n\n\nI. \n\n\n2 . \n\n\nWhen the cord stops pulsing, put 2 clean ties around it, using square knots. \nPut one tie about 2 finger widths from the baby and put the other one \nabout 2 more finger widths farther from the baby. \n\n\nThe first loop of \na square knot... \n\n\n\n...the second loop of \na square knot. \n\n\n\nCut the cord between \nthese 2 ties with a new \nrazor blade. If you \nmust use something \nelse to cut the cord, \nmake sure it has been \nboiled for 20 minutes. \n\n\n\nTie the cord in 2 \nplaces before cutting. \nThe chance of a \nbaby getting tetanus \nis greater when the \ncord is cut far from \nits body. \n\n\nIMPORTANT \n\n\nTo avoid tetanus and other infections , the cord and anything that touches \nit must be very clean. Never put dirt or animal dung on the cord stump. \n\n\nCare of the eyes \n\nGonorrhea can cause blindness. \nSince many women do not know \nthey are infected, put \\% \ntetracycline, erythromycin, or \nchloramphenicol eye ointment \nin each of the baby’s eyes \nwithin an hour of birth. \n\n!(jf)rlU S+k *r \n\n\n\nPull down the \nlower lid to put \na little bit of \nointment inside. \nPutting ointment \noutside the eye \ndoes no good. \n\n\n\nproblems in \nnewborn babies \n\n\nWWW. \n\n\nWhere Women Have No Doctor 2010 \n\n\n\n\n84 Pregnancy and Childbirth \n\n\n\nRolling the nipples \ncon help the womb \ncontract and stop \nbleeding. \n\n\nStage 3: The placenta comes out \n\nWhen the baby is wrapped and at the mother's breast, it is \ntime for the placenta to come out. \n\nWatch the vagina to see when the cord gets longer. This \nmeans the placenta is separating from the womb. Also watch \nto make sure there is no heavy bleeding. When the cord \nlengthens, tell the mother to push out the placenta. Do not \npull on the cord. \n\nIf the placenta does not come out right away and there is \nno bleeding, it is OK to wait up to I hour. \n\nTo help the placenta come out: \n\n• Have the mother squat and push. If she cannot push, have \nher blow into a bottle, sneeze, or cough. \n\n• Ask the mother to pass urine. \n\n• Encourage the baby to nurse, or have someone roll the \nmother’s nipples. This will help make her womb contract. \n\n• If nothing else works, give her an injection of 10 milligrams \nof oxytocin in her buttock or thigh. \n\n• If the mother starts to bleed, see page 92. \n\n\n>■ When the placenta \nis out, put it in a bowl \nand check it to make \nsure it is all there. \n\n\n\ntoo much bleeding \n\n\nCheck the placenta \n\nUsually the placenta comes \nout whole, but sometimes a \npiece gets left inside. This \ncould cause bleeding or \ninfection later To see if \neverything has come \nout, check the top and \nbottom of the placenta, \nand the membranes from \nthe bag of waters. \n\n\n\nIf the mother is bleeding, or there seems to be a piece of \nthe placenta or membranes missing, follow the instructions on \npage 92 for too much bleeding. \n\n\n\nDanger signs during labor 85 \n\n\n\nDanger signs during \n\nLABOR \n\n• waters break but \n\n• bleeding before the \n\n• green or brown waters \n\nlabor does not start \n\nbaby is born \n\n• fever \n\n• baby lying sideways \n\n• too long labor \n\n• convulsions or “fits” \n\n\nWaters break but labor does not start \n\nMost women will give birth within 24 hours after their \nwaters break. If labor has not started after 1 2 hours, the \nwoman and her baby could get a serious infection. \n\nWhat to do: \n\n• The mother must not put anything in her vagina. She \nshould not have sex. This could cause an infection. \n\n• If she has a fever or there is a bad smell in the vagina, an \ninfection is starting. She needs intravenous (IV) antibiotics. \nEven if labor starts, the woman and her baby could die. \n\nGo to a health center or hospital. \n\n• Try to get labor started. The woman should swallow \n2 tablespoons of castor oil, roll her nipples, or have \nsomeone suck them for a while every few hours until labor \nstarts. There may also be special local teas that women use \nto start labor. If labor still does not start after a few more \nhours, she should go to a health center or hospital. \n\n\nDANGER!! Do \n\nnot use injections \nto start labor. \n\nThey can cause \ncontractions that \nare so strong that \nthey can kill the \nwoman or the baby. \n\n\n\nTRANSPORT! \n\n\nA \n\nOIL \n\n& \n\n\n\n\nBaby lying sideways (transverse) \n\nIf labor has started and the baby’s arm comes out \nfirst, it almost always means the baby is sideways. \nCheck the baby’s position (see pages 75 and 77). \n\nA baby lying sideways cannot be born without an \noperation. Do not try to change the position of the \nbaby once labor has started. This can tear the womb \nor separate the placenta from the womb wall. \n\nWhat to do: \n\nTake the mother to the hospital. \n\nBleeding before the baby is born \n\n\n\nSome light, pink-colored fluid, or mucus and brown blood \nduring labor is normal. But if the mother is bleeding bright red \nblood, it could mean that the placenta is separating from the \nwomb wall or is covering the opening of the womb. This is \nvery dangerous. \n\nWhat to do: \n\nTake the mother to the hospital right away. If possible, start \nan IV and give her IV fluids. \n\nI I if (I r ~- \n\n\n\nTRANSPORT! \n\n\nWWW. \n\n\nWhere Women Have No Doctor 20 1 0 \n\n\n86 Pregnancy and Childbirth \n\n\n\nshould not see the \nsun rise twice. \n\n— Proverb from Niger \n\n\n\nTRANSPORT! \n\n\n\nTRANSPORT! \n\n\n>- A woman who \nis only a little warm \nmay just need to \ndrink more fluids. \n\n\n\nTRANSPORT! \n\n\nToo-long labor \n\nIf the mother has been in good strong labor for more than \n1 2 hours, or she has been pushing for more than 2 hours without \nany signs that the baby will be born soon, there may be a problem. \n\nWhat to do: \n\nIf her contractions are not coming every 2 or 3 minutes \nand lasting for a full minute, she may not be in good labor \nyet. Encourage her to sleep. If she cannot sleep, ask her to \nroll her nipples and walk between contractions to help labor \nget stronger. Encourage her to drink and eat light foods. Fruit \njuices or tea with sugar can give her energy. \n\nIf the mother has been in labor for more than I 2 hours, or \nhas been pushing for more than I hour; take her to a health \ncenter or hospital. She may need medicines to help her labor \nor an operation for the baby to be born. \n\nGreen or brown waters \n\nBrown or green waters can mean that the baby is in trouble. \n\nWhat to do: \n\nIf it is still early in labor or if the mother has not started \npushing, it is best for this baby to be born in a hospital. \n\nIf the mother is in Stage 2 of labor and the baby is \ngoing to be born soon, have the mother push as hard \nas she can and get the baby out quickly. As soon as \nthe baby’s head is born, wipe its mouth and nose with \na clean cloth or use a suction bulb to suck the \nmucus out. Keep the baby’s head lower than its \nbody to help the mucus come out. If the baby \nhas difficulty breathing, take it to a hospital. \n\nFever \n\nFever is usually a sign of infection. \n\nWhat to do: \n\nTouch the woman's forehead with the back of one of your \nhands, and touch your own forehead with your other hand. \n\n(See page 530 for taking temperature with a thermometer if you \nhave one.) If she feels a little warmer than you, she may just \nneed fluids. Give her plenty of water, tea, juice, or soda pop. \nRemind her to pass urine every few hours. \n\nIf she feels very hot to touch and she has chills, take her to a \nhealth center or hospital. She needs antibiotics right away. Give \nampicillin, 500 mg by mouth every 6 hours, or inject 1 .2 million \nUnits of procaine penicillin into her buttock or thigh, every 12 \nhours until you can get to a hospital. \n\n\n\nWhere Women Have No Doctor 20 1 0 \n\n\nwww. nesperia.n.orc \n\n\nDanger signs during labor 87 \n\n\nSeizures (“fits”), or very swollen hands and face \n(eclampsia) \n\nIf the mother starts to have a seizure (“fit”): \n\n• Put something under\n…[truncated]", "summary": "Where Women Have No Doctor A health guide for women A. August Burns Ronnie Lovich Jane Maxwell Katharine Shapiro Editor: Sandy Niemann Assistant editor: Elena Metcalf Hesperian Berkeley, California, USA WWW enan.org Hesperian Foundation and the contributors to WhereWomen Have No Doctor do not assume liability for the use of information contained in this book. This book should not replace properly supervised, hands-on training. If you are not sure what to do in…", "source_url": "https://archive.org/details/WhereWomenHaveNoDoctor", "pdf_url": "https://archive.org/details/WhereWomenHaveNoDoctor", "case": "hesperian", "sub_case": "A. AUGUST BURNS", "tags": ["hesperian", "RADICAL MEDICINE; PEOPLE'S HEALTH. HERSPERIAN FOUNDATION"], "page_count": 0} {"title": "A directory for midwives: or, a guide for women, in their conception, bearing, and suckling their children. The first part contains. 1. The anatomy of the vessels of generation. ... 9. Of nursing children. To cure all diseases in women, read the second part of this book. By Nicholas Culpeper, ... Newly corrected from many gross errors. 1755", "content": "By Nicholas Culpeper, Gent. Student \n\n\n— \nf 4 \n\n4 \n\nö \n\n\nDIRECTORY \n\n\n1300 \n\n\nMIDW I a8 \n\n\nOr, A Guide for \nW OM E N, \nConception, \n\n\nIn their Bearing, and \nSuckling their Children. \n\n\nThe Firſt Part contains. \n\n\nThe Anatomy of the Veſſels of Generation. \nThe Formation of the Child in the Womb. \nWhat hinders Conception, and its Remedies, \nWhat furthers Concepticn. \nA Guide for Women in Conception. \nOf Miſcarriage in Women. \nGuide for Women in their Labour. \nA Guide for Women in their Hing -In. \nOf Nur/ing Children. | \n\n\nTo 2 all Diſeaſes in TVomen, Read the Second \nPart of this Book. \n\n\nO e Pee yn \n\n\nin Phyfck and Aſtrology. \nNewly Correct from many groſs Errors. \n\n\n£ 1 \nPrinted for S. BALLARD, R. Wars, S. BIRT, \n\n\nSos ren, and L. Hawes, and J. Hopces, \nM. DC. LV. \\ X \n\n\n—— \n\n\nͤ—U—ü—ü— —ü—s \n\n\n9 —— _ \n. — ———_—_———— \n\n\n\\ 4 = 3 : 8 ; \n\n\n* \nPORE Ne \n* % \n* \n— \n17 \n** \n4 \n0 \n* \n* \n— \n\n\n„ \n\n\n* E —— 8 —— EXERER \nXN. Je he NN \n\nE ED S \n\n* N \n\n\nTo the MIDWIVES of England, Nicholas \nCulpeper wiſheth Succeſs in their Office \nin this World, and a Crown of Glory \n\n\nin that to come. \nWorthy Matrons, E \n* O U are of the Number of thoſe whom \n\n\nmy foul loveth, and of whom I make - \nGi mention in my Prayers, and ha- \nving (upon fixed \"Reſolutions ) conſe- \ncrated the reji of my Life to the Service of my \nCountry, in what Knowledge I was brought \nup in, or have ſpent the greateſt part of ny \nStudies about: \"The moving cauſe of which, \nwas a ſerious Conſideration of the notable In: \n* juries offered to Men and Women and indeed \nTo the Kingdom in general, by abſconding the \nRules of Phyſic from them, either not writing \nthem at all, or to no purpoſe, whithis ſo appa \nrent, that a Man needs not the Eye of a Lynx \n| to ſee it, he may read it running, though he \ns as blind as a Mole, if he hath but bat If fo \nmuch Natural Viſtindt. What Inſis n. In- \n; A 2 jury \n\n\nTo the Midivi. VES. \n\n\nJury 15 it, that Men and Women ſhould be \ntrained up in ſuch I gnorance, that when they \nare Sick and have Herbs in their Gardens \nconducin to their Cure, they are ſo Hoodwinked, \n\n\nthat they know not their Vertues. IJ not this to \n\n\n#phold a Company of Lazy Dottors, moſt of whoſe \nCovetouſneſs outweighs their Wits as much as a \nMillſtone outweighs a Feather ? How they will anſ- \nwer for it another Day, God knows, I pity their Con- \ndition: This world will not laſt always. The Con- \nde of this, I ſay, put me upon it, to write \n\nhyſic in my Mother-Tongue, I thought, and, yet \nT think I am not miſtaken in my thought, that it were \n& goed, acceptable Work, well pleaſing both to God \nand Man, to employ that talent God hath given me, \n\n\nfor the repreſſing of this ſo great, fo apparent, ſo \nſenſible an Evil, I 1 fail, it's in the Power, not \n\n\nin Will; and God accepteth the Will for the Deed, \n\n\nand ſo will godly People for Godlinefs is derived from \nGod's likeneſs, I conceived a few thoughts, aud I \nhope to bring them to perfect Birth, viz. To lay \n\n\ndown ſome Rules whereby a Man may as well prevent \n\n\nSickneſs before it comes, as a Remedy for it when it 1s \ncome. And that this may be done Mathodically, for \nthings laok beſt when they are in Order, becauſe God \n2s the God of Order, I determined to write of the \npreſervation of Man, even from his Conception to his \nGrave. What now remains, but to bring this De- \n\n\nzerminatian into aft ? In doing which, I began here \n\n\nand having began here, to whom ſhould TI Dedicate \nit, but to you? And though I confeſs the Theory \n. 0 \n\n\n— \n\n\n8 \n\n\nTo the Midwives. \nof this be requifite, very requiſite to all Women, \nyet to whom doth the Practical Part of it belong, \nbut to your ſelves ? If you pieaſe to make Experience \n| of my Kules, they are very plain, and eaſy enough; \n\n| nei: her are they ſo many, that they will burthen your \nBrain, nor ſo few that they will be inſufficient for \nyour Neceſſity. If you make uſe of them you will \nfind your Work eafie, and you need not call for the \nhelp of a Man-Midwite, which is a Diſparagement, \nnot only to your ſelves, but alſo to your Profeſſion. \nAnd let me tell you this (and I'll tell you but the ' \ntruth) to your Knowledge, Care, and Skill, is com- \nemitted both the being and well being of Women in \n- Labour. The Creator of Heaven and Earth, the \n; Ged of all the World, the greateſt being of all things, \ncommits the Life of every Child of his to your Charge, \neven from the very firſl Minute that he allots it ta \ndraw its Breath, and at your hands will he have \nan account of it another Day. Oh! What manner \nof Woman ought a Midwite to be ! With what \nKnowleage, Skill, Care, Induſtry and Sincerity ought \nſhe to perform her Office? Let every honeſt Woman \nthat takes this Charge upon her, take Care of it, \nand when ſhe comes to deliver a Woman, let her know, \nthat for that Day or Night's Work, ſhe muſt ano- \nther Day give account before Jehovah, the Lord \nJeſus Chriſt, and all the Angels. Þ \n\n\nSo ſoon as you have read this, you will preſently. \nagree with me, that a Midwite ought to be as quick \n fighted as Argus, her wits muſt be in her Head, \n\nA 3 | for \n\n\nTo the Midioi ves. \nfor Becks are at home. Hippocrates was never bet- \n\n\nter ſeild in the Rules of Pas 2 ow a Midwife j \nought to' be. | ; \n\n\nad \n\n\n& A. a \n\n\nTo ind 72 all in a dt ord, all the Affections that © ö \ncan be in a Woman, ought io be in a Midwiie, Ee \nfirſs flep to which is to know your Ignorance in that \npart of Pkyſick «which is the Bafis of your att. When \nyou know- what you want, then you know what to \\ \ncrave; and you now who \"ſaid, If any want Wi-... \n\n( \n\n\n.(® \n\n\ndom let him aſk it of God (not of the College \nof Phyſicians, fer if they do, they may hap to go \nwithout their Frrand, unleſs. they bring Money ith \nthem) for he gives liberally to all Men, and up- \nbraideth no Man. Many of you are antient, but \nif you be too Old to learn, you are as much too proud. 1 \nGod ſpeaks not now by Voice to Men and Women as . \nformerly he did, but he ſpeaks in, and by Men, and \n *tis no part of Wiſdom for lo ſtop the Far againſt il. \nFhen Chriſt Preached in Noah, the Old World. did \nfo, and you kuiw what came. after. I confeſs, God \nhath given me ſome little Sparks of Knowledge, 1 \nF &o not call them little as they come from Goa, for | \nF fuch à word*would hold forth, if not Blaſphemy, 2 \nF Jet exiream Ingratitude; but I call them little : \ncomparatively, in reſpect of what ſhall ſhortly be \nrevealed to the Sons 55 Men. Yeu all know the Day \n; muſt break before the Sun riſeth, and this I know \n(os ſurely as I know my 09 Name) if I reveal what \nI know, this lighi ſhall increaſe in me a perfect Day. \nVI bide it, I know as well what became of that Ser- \nvan \n\n\nTo the Midwives. \nvant that wrapped up his Talent in a Napkin, and \n\n\n/ \n\n\n* * buried it in the Ground; and when I think what will \nbecome of him, I tremble to think what will become of \n- | others that do the like. \n\n\nTo conclude: Grave Matrons, Be diligent in your \nOffice, and be as careful as diligent, as well to pre- \nvent Evils before they come, as to provide for then \nwhen zhey are come. So may you expe#? the Bleſſing \nof God upon you and yours, the Lord will build your \nHouſes as he did the Midwives of the Hebrews, \nwhen Pharoah kept their Bodies in a great Bondage, \nos Phyſicians of ous Times do your underſtandings. \nAnd when the Days allotted for you to live in this \nWorld are expired, and the time of your Change ſhall \ncome, the Lord will provide an Habitation for you \nn t made with Hands, which will never paſs away. \nYou know whoit was that promiſed, It you be faith- \ntul to Death you ſhall have a Crown of Lite. \n\n\n.(® \n\n\nhave written in this Book, not to be according to truth, \n. for am but a Man, and therefore ſubje to failings, \nfirſt judge charitably of ine: Charity and Honeity \nalways walk hand and hand together, and think \nIll of no Man. 2dly, Acquaint me wwith them, and \nthey ſhall be both ackuowledged and amended. As for \nmy ſelf, 1 defire durirs my Life, always to. remain, \n\n\nYours to what I may, or can, \n\n\nNich. Culpeper. \n\n\n7 \n\n\nBOGRS Printed for S. BALLARD, R. WARE. \n\n\nS. BIN T, C. Hirtcn, and L. HAwzs, \nand J. Hopes. \n\n\nT HE Erglh Phyſician enlarged, with there hundred \nand fixty Medicines made o Engliſb Herbs, that were \n\n\nnot in any Impreſſion until this; being an Aſtrologo \n\n\nPhyſical Diſcourſe of the vulgar Herbs of this Nation; \n\n\ncontaining a compleat Method of Phyſick whereby a \nMan my preſerve his Body in Health, or cure himſelf, \nbeing fick, for three Pence Charge, with ſuch Things \n\n\nas only grow in England, the being moſt fit for Engliſt \nBodies, &c. by Nich. Culpeper, Student in Phyſick and \n\n\nAſtrology, Price 2s 64. \n\n\nThe Ladies Diſpenſatory; or, every Women her own \nPhyſician, treating of the Nature, Cauſes, and various \n\n\nSymptoms of all the Diſeaſes Infirmities, and Diſorders, \nnatural or contracted, that moſt peculiarly affect the fair \n\n\nSes in all their different Situations of Life; as Maids, \nmarried Women and Widows ; with a Variety of pro- \n\n\nper Remedies in Words at length, adapted to each \nparticular Caſe, agreeable to the beſt modern Practice. \nAlſo a compleat Index, an Explanation of difficult \nTerms, and a copious Preface, including a pathetic \nAddreſs to all faſhionable Mothers, in behalf of them- \nfelves and their tender Offspring. The ſecond Edition, \nPrice, 2s 6d. \n\n\nAn Eſſay towards a Complete New S{ſtem of Midwifry, \n\n\nTheoretical and Practical. Together with the Diſcrip- \ntions, Cauſes, and Methods of Removing, or Relie- \nving the Diſorders peculiar to Pregnant and Lying: in \nWomen, and New-born Infants. Interſperſed with, ſe- \nveral New Improvements ; Whereby Women may be \ndelivered, in the moſt dangerous Caſes, with more Eaſe \n\n\nSafety, and Expedition, than by any other Method \n\n\nheretofore practiſed: Part of which has been laid before \nthe Royal Society at London, and the Medical Society \nat Edingburgh ; after having been peruſed by many of \nthe moſt Eminent of their Profeſſion, both in Gree? Bri- \ntain and Ireland; by whom they was greatly approved of. \nAH Drawn up and Illuftrated with Several Curious \nObſervations, and Eighteen Copper-Plates. In 4 Parts. \n\n\nBy JOHN BURTON, M. D. \n\n\nOf the Veſſels dedicated to \nG EN E, RA T I \n\n\n\"= \n\n\nBOOK I. \n\n\np R O OE MI U M. \n\n\nH E Eternal God, the Creator of all things, \nhaving made that wonderful Work of his the \nframe of this World every jot of which ſhew \neth forth the infinite Power and Glory of \nGod to the Sons of Men; for God made the \norld to fhew his infinite Peaver and Wiſdem, and he will de- \nfrray the World to fhew' his Fnfice; and he yet preſerves the \nWorld to fhew his Mercy and Patience to the Sens of Men) \nhe afterwards made Man in his own Image, an Epitome of \nall that he had made, in ſuch a manner, that whatſoever \nis to be ſeen in the World may be found in Man, And he \nmade him Ruler over the Workmanſhip of his Hands, ſo \nthat there is nothing within the whole Circle of the Creation \nwhich God did not make ſubject to the induſtrious Capacity \n\n\nof Man; but Man being thus happy, made himſelf a» un- \n\n\nhappy by his Fall, that he is loathſome even to himſelf and \nothers, even at his very Nativity, which is moſt pathetically \ndeſcribed in Ezek. 16. 4,5. And as fer thy Nativity in the \nDay thou waſt Born, thy Navel was not cut, neither wwas thou \newaſhed in Water to ſupple thee; thou craſt not ſalted at an \nor fuoadled at all, No Eye pitied thee to do any of theſe un \nto thee, to have compaſſion upon thee but thou waſt caſt out \ninto the open field, to the loathing of thy Perſon in the Day \nthat thon wwaſt Born: And from this original Sin pro- \nceed thoſe abominable Actions which we may daily ſee \nin the World; for by it the underſtanding is blinded, the \nWill perverted, and Conſcience ſhipwreck'd. After this the - \nLord in pure Mercy to Mankind, ſent the Lord Feſus Chriſt, \nhis only begotten Son, who was equal with the Father, to \n\n\ntake our Nature ppon him, and thereby unite us again to the \n\"7 2 Deity \n\n\n2 . Culpeper's Midwife Enlarged. \nDeity, and to ſatisfy his Juſtice to the uttermoſt for our \nSins, whereby we are again intereſted in Heaven ; what \nremains then of us to be done more than by conſidering the \n_ uncertainty of Man's Life, and. how many Caſualties he is \nſubject to here below, to labour what in us lies to icarch \nout the ſecrets of Nature whereby we may preſerve our own \nLives the more to glorife 'our Maker and to communicate 5 \nthat knowledge, which by our induſtry we have obtained, | \nunto the Sons of Men our Brethren? Doubtleſs this was \nthat which moved Sz/czzom to make choice of Wiſdom, ac- \ncounting Riches but dung, and a Kingdom but vanity 3 \nneither did he keep cloſe his knowledge to himſelf (as 100 \nmany now a-Days. do) but he publithed large Diſcourſes \nboth of Birds and Beaſts, Herbs and Trees, and of all the \nStars of Heaven, however through the Iniquity of the \nTimes they are ſince loſt. The very ſame Principles firtt | \nmoved me to publiſh what I knew to the World ; and ex- Y \n1 witneſſeth to me, that the more I reveal that \nnowledge God hath given me to the World, the more he \nfill teacheth me; and being determined within my ſelf, \nnot to give over till I have finiſhed the whole Body of Phy- \nfic, I begin firſt at the Principles. namely, The Anatomy \nof the Veſſels dedicated to Generation; for above all \nthings I hold it moſt fitting that the Women ( eſpecially \nMidwives } ſhould be well ſkill'd in the exact knowledge of \nthe Anatomy of thoſe Parts. Let it not oe objected to me \nthat many good Midwives are ignorant of it: What then, f \nthe more is the Pity, ſay I; muit not I teach my Child a | \nreaſon for what it ſaith, becauſe a Parrot can ſpeak as \nplain as it without it? A Midwife is jor elſe ſhould be) Na- \nture's helper; and how can any help Nature, and not be \nwell -{\\iI'd in the Tools by which Nature doth her work? \nThis then is the Buſineſs of this Book, a7z.. To give you a \nbrief, yet very perfect Anatomy of thoſe Members which \nNature uſeth as Inſtruments to beget its like, to which I 1 \nhave added ſome means how to preſerve them clean and (3 \npure, the Neglect of which I conceive to be the reaſon of \nmoſt Miſcarriages in Women, nay, and of the Death of \nChildren in their Infancy : Which being done in all reaſon, | \nthe manner of Nature's forming the Work, and faſhioning | ; \n\n\nCE IT TI IE. 1 \n— = \n” \n\n\nWy . \n\n\nwg \nou \n\n\n| Culpeper's Midtoife Enlarged. - 3 \nthe Child in the Womb, is next to enſue, ſhall (the Lord \n\n\naſſiſting me) in the next place be handled, \n\nThe Inſtruments of Generation are two ſorts, Male, and \nFemale: Their uſe is the Procreation of Mankind; the \nOperation is by Action and Paſſion, the Agent is the Seed, \nthe Patient Blas; So that the Body of Man being compo-- \nſed by Action and Paſſion, he muſt needs during his Life \nbe feet to them both. Let no Man object to me, that \nmany have written worthily of this ſubject before; tis very \n\n\nprobable, and 'tis true that there is no leſs reaſon and \n\n\nunderſtanding required to judge of Sciences formerly writ- \nten, than there is to be the firſt Writers of them. I have \nbeen as plain as I can, and that ſatisfies me, and ſo I \nhope it will do all honeft People. \n\nTo return to our purpoſe, that this may be made clear \nand hone?, and Women know what they have to do, I \nſhall divide this Book into two Sections. FR \n\n\n3 3 I. Genitals of MEN. | \nVIZ, . \n2. The Genitals of W OMEN. \n\n\nAll theſe are far more exatly deſcribed in Veſtingius's Aua- \ntomy in Engliſh, Aud also in Riolanus's Anatomy, tvey are \nmot clearly deſcribed, with the Diſeaſes incident 270 theſe Parts, \nand the Seat of e Diſeaſes. And for the Cure of all Dejeajes, \n\n\nfee Riverius's Prad e of Phyfick in Engliſh. \n\n\nThey that think the uſe of theſe Medicines is two brief \n(it's fo only for cheapneſs of the Book) let them read \ntheſe Books of mine. viz. Platerus, Sennertus, Riwerius, \nKRiolanus, Bartholinus, Fobnſlon, Veſtingius, &. \n\n\nS \nThe Genitals of MEN, _ \n\n\n* \n\n\n< \n> \n\n\nF Irſt for the Genizals of Men (for I hope good Women \nwill pardon me for ſerving my own Sex firſt) ſome pre- \npare Matter to make Seed of, and they are called Vaſa Præ- \nparantia; ſome elaborate, or work this Matter, as the Car- \npus Variceſum; ſome make the By fruitful, as the Ts \nh A ome \n\n\n= \n\n\n4 Culpeper's Midwife Enlarged. \n\nfome carry the Seed back from the Stones, and thoſe are \ncalled Deferentia; ſome keep or contain the Seed ſo carried, \nas the Seminal Veſels, or the Praſtatæ; ſome ejaculate or \ncaſt out this Seed from the Veſſels into the Womb, as the \nTard. I would willingly ſpeak a Word or two of each of \ntheſe Parts; but leſt kind Women (whom my intent is to \nPleaſe in this Treatiſe, if doing good to them will pleaſe \nthem) ſhould be offended that I explain not thoſe ſtrange \nNames which the Rabbies of our and former Ages have uſed \nto muffle up our Eyes, leſt we ſhould ſee the truth and fo \nbreak the yoaks of Bondage from off our Necks) left ( I ſay) \nthey ſhould be offended, I deſire them to take notice, that \nthey ſhall find them explained in an Alphabetical Order at \nthe latter end of the Book ; the — of former times \n\n\nBath been ſuch, that I want fit Engliſh Terms to expreſs \n\n\nthem unleſs I ſhould Coin them, and that I leave to be done \nby ſuch as affect Novelties, If I ſhould every time they \nmention their outlandiſh Words (part of which are Greet, \npart Latin) ſtand to explain them, it would trouble the Rea- \nder's Patience much to read them, and mine more to write \nthem therefore when you meet with them, ſearch the Table \nat the latter end of the Book and you may underſtand them. \nI would defire ſuch Gentlemen that are ſkilled in Anato- \nmies (of which I am afraid there are but few) to pardon me \nin that I have not follow'd the vulgar Rules of Anatomy, I \ndeſire them to know that I am not unſkilled in moſt Anato- \nmies that are written; and h2ve been an Eye-witneſs in all \nI have written: My. Opinion is, that he is not very wiſe \nthat altogether neglects Authors, but he is a Fool in grain \nthat believes them before his own Eyes, I commit my wri- \nup to the Tryal and Cer ſure of time, as they have done \n\n\nbefore me, and fhall with gladaeſs embrace that Man that in \n\n\nthe Spirit of Meakneſs (which is next of kin to the Spirit of \n\nGod) elis me of my Errors. Be diligent, be diligent ; God \nand good Men hate idle Men and Women; and that you \n\nmay be Methodically diligent, be pleaſed to accept of this \nfirit Section, ſubdivided into theſe enſuing Chapter; I hope \n\nyou will pardon me if I ſhould be a little critical, or at leaſt \n\nfer: ear your cenſure till you know, and are able to prove I \n\nam n an Error; he that cenſures before he knows, publiſh- \n\n| ee = \n\n\n. - _ \ne \n\n\nCulpeper's Midwife Enlarged. 3 \n\n\neth to the World that he is an envious Fool. 8 \nwould be knowing Fhyſicians, let them ſtudy theſe Books \nUS, Riolanus, Bar- \n\n\n» of mine, wiz. Platerus, Sennertus, Riveri \ntholinus, Fohnſlon, Veſtingius. _ \n\n\nOf the Preparing Veſſels, \n\n\nCorpus Varicoſum 2 \nJ The Teſticles or Stones 3 q \n2 Vaſa Deferentia 4 ; \n> _ The Seminal Veſels 5 \n1 The Tard. 5 | 6 \nOf all theſe in Order ; and although ( perhaps ) they may \n\nbe more than many of you have heard of, yet not one more \n\nthan is true, nor a tittle more than is uſeful. \n| . \n1 Of the Vaſa Præparantia. \n| Their THESE Galen calls ai, — \n\n\nNames. and the Latins Vaſa Preparantia, the fitteſt \nterm we in Engliſh can give them ( for we \n: muſt borrow terms of other Nations that we may make the \ncommon People believe wonders, that ſo our {elves may \nif grow rich and proud, and keep, Folk in ignorance, though \n( - to their own. undoing, and the loſs of many a dear \n| J . Life) is Preparing Yefjels, which name is taken from \ntheir office which is to prepare that matter of ſub- \n| ſtance which the Stones convert into Seed and fit it for that \nwork ; they are in number four, two Veins, and as many \nArteries. | \nAnd here by the way let me inſtru you in one notion \n(for I make no queſtion that Phyſicians have kept you in \nIgnorance enough) the liver is the original of Blood, and \niſtributes it through the Body by Veins and not the Heart, \nas 4riftotle's waking Dreams was, viz. That the Heart was \nfirſt formed in Man, and is the ſeat of Blood, and the Sun \nof the Body, as the Sum is the Hear: of the World: But we \nſhall prove another manner of Microceſmical Sun by and by, \n. ; WAEN- \n\n\n6 Culpeper's Midwife Enlarged, \nwhen we cone to ſhew Aſtrologically how Man is formed in \nthe Womb. Y:/ingins and many other Anatomiſts which \ndanced after 4/otle's Pipe, fell into the fame Error. It's \nuſe is to nouriſh the Body and repair decaying Fleſh ; and \nthat you may conceive to be the reaſon why Men which keep \na very ſlender Diet, fall away in Fleſh, becauſe they want \nFood to breed Blood enough to nouriſh them. The Heart is \nthe original of the vital or quickning Spirit, which it diſtri- \nbutes to the Body by the Arteries : I pray remember this \nall along. For you will ſee ſome effects of it in the next \nChapter. | \nThe Veins (as I told you) are two, a right and \nNumber. a left; the right proceedeth from the Original \nJens Cava; the left from the Emulgent Vein, al- \nthough haply through that ignorance you have been trained \nup in, you know not What belongs to theſe Veins, neither \nis my preſent taſk to teach you ; yet hereby you may come \nto a fight of your ignorance and that is the firſt ſtep to \nknowledge; and I aflüre you, if) ou want love to know- \n\n\nledge no more than I want will teach you, you may {it God \n\n\nhinder not) have more by one half than you have, before \nyou he two Years older. | \n\nI confeſs the Learned make a grievous quoyl what the \nreaſon is, theſe two Veins ſhould p.occed from a different \nRoot: I could quit them, and mine own Opinion too, and \nI ſuppole you partly believe it; but I forbear, it being my \nOpinion that young Naturaliſts as well as young Chriſtians, \nouzht not to be led into doubtful diſputations. \n\n\nBoth Arteries ariſe from the great Artery, which the \n\n\nGreets call ax», which is indeed the great Trunk and \n\n\nOriginal of all the Arteries. \n\nSuch as would cure all Diſeaſes, let them read theſe \nBooks of mine, wi2s. Platerus, Sennertus, Riverius Riolanus, \nBarthelinus, Tohnfton, V. eltingius, &c. \n\n\nCAP. \n\n\nOf the Corpus Varicoſum. \n\n\nY O U remember what I told you was the uſe of the \nVeins and Arteries: the preparing Veins and Arteries, \n\n\nthe \n\n\nC \nſ \n3: \n\n\n— 2 \n8 \n\n\npad 4 — — — — — Þ \"2 Þ — 2 jay \n\n\nCulpeper's Midwife Enlarged. 1 \nthe one carrying Blood the other vital Spirits, and all tend- \ning to the Propagation of Man: All four tend down directly \nto the Stones; tis not my preſent ſcope to tell you which \nway : They ſerve as. Labourers to carry the Stones \nwhat they nced; as Labourers carry Brick and s Uſe. \nMortar to the Maſons to build an Houle, ſo theſe . \ncarry Blood and vital Spirits to the Stones to make Seed, \nand now you know whereof Seed is made, iK. Vital and \nNatural Blood or Blood and Vital Spirits (which you pleaſe) \nconcocted by the Stones. We ſhall have occaſion further to \nſpeak of this before we come to a concluſion of the Book, it \nis not proper in this place. But ſtop a little, Labourers tem- \nper their Mortar before they bring it to the Brick-layers ;. \nneither is it fit the Stones ſhould & all the Work themſelves, \nhaving ſour Servants to attend them, therefore theſe four \nVeſſets, though at their firit deſcenſion they keep at ſmall \ndiſtance the one from the other, before they enter the Teſ- \nticles or Stones (call them by which Name you pleaſe) they \nmake a curious implication, intertexture, or twiſting the \nene from the other, which the Greets call axarmumzo (if \nbe not miſtaken) the Word ſignifies a 4%, ſometimes the \nVeins go into the Arteries ; ſometimes the Arteries into the \nVeins ; tuen they ſeparate again; the beholding of which \nbrings an exceeding deal of delight to the Eye, and. con- \ntent to the Mind (I could ſhew it any Man in the Anatomy \nof a Dog) this implication, weaving or Twiſting (as I call \nbefore) is that which ſome Chirurgions called Pamfinforms, \nand ſome Corpus Yaricoſum, which was the thing propound- \ned to be treated of in this Chapter. ̃ \nI do confeſs the ſame contexture of Veins and Arteries, \nthough not in the ſame form, may be found in other parts \nof the Body, as in the Arms and Legs, elſe a Man being \nthere wounded could not bleed to Death, for unleſs the vital \nSpirit comes out as well as the Blood, he might not looſe \nthc Nouriſhment for the time, he could not looſe his Life. \nBut to proceed | | \nThe ſubſtance of this interweaving of. the \nSub/tance, Veins aud Arteries is very hard, long, almoſt \nForm, in Form of a Pyramid; wichout any ſenſible \n| hollowneſs, 6 0 \n5 25 \n\n\n— xx — — COIN — \n\n\n8 Culpeper's Midwife Enlarged. \n\nVe Their Uſe is to mix exactly the Blood and vita! \nSpirit, and of them both to make one Body, they \n\n28 alſo to change the colour of them from red to white, \n\nthat fo the Stones may have a fit matter to work upon, and \n\nthe eaſier Work to do; therefore the, inter weaving reacheth \n\n\ndown even to the Teſticles themſelves, till it even pierce \ntheir Subſtance. \n\n\n— Ea \n\n\nCHAP, II. \n2 Of the Teflicles, or Stones. $ \n6 & HE Stones are called in Latin, Tefes. that Names. \nis witneſs, becauſe they witneſs one to be a 1 \nMan; aſk the Pope elſe, he will tell you I ſay true. The \nGreeks call them 8%; becauſe they are two. I need not \ntell you where they are placed, for every Boy that 4 \nknows his right hand from his left knows that. Place. \nTheir Subſtance is white, ſoft and ſpungy, full \nof ſmall Veins and Arteries, and that's the reaſon Su Hances. \n| that wien Humours flow down into them, they \nſwell to ſuch a bigneſs. 7 \nTheir Form is oval, but their bigneſs is not a- Form. FC \nlike, ſay Authors ;. he that hath a mind to know. | Br \nit's but feeling: They ſay the left is the biggeſt, but tbe | \nright is the honeſt, which (ſay they) breeds the beſt and | \nKrongeſt Seed; and ſo they ſee Nature together by the cars ö \nwith it ſelf, as through the Stones could not agree in their \n_ own action. I ſuppoſe the firſt reaſon of this Fancy in au- \n\n\nthors aroſe firſt from a truth (as indeed moſt Errors did) they \nknew there was both a Microcgſirical Sun and a Microco/micat \nMoon in the Body of Men; the one of which gave vital \nHeat, the other radical Moiſture to it: Then comes old \nAriſtotle, and he finding that the Cæleſtial Sun ruled the right \nEye. and almoſt all the right part of the Man, and the Ce- \n\n\nteſtial Moon the left, and having an over weening conceit of f \nhimſelf that he knew every thing. tho' indeed ne knew no \nthing at all rationally of the influence of the Planets upon 7 \n\n\nMan, preſently concludes (before once he had looked whe \nther or no he could prove it ) that it was the Cœleſtial _ | \nwhic \n\n\nCulpeper's Midwife Enlarged 9 \nWhich cauſeth the heat and ſtrength of the right fide of the \n\n\nBody, which indeed is no ſuch matter, for it is the Microceſ- \n\n\nmical Sun within the Body which gives the heat to it, and \nthe Microco/mical Moon which gives the radical moiſture, and \nthat I prove by Argument, becauſe Man is internally hotteſt \nin the Winter-time, when the Cæleſtial Sun is the greateſt \ndiſtance from him, as appears by the quickneſs of his digeſ- \ntion then. Each Stone hath a Muſcle, which the Learned \ncalled Cræmaſter, from the Greek word rguau, \nMuſcles, which ſignifies to old up, becauſe they pull up the \nStones in the Act of Generation, that ſo the Veſ- \nſels being ſlackned, may the better void the Seed. Age \nweakens theſe Muſcles, and then the Stones hang down \nlower than they do in Youth and Health. < \nThe uſe of the Stones is, Fi, to convert Blood \nDe. aud Spirit into Seed, for the Procreation of Man; \n| and yet by your leaves, they convert not all the \nBlood that come: to them into Seed, but keep ſome for their \nown Nouriſhment. Secondly, They add heat, ſtrength and \neourage to the Body, and that appears, becauſe Eunuchs \nare neither ſo ſtrong, nor hot, nor valiant as other Men; \nneither is an Ox ſo hot, or valiant as a Bull.. As for the \nTunicles or Skin that cover and enwrap the Stones, they \n2 nothing to our preſent ſcope, ſo I willingly onut \nthem. | \nTranſverſe the Stones into a ſmall Body like a filk Worm, \nwhich is called Epididymis, by one extremity of which, the \nVeſſels call'd Deferentia enter the Teſticles and from thence \ncarry out the Seminal matter; from the other extremity \npaſſes that Veſſel call'd Jaculatorium. | \n\n\nCHAP. \n\n\nOf the Vaſa Deferentia. \n\n\nHE Veſſels call'd Deferentia are thoſe which carry the \nSeed, being perfected and throughly concocted by the \n\n\n* Their heat and force of the Stones, from the Stones to \n\n\nOffice. the Seminary Veſlels, which. are ordained to keep it \ntill time ſerve or need require, its expulſion, | \n| | +5 TIP \n\n\n10 Culpeper's Migwife Enlarged. \n- *They are in Number two, and no more, in co- \nlour White, in ſubſtance Nervous or Sinewy ; Number. \nthey have a certain obſcure hollowne!s in them, \nand therefore Heropbilus calls them Tops orTegwelnss, or the \n' Spermatick Pore:. : \n\nThey ariſe up fromthe Stores even unto the Belly, not far \n\ndiſtant from the Preparing Veſſels ; when they are \ncome into the cavity of the Belly, they turn back Uſe. \nagain, and paſs to the back ſide of the Bladder, | \nbetween it and the right Gut, when they come near the neck \nof the Bladder, they are joined to the ceminal Cells, which \nare not much unlike the Cells, of an Honey-Comb ; theſe \nCelis contain an Oily ſubſtance, for they draw the ſofteſt ſub- \nſtance from the Seed, which they empty out into the paſlage \nof Urine, chiefly in the Act of Copulation: The ſuppoſed \nreaſon is, that the thin internal ſkin of the Yard be not of- \nfended with the Acrimony or fharpueſs'of the Seed. The Vaſa \nDeferentia having paſſed, theſe fall into the Glanduia Proftaice, \nwhich are the Veilels- ordained to keep the Seed ; to them \nnow turn we. \n\nTo be ftkilkul Phyſicians, ſtudy theſe Books of mine, \nviz. Platerus, Sermertus, Riverias, Riclanus, Bartholimus, \n\n\nFohnflon, Veſtingins. \n. RE” | C H A P. V : \n_ 34 > nn . Seminal - Vefjets. \n\n\n* HE Praſtatæ or Glandule Seninates, are Deſcription, \n\nof ſuch a body as the Vulgar when they \nfind the like in their Meat, call Kernels. \n\nThey are placed between the Neck of the Place. \nBladder aud the right Gut. Theſe compaſs about \nthe Vaſa Deferentia, and through the midſt of theſe paſſeth \nthe Urethra, 'or common paſſage both for Seed and Urine ; \nvou may if you pleaſe, call it the conduit of the Yard, I \nknow not ſuddenly what fitter Engliſh word to give it; 1 \nam perſuaded, and I have {ome hunbred crabbed terms \nto witneſs it, that the Phyſicians have taken far more pains \nto lead Men into ignorance, than I ſhall or can do to dae \nmem \n\n\nCulpeper's AZdw:fe Enlarged. 11 \nthem knowledge. The ignorance of our Fore -fathers made \nPhyſicians laugh in their Sleeves; but the end of all things \nhaitens, and that knowledge is breaking out, which ſhall ſo \nenlighten the world, that he who hath but half an eye may \nſee their baſeneſs without a pair of Spectacles. At the mouth \nof the Urerhre, where it meets with the Vaſa Deferen ia, \nwhich is (I told you in the Seminal Veſſels, is a Caruncle) \ntheir is another of their Terms) in plain Engliſh a thick ſkin \nits office is that the Seminal Veſſels, being of a Spungy na- \nture, might not ſhed their Seed againſt their Will. This Skin \nwhich is very fullof Pozes,the Pores open through heat of the \nact of Copulation, and io gives paſſage to the Seed, which \nbeing of a very ſubti! Spirit (and the ſubtiler for being \nmoved) will paſs through as Quick-ſilver paſſeth through \nLeather; you can fee no holes in the Leather by which \nit paſſeth, neither can you ſee in this Skin, unleſs in we \nAnatomy of a Man that had ſome violent running of the \nReins when he died, then they are conſpicuous; for indeed \ntheſe Veſſels are the proper ſeat. of that Diſcaſe, however \nit came in time to be called the running of the Reins: I \nhaye often read that the Reins ſeparate the Urine, but that \nthey contain Seed is believed by none but by the Sons of \nTradition. 8 1 _ 2 \n\nBeſides, many times, by hanging of a Dog, his Breaſt \nbeing ſwelled by retaining his Breath, and his Bowels be- \ning compreſſed by ſwelling of that hard dung ſticking in the \nright Gut (which will always be if you give him binding \nMeat the day: before you hang him) doth: io compreſs the. \nVeſſels, that you may plainly.diicern theſe Paſiages or Pores \nopen. Many times when Children are cut for the Stone, \nin drawing away the Stone, (which in my Opinion is a like- \n\n\nlier way to cure Children) I ſay, many times in drawing \naway the Stone, theſe Veſſels are torn, and then if -haply \n\n\nthe Patient happen to live, he may keep. other Mens Chil- \ndren if he. pleaſe, but will never be able to get one of his \nown. Their ſubſtance is hard, ſpungy, of the bigneis of a \n+ Walnut, or very near; and their uſe was taught yon in the \nformer Chapter. 8 Worn \n\n\nCHAR. \n\n\n12 Culpeper's Midwife Enlarged. \nCHAP. VI. | \nOf the Tard. \n\n\n$ Ron Latins have invented very many Names for the \nYard, Iſuppoſe done by Venereous People( which Rome \n\n\nit ſeems was fall of them, ſince which times Vices have in- \ncreaſed there faſter then Vertues) I intend not to ſpend time \nin rehearſing the Names, and as little about its Form and \nSituation, which are both well known it being the leaſt part \nof my intent to tell People what they know, but teach them \nwhat they know not. | \nI. The Parts of it are partly common fo it, \n\nand the reſt of the Body. 1/7. The outward ſkin, Parts cf \nwhich inveſteth the whole Body; the Eyes, the Tard \nMouth, &c. excepted ; as alſo the top of the common. \nYard, the Greeks call it d p,, the Latins | \nCuticula; and we in Engliſh the outward ſkin, or Scarf.ſkin; \n\nit is very thin, as thin as the Skin you peel off from the out- \nſide of a Codlin, it is eaſily loſt, and as ſoon grows again, \nand is altogether void of Senſe; you may caſily thruſt a \nNeedle through it and feel ns pain: Its uſe is to defend the \n\n\n| other Skin from Duſt, Smoak or what elſe might offend it, \n\n\nor penetrate its ſubtile Pores 24. The Skin the Greets call \ndeu, the Latins Cutis which is ſomewhat thick and full \nof Pores, through which the Sweat and Fulginous Vapours \nof the third concoQticn (which concocts Blood into Fleſh) \n\n\npaſs out; theſe Pores are very many, as thick as the holes \n\n\nof a Sive, but not ſo big, indeed they are as thick as they \ncan be, and ſo ſmall that they are not viſible to the Eye; \n\ntherefore Phyſicians call Sweating and the Paſſage of Va- \npours through them, ſenſible Tranſpiration, intend they \nare far wider in ſome Men and Women Bodies thaty they \nare in other ſome, and that's the reaſon ſome Sweat more \neaſier than others do, and ſuch as do Sweat often and eaſily \n\n\nare not ſo ſubje& to Fevers as thoſe are which do not, be- \n\n\n- Cauſe Fevers are uſually cauſed by Sooty or Fuliginous Va- \nPours, which infect the Blood: which often Sweating con- \n\n\nſumes, and ſuffers them not to putrifie : Hence it comes to \n| aſs \n, P \n\n\nmn PY we WW = \n\n\nASS. Ws, \n\n\nGW &'w $4 wo \n\n\n0\" op $4... 4 0 0 1. # We 7 06... op Os \n\n\n— — ——— —— — \n\n\nCulpeper's Midwife Enlarged 13 \n\n\npals that Sweating is a laudable remedy in Fevers, I confefs \nthis Skin is ſomewhat thiner upon the Yard than it is upon \n{ome other Parts of the Body flaggy when the Yard ſtands \nnot, but ſtiff when it doth ; this Skin is very ſenſible, be- \ncauſe the Nerves concur to make up its Being. And here \nT befeech you to take Notice of another grand Truth, wiz \nThat the Brains give Senſe to the Body by the Nerves or Sinews \n(as the Vulgar call them.) And yet Ariftotle for all his great \nLearning, was of Opinion that the Senſe lay in the Fleſh, \nnot in the Skin; and Avicer, a notable Arabian Phyſician, \n\n\nheld it lay in the Fat, which is more ridiculous than the \n\n\nformer. | 8 | \n\n3. The Carreaa Membrane, or fleſhy Skin, ſo called be- \ncauſe it lies between the Fleſh, not becauſe its Body is \nfleſhy, paſſeth in other Parts of the Body underneath the \nFat and ſticks cloſe to the Muſcles ; but in the Yard there \nis no Fat at all, only a few ſuperficial Veins and Arteries \npaſs between the former Skin and this, which when the \nYard ſtands, are viſible to the Eye. . Theſe are the Parts \n\n\ncommon both to the Vard and alſo to the reſt of the Body, \n\n\nwhich although I have been ſomewhat large about, yet I \n\n\ncannot account it tedious, becauſe it conduceth to the teach- \ning of Knowledge to my Couatry Men and Women, who \nhave been too long Reined in with the Bridle of Ignorance \nby Phyſicians, that ſo they might the better be ridden by \nthem; for juſt for all the World as the Popiſh Prieſts ſerve \nthoſe they call the Laity, which is but a Word derived from \n\n\nthe Greet Word a, which is People in plain Engliſh, as \n\n\nthough the Prieſts were no People, but either Angels (or \nwhich is more probable) Monſters; as I ſay, the Popiſh \nPrieſts ſerve their Laity, ſo do our Phyſicians ſerve the com- \nmonalty of this Nation, vi. hide all from them they can; \nfor they know jas well as I know I am alive) that ſhould \nthe Vulgar but be a little acquainted with their Myſteries, \nall their Jugling and Knavery would be ſeen, and their \nWealth and Eſteem, which is the Diana they adore, would \n\n\nbe put to a non plus; and that's the reaſon when you hear \n\n\nany of them cry out againſt me for writing Phyſic in my \nMother-tongue, they bring no other Arguments than what \n\n\nthe Papiſts bring for themſelves in the ſame Point; neither \n\n\nhave \n\n\n— \n— \n\n\na — —25—— — — EIT \n— 2. — — — — 0 — — \n= \n- > 22d. Set das ö 9 \n—_— htm * — R \n— 4 — = _ 2 Is - \n* IF+ Ee an — 3. \n2 2 WII n : \n— _ = B * * 8 \n\n\n1 \n\n\n— — —- p ˖—%i—[—— ——— — = \n\n\n14 Cu Ipeper's Midwife Enlarged, \n\n\nhave they Wit enough to make any better. One holds the \nWord of God, the other Phy/ic to be a Myſtery, and the Vul- \n\n\ngar muſt be ignorant in them both, or elſe they will do \nthemſelves a miſchief. A learned Argument! Knowledge \ndoth Men a miſchief; what a mad Man was Solonon to atk \nthat when he had all the World to chooſe in? he ſhould \nhave aſked of God a heap of Money as big as Mount Za, \nand then above three quarters of the People of this Nation \nwould have been of his Judgment. Thoſe parts of the \nYard which are peculiar to itſelf, and to no other Parts of \nthe Body are ſix. FH: IM \n\n\n1. Two Neryous Bodies. \n\n2. The Septum. Parts of \n3. The Urethre, the Yard \n4. The Glaus. 3 particular \n&. The four Muſcles. to itſelf \n6. The Veſels. \n\n\nOf theſe in Order. \nThe two Bodies (for they are two, though joined together) \nare long, hard and ſinewy; they are ſpungy within and full \nof black Blood; the ſpungy Subſtance of the inward part \n\n\nof it ſeems to be woven together like a Net, and conſiſts of \n\n\ninnumerable twigs of Veins and Arteries. The black Blood \ncontained therein is very full of Spirits, and the Latins call \nit Pectiniformis. The delights or deſire of Venus adds heat to \ntheſe, which cauſeth the Yard to ſtand ; and that's the rea- \nſon venercal fights and venereal tales will do it; it needs be \nno ſtranger to any, that Venus (being a Planet cold and \nmoiſt) ſhould add heat to thoſe parts, that than the Moon \n\n\n(being colder and moiſter than ſhe) ſhould burn by night, as \n\n\nthe Scripture witneſtes, P/al. 121 6. An Aſtrologer can \ngive you a natural reaſon of either, and ſo ſhall I when I \ncome to handle the Formation of the Child in the Womb \nAſtrologically ; the hollow ſpungy intertexture or weaving \nwas ordained purpoſely to hold or contain the Spirit of ve- \n\n\nnereal heat; ſo that the Yard may not fall before it hath \n\n\ndone its work ; you ſee what a rational piece the Lord made \nwhen he made Man. Theſe two lateral or ſide ligaments \nof the Yard, where they are thick and round, ſpring from \n\na „ \n\n\n— 2 | \n. L. ©00 by hey ln) Pa a K 4 wei. \n\n\n„„ v1 ES” Abb \n\n\nJ p ² V AS. IL. cn Ga \n\n\nCulpeper's Midwife Enlarged. 13 \n\n\nthe lower part of the Share- bone, and not from the upper \npart, as Galen dreamed; at the . they are ſepara- \nted the one from the other, and reſemble a pair of Horns, \nor the Letter Y, where the Urethræ or common channel of \nUrin and Seed paſſeth between them. \n\n2. They, ſoon as they come to the joining of the Share- \nbone are joined by the Septum Lucidum, which is my ſecond \ninternal part to be deſcribed; it is in ſubſtance white and \nnervous, or ſinewy; its office is to uphold the two lateral \nor fide ligaments, and the Urethre. | | \n\n3. The Urethre is the third of the internal parts of the \nYard, and which for all Phyſicians have given ſuch an un- \ncouth word, it is nothing elſe but the Channel by which \nboth Seed and Urin is conveyed out. | \n\nIt is in ſubſtance ſinewy, thick, ſoft, and looſe, like to \nthat of the ſide ligaments before-mentioned, it begins at \nthe neck of the Bladder, yet doth not ſpring from it (for if \nyou boil the Bladder of any Beaſt, you may ſee it ſeparate \nitſelf from it) but is only joined to it, and fo paſſeth to the \nGlans. ' \n\nIn the beginning of it are three holes; one in the midſt \n\n\n2. which is largeſt, which receives the Urin into it; the other \ntwo are ſmaller, which are ſent from each ſeminal Veſſel to \nit, by which it receives the Seed. \n\n\nThe Muſcles of the Yard are four, two on each fide. \nBut before I treat of them, give me leave to tell what a \n\n\nzZ Muſcle is. 4 Muſcle is an Inſtrument of weluntary motion, \n| without which no part of the Body can move iifelf ; the Micro- \n«| coſmical Sun moveth the whole Body, as we ſhall ſhew more \n4 hereafter ; but becauſe there is no way from the beginning \nof a thing to the end, without a mean, ſo the Microcoſmical \n4 = in the Body makes uſe of the Muſcles to move the \nBody. \n\n\nIt conſiſts of Fibrous Fleſh to make up its Body, of \n\n\n2 Nerves for its Senſe, of Veins for its Nouriſhment of Arte- \nFries for its Vital Heit of a Membrana or Skin to knit it to- \ngether, and to diſtinguiſh one Muſcle from another, and all \n\"4 of them from the Fleſh ; you may, if you look, eaſily diſ- \ntinguiſn them in a Leg of Mutton or any other Meat where \nthey are. But to proceed, the Yard (as I told you} is \n\n\nendued \n\n\n16 Culpeper's Midwife Enlarged. \n\n\nendued with four of them, two on each fide. It is my pre- \n\n\nthe one of each ſide is ſhorter and thicker, and their uſe is \nto ere the Yard and to make it ſtand, and are therefore \ncalled Erectores. The. other are longer and ſmaller, and \ntheir office is todilate or open the lower part of the Urethre \nor Channel both for making Water, and voiding the Seed, \nand are therefore called Acceleratores. 2 \n5. The Glaus is the extream part of the Yard, ſoft and of \n\n\nwherewith it is covered; it is covered with the præputium or \nfore-Skin, which in ſome Men covers the top of the Yard \n| you cloſe, in others it doth not, which moving up and \nown in the act of Copulation, brings Pleaſure both to the \nMen and Women; The top of this\\s that which the Jeu \nwere commanded to cut off on the eighth day. The Liga- \nment by which the Præputium or fore-Skin is tied to the \nGlans, is called Franum, or the Bridle. | \n6. The Veſſels of the Yard are Veins, Nerves and Ar- \nteries. And yea /e/alus, (if Columbus ſpeaks true) affirm'd \n(tho' moſt falily) that there was neither Vein nor Nerve in \nit. Some Veins and Arteries paſs by the Skin, and, as I \n\n\ninward part of the Yard ; here the Arteries are wonderfull \ndiſperſed thro' the Body of the Yard, far exceeding the Diſ- \nperſion of the Veins, for the right Artery is diſperſed to the \neft ſide; and the left to the right ſide. | \n\nIt hath two Nerves, the leſſer of which is beſtowed upon \n\n\nNverius, Riolinus, Bartholinus, &C, \n. \nOf the Genitals in Women. \n\n\n* \n\n\nſent ſcope to ſhew whence they ariſe only take notice, that \n\n\ntold you before, are viſible to the Eye, others paſs by the \n\n\nthe Skin, the greater upon the Muſcles and Body of the \nYard. To cure all Diſeaſes read my Platerus, Sennertus, \n\n\n— \n\n\n2 2 \n\n\nan exquiſite feeling, by reaſon of the thinneſs of the Skin \n\n\nAving ſerved my own Sex, I ſhall ſee now if I can, \npleaſe the Vomen, who have no more cauſe than Men \n(that I knowof) to be aſham'd of what they have, and \nwould be grieved, as they had cauſe (for they _— C \n\n; Ds ve) \n\n\nz \n3 \n* \n* \n\n\n* \n0 \n* \n* \n\n\nwy \n\n\nCulpeper's Midwife Enlarged. 17 \n\n\nlive) if they were without; but have cauſe if they rightly \nconſider of it, to thank me for telling them ſomething they \nknew net before I ſhall divide it into theſe Chapters: 1. OF \nthe privy Paſſage. 2. Of the Womb. 3. Of the Stones. 4. \nOf the Spermatick Veſſels. | - \n(All theſe are far more exactly deſcribed in Veſtingius's Anato- | \nmy in Engliſh. Ana alſo in Riolanus's Anatomy they are moſt \nclearly deſcribed, with the Diſeaſes incident to the Parts, and the \nSeat of the Diſeaſes. And for the Care of all Diſeaſes, fee Ri- \n\n\nk » verius's Practice of Phyfick in Eng lis ) | | \n\n\nC HAP. I. \nOf the Privy Paſſage. \n\n\nI N this I ſhall conſider but theſe ſeven following \n1 Parts, | | \n1. The Lips, which are viſible to the + You may fee \nEye at the htrit Sight, they are framed of what they are \nthe Body, + and have pretty ſtore of ſpungy in the beginning \nfat; there uſe is to keep the internal Parts of the Chapter \nfrom Cold and Duſt, the Tard. \n2. The Mile or Wings, which appear when the Lips \nare ſever'd, they are framed of ſoft and ſpungy Fleſh, and \nthe doubling of the Skin. placed at the fides of the Neck \nthey compaſs the Clitoris, and in Form and Colour reſem \nbleing the Comb of a Cock, | EZ \n3. The C/toris is a ſinewy and hard Body, full of ſpun- \ngy and black Matter within, as the ſide Ligaments of the \nYard are; in form it repreſents tht Yard of a Man, and ſuf- \nfers Erection and falling as that doth ; this is that which \ncauſeth Luſt in Women, and gives delight in Copulation for \nwithout this a Women neither defires Copulation, nor hath \nPleaſure in it, nor conceives by it. Some are of Opinion, and \n{ could almoſt afford to ſide with them, that ſuch kind of \nCreatures they call Hermaphrodites, which they ſay bear the \nGenitals both of Men and Women, are nothing elſe but \nſuch Women in whom the C[:roris hangs ont externally, \nand ſo reſembles the. form of a Yard ; I leave the truth or \nfalſhood of it to be judged by ſuch who have ſeen them A. \n| 5 natomized : \n\n\n18 Culpeper's Adwife Enlarged. \\ \nnatomized: However, this is agreeable both to Reaſon and \nAuthority, that the bigger the C/ztoris is in Women, the \nmore luſtful they are. \n4. Under the Ciitoris, and above the Neck, is the Paſſaga 4 : \nof the Womens Urine, ſo that the Urine of the Woman 5 l \ncomes not thro' the Neck of the Womb, neither is the Paſ- * A \nfage of the Urine common as in Men, but particular and by I”; ; \nitſelf ; and therefore Injections for ſuppreſſing of Urine in \nWomen, or the like, you may if yu... haye not a Care, ea- \nſily err, by putting the Syringe into the Neck of the Womb, \n. Inſtead of the Paſlage of Urine. | \n\n5. Near this are four Caruncles, or fleſhy Knobs, which \nbecavſe they reſemble the form of Mirtle-berries, the La- \ntins call them Myrtiformes : Theſe are round in Virgins, but \nhang flagging when Virginity is loſt ; the uppermoſt of them \nis largeſt and forked, that ſo it might receive the Neck of \nthe Paſſage of Urine, the other are below this on the fides, \nthey all keep. back. both Air and other things from entering: \nthe Neck of. the Womb. — \n\n6. In Virgins the Caruncles or Knobs are joined together \nby a thin and ſinewy Skin or Membrane, interlaced with \nmany ſmall Veins, which hath a hole in the midſt thro' \nwhich the Menſtrual Blood paſſeth, about the bigneſs of \nones little Finger; in ſuch as are grown up, this is that no- \nted Skin which; is called Hymen, and is a certain note of \nVirginity where-ever it is found, for the firſt act of Copy- \nlation breaks it. I confeſs much controverſie hath been \namongſt Anatomiſts concerning this; ſome holding there is \nno ſuch thing at all, others that it is, but it is very rare; the \ntruth 1s, moſt Virgins have it; ſome hold all; I muſt ſuſ- \npend my own Judgment till more Years bring me more Ex- \nperience; yet this is certain, it may be broke without Co- \npulation, as it may be gnawn aſunder by a Defluxion of \narp Humours, eſpecially in young Virgins, becauſe it is \nthineſt in them, as, alſo by. unſkilſul Pęſaries, to provoke » \nthe Terms, and how many ways elſe God knows. \n\nWhat Authors inſert of the Hymen, I can tell you; firt P \nthe Arabizns. held it to be a Conjunction of five Veins {© © \nplaced on both ſides, that they are joined together: This , \nOpinion was long ſince exploded, \n\n\n5 22 2 ky \n\n\n„% „ 2 o e =» 2 \n\n\nbg yy — * \n\n\n2. Fernelins \n\n\nabove the Neck of the Bladder. Whatſoever it be his tis \n\n\nCulpeper's Midwife Enlarged. 19 \n\n\n2. Fernellus and Linus were of Opinion that the ſides of \nthe Neck of the Womb ſtuck together, which in the firſt \nAct of Copulation, were broken aiunder, , This is as vain \nas the other; \n\n\n3. Severinus Pinæus held it to be a Membrane, which \n\n\nbound together thoſe four Caruncles, or ileſhy Knobs, as I \ndeſcribed it before. | | | \n4. Veſalius, Fallopius, Caſſerius, and other Talian Anato- \nmiſts held it to be a tranſverſe Membrane, occupying the \nwhole Cavity of the Neck of the Womb, and placed a little \ncertain. | \nFirſt, That where it is, it hath certain Veins in it which \nbleed in the breaking of it; this was that note of Virginity \n\n\nwhich God gave to the Hebrews ; and I mylelf believe it is \n\n\nnatural in all Virgins, unleſs they break it with their Fingers, \nor by ſome other means. For it was no way probable, that. \n\n\nGod would have given them for a certain fign of Le xe \n\n\nwhich Columbus and Ambroſe Parry ſay is not always found; \nand Laurentius denies that ever he ſaw it. It is very pro- \nbable the Hebrew Virgins were more chary in preſerving it, \n\n\nthan the Ztalians were; and good reaſon they ſhould, not \n\n\nonly for their Honour ſake, but alſo for the command of \nGod. The Caruncula or fleſhy Knobs, together with this, \nreſembles the form of a Roſe half blown, and therefore an- \nciently called a Flower, and thence came the Word to de- \nHower a Virgin. | | | \n\n7. The Neck of the Womb is nothing elſe but the dif- \ntance between the Privy-paſſage, and the Mouth of the \nWomb, into which the Man's Yard goes in the act of Co- \npulation, and in Women of reaſonable ſtature it is eight \nInches in length. \n\nIts Subſtance is fleſhy without, ſkinny and exceeding \nwrinkled within. And it is ſo wrinkled, \n\n\n1, That it may better retain the Seed in the Act of Co- | \n\n\npulation. \n\n\n- \n\n\ning of Children, and the Paſſage may be wider; the Neck \nof the Womb is ſeated between the Faſſage of Urin and the \n\n\nright Gut, to ſhew fond Man what little Reaſon he had a \n\n\nB 2 be \n\n\n2. That it may dilate and ſtretch in the Travail or Bear- \n\n\n20 Culpeper's Midwife Enlarged. \nbe proud and domineer, being conceived between the Places \nordained to caſt out Excrements, the very ſinks of the Body, \nand in ſuch a manner that his Mother was aſhamed to tell \nhim how it hath two Membrane, and if you cut them you \nmay perceive between them a ſpungious Fleſh, ſuch as is \nfound in the fide Ligaments of the Yard which containeth \nSpirits, and cauſeth it to ſwell in the a& of Copulation, \nand furniſhed it with innumerable ſprings of Veins and Ar- \nteries : To cure all Diſeaſes, read my Platerus. Sennertus, \nRiverius, Riolanus, Bartholinus, Jobinſton, Veſtingius, &c. \n\n\nCHAT. it \n27 the Womb. \n\n\n| E and Hippocrates, and moſt of the Greeks call the \n\nWomb pray and „ae and ſome ase, and there: \nfore the uſual Word the Septuagint gives for [great with \n| Child} is 7 xæsg tg, the Latin, call it Matrix and \nNames. Uterus ; and we Engl; ſome follow the Latin Word \n\nMatrix, but the only Engliſn Word is the Womb. \nParts. Its Parts are two the Mouth of the Womb, and the \n\nbottom of the Womb. \n\n1. The Mouth is a hole at the entrance into it which may \nbe both dilated and ſhut together like a Purſe ; for altho' in \nthe Act of Copulation it be big enough to receive the Glans \nof the Yard, yet after Conception it is fo cloſe ſhut, that it \nwill not admit the Point of a Bodkin to enter; yet again at \nthe Woman's Delivery it is ſo open, that it makes room \nenough for the Child to come out, be it never ſo big. This \nwas the matter of Calen's Admiration, and gives cauſe to \nevery one of us to admire at the Wonderful Works of God \nin the Creation of Man! Who is there that knows himſelf, \nbut may know there is an All. powerful God ? \n\nIf the Matrix be inverted, hardned, ulcerated, have \nScars on it, or-be too moiſt, there can be no Conception : \nFor if it be inverted, it is not directly oppoſed to the Yard, \nthen cannot the Seed be directly caſt into it, the Seed cools, \nand by conſequence becomes unfruitful. If it be hardned, \nit admits not the entrance of the Glans or top of the Yard : \n\n\nH it be ulcerated, it flies the very touch of the Yard : If it \n| | have \n\n\nCulpeper's Midwife Enlarged. 22 \n\n\nhave a Scar on it, there is no way for the Seed to enter in \n\n\nIf too moiſt, it cannot retain the Seed when it is in. Of all \ntheſe their Signs and Cures, in another Chapter. Only \ntake notice, that Hippocrates in his firit Book of the Diſeaſes \nof Women, affirms, that the often uſe of the act of Copu- \nlation makes the Womb ſlippery, and hinders Conception. \nAs alſo, tho' Authors ſay, it is the Inverſion or Hardneſs, or \nUlcers or Scars of the Womb hinders Conception by ſueh \nmeans as I recited, it is not probable to me; for Nature be- \ning ſent in the World by the Eternal God, for the Increaſe \nand Multiplication of Things in the Elementary World, \nhatteplaced a Magnetic Vertue in the Womb, that it draws \n\n\nthe Seed to it, as the Load-ſtone draws Iron, or the Fire \n\n\nthe Light of the Candle. I rather therefore think the rea- \nfon why theſe hinder Conception, is this, becauſe the \nWomb is fo buſied in ſaccouring itſelf, that it cannot per- \nſect any Conception, you know a Man that is fick or \nwounded, cannot Work, tho' his Work lie beſide him. \nThe Womb itfelf in Figure is almoſt perfectiy Figures \nround, in Virgins it ee not the bigneſs of a Walnut, \nyet when a Woman hath conceived, it dilates itfelf to that \nCapacity, that it is able to contain the Child with all its \nAppurtenances, It is imall becauſe the Seed is bat little in \nquantity, which it ought to embrace and cherith ; \n\nit is made up of two Skins, the one internal, the I Frame. \n\n\nother external, the external is thickeſt, and very \n\n\n{mooth and ſlippery, if you except thoſe Parts where the \nSpermatick Veſſels enter into the Wourb, the internal are \nfull of holes. | LE, 7 \n\nIt differs much in form from the Matrix of Beaſts, and \nthat Galen was ignorant of, for indeed and in truth Galen \nnever ſaw a Man or Woman diſſected in his Lifetime, it be- \ning accounted abominable in his time to uſe ſuch ſuppoſed \nCruelty upon the dead Corps, and therefore he diſſected only \nApes, which was the cauſe he wrote ſuch an Apiſh Anato- \nmy: It ſeems the Grecians in Galen's Days were as peviſh \nas our Citizens now-a-days are, who think their Children \n\n\nor Friends were little leſs than Murthered even after they are \n\n\ndead, if a Chirurgeon ſhould but open their Bodies to ſee \nbut of what Diſeaſe they died; which if they would but \nB 3 {,. - duffer \n\n\n29 _ Culpeper's Midiviſe Eularged. \nAuffer, it would tend infinitely to the increaſe of know- \nledge in Phyſicians, and the good of Mankind in ge- \nneral, yea, and to the preſervation of their own Children \nthen living ; for I know divers that have buried their own \nChildren of one and the ſame Diſeaſe. It hath but one \nonly Cavity, and yet Mundimus his Opinion was, That there \nWare ſeven Cells in it; and he and Galen (becauſe they were \nfamous Men, were followed as little God-a-mighties ihat \nthey cannot err) have ſo poiſoned the World with this Doc. \ntrine, that moſt Midwives that I have talkod with, hold in- \ndeed that the Womb hath ſeven Cells, each able to contain \na Child a piece, forſooth ; and ſo a Woman may have ſe- \nven Children at a Birth naturally, and no more; and this \nis juſt as true as the Moon is made with green Cheeſe. \nThere is in truth but one only Cavity in the Womb, and I \ncannat but admire why any that hath ſeen a Woman Ana- \ntomized, ſhould be of any other Opinion, unleſs they ſhould \ntake the Holes where the Spermatick Veſſels come into the \nWomb, to be Cells. I ſhall (God willing) in my next \nBook ſpeak more of the Conception of Twins in the Womb, \nand alfo how they are ſeparated. I ſhall here end with the \nWomb: For what elſe neceſſary concerning it is to be deſ- \ncribed, the next Book will manifeſt. \n\n\nCHAP. III. \nEY. 0 rbe Stones. \n\n\n| FEE Stones of Women (for they have ſuch kind of \nToys as well as Men) differ from the Stones of Men, \n1. In Place; for they are within the Belly in Women, \n\n\nbut without in Men. | | \n2. In Magnitude ; for they are leſs in Women than in \n\n\n5 In Form ; for they are uneven in Women, butſucoth \nFRY They are not Raid in Women by Muſcles, but by Li- \n\n\ngaments. \n5. They have no Profates. \n\n\nin \n\n\n6. They \n\n\n— \n\n\nWn OOO. OO. \n\n\nCulpeper's Midwife Enlarged, 23 \n6. They differ in Figure; for they are depreſſed or flatiſh - \nin Women, but oval in Men. \n\n7. They have but one Skin, whereas Men have four; \nand the reaſon is, becauſe Mens are expoſed to the cold as \nbeing without the Belly, ſo arenot Womens. \n\n8 Their Subſtance 1s more toft than m Men. 1 3 \n\n9. In Temperature they are colder than Mens are. \nThe uſe of the Stones in Women is the fame that they are \n\n\nin Men, wiz: Two concoct Seed, and of this Judgment \n\n\nwas Hlippocrutes in ancient Days, and yet Aiſtotie had the \nface to deny that Women had any Seed at all, though againſt \nboth Reaſon and Experience. Alfo Jouian Puntamm in his \nCaleſtial Obſervations, goes about to prove the very ſame \nthing in the Moon, which Ariftatle quotes in Women; he af- \n\n\nfirms, That the Moon only ſupplies matter for the Sum to \n\n\nwork upon in the Generation of things here below; even as \nthe Female doth the Male in the Generation of Man; and \nthat he learned of ri/forke, and fo he confeſſes; But thoſe - \nthat have ſtudied Hermetical-Phytoophy know. well enough, \nthat the moiſture which the Meer bettows' upon the Earth, \nhath an active Principle in it, yea ſuch an active Principle \nthat the World cannot ſtand without it, nor Philoſophers \noperate without it. Other Opinions there are, which I ſhall \nnot mentian here beeauſe they belong not properly to the \npoint in Hand, but reſerve them to their proper Place. \n\nAnd thus much briefly for their Scn aer. \n| D the Senunal Veſſels. L ig \n\n\nHE Spermatick Veſſels in Women alſo are divided into \nPræparantia, or preparing Veſſels; and Deferentia, or \ncarrying Veſſels. 5 | 4 \nThe Preparantia differ not in number from thoſe in Men; \nfor they alſo are four, two Veins and two Arteries ; their \nRiſe and Original is the ſame alſo as in Men: The right \nVein ſpringeth from the Trunk of the Yewa Cawa (what he \nVena Cava is, you ſhalt be taught at the latter end ef the \nBook, where all hard Names ſhall be explained, and that \n5 B 4 . Courſe \n\n\n_— . 8 \n\n\n24 Culpeper's Midtviſe Enlarged. \n\n\nVein I ſay ſpringeth from the Trunk of the Vena Cava under \nthe Emulgent, but the left ſpringeth from the Emulgent of \nthe ſame ſide, both Arteries ſpring from the great Artery, \nwhich the Greets call dos * 7 | \n\nVet there is ſome difference between the Preparing Veſſels \nin Men, and thoſe in Women ; elſe I needed not have trou- \nbled myfelf about them. : \n\n1. They are ſhorter in Women than they are in Men, be- \ncauſe their Paſſage is ſhorter, the Stones of a Woman lying \nwithin the Belly, but of Men without, in lieu of which \n\nthey have far more wreathings-to and fro, in and out, than \nthey have in Men, ſo that the ſubſtance they carry may be \nthe better prepared: They often turning to and fro, making \namends for the ſhortneſs of the Paſſage. \n2. They are not united as they are in Man, before they \n\n\nwhereof the greater only paſſeth the Stones, the leſſer to \nthe Womb, for nouriſhment both of itſelf and the Infant in \nit. One quaint Obſervation let me note, and then I have \ndone with the Preparing Veſſels: It is thus; The Sperma- \ntick Veins receive the Arteries as they paſs by the fide of the \nWomb, and ſo there is a mixture between the vital and na- \n\n\nFor if you blow up the Spermatick Vein with a Quill, you \nmay perceive both the right and left Veſſels of the Womb \n\n\nmunion of all the Veſſels of the Womb. The Deferentia or \nCarrying Veſſels ſpring from the lower part of the Stones. \nThey are in colour white, in ſubſtance finewy, they paſs \nnot to the Womb ſtraight, but wreathed,. that ſo the ſhort- \nneſs of the way may be recompenced by the multitude of \nthe Windings ; near the Womb, they become broad again. \nThey proceed in two Parts from the Womb, which reſemble \nHorns, and are called the Horns of the Womb : And they \nmay be ſeen in Female Beaſts as well as in Women, tho' \n\n\nrentia end, and by them paſs into the Womb. \nSuch as would be {kiltul Phyſicians, let them read thoſe \n| e | : Books \n\n\n- \n” \"a \n\n\n_ Courſe hereafter will I keep in all my Writings.) The right \n\n\ncome ta the Stones, but are divided into two Branches, \n\n\ntural Blood, that ſo the Work might the better be wrought :- \n\n\nblown up from whence may be eaſily apprehended the Com- \n\n\ntheir Wombs differ far: In theſe Horns do theſe Vaſal Defe- \n\n\nCulpeper's Midwife Enlarged. 25 \n\n\nBooks of mine, wiz. Platerns, Sennertus, Riverius Riolanus, \n\n\n| Bariholimis, Fohnflon Veſtingius, &C. \n\n\nSKC T. . \nHow to preſerve the Juſtrumen ts of Generation pure. \n\n\nJF is ſo apparent a Truth, that it needs no proof, that \n\nthe reaſon why ſo many Infants die in their Infancy is to \nbe ſought for in the Parents, it being clear that the Children \nof unhealthful Parents ſeldom live long; this was clearly \nſeen by the ancient 4/chymiſts, who referred the Original of \nall Diſeaſes to the Seed of the Parents, even as the Original \nof Plants is in their Seeds; for the Diſeaſes have not their \nOriginal from the Elements, but from their own proper Seed \nof that Diſeaſe in them. PZ:Joſophers know that the Sun \nmakes Gold of one Earth and Flints of another, according \nas they are ſitting, let ſuch therefore as defire to have their \nChildren live, ute ſuch means as may keep the 1/?ruments of \n\n\n| Gereration pure and clean, and their Blood pure, that ſo their \n\n\nSeed being pure Nature having pure matter to work upon, \nmake her work perfect and ſo ſubject to live, and not prone \nto die: To this end. I ſhall give here two. general Reme- \ncies to two general Evils, which. I conceive to be the chief \ncauſe of the Death of Children in their Infancy, and ler \nſuch Parents as defire their Children ſhould live, be very \ncareful in obſerving: of them; as for particulars, they may \nbe found hereafter in this Book. n | \n\nThe firſt, Temparence of Diet. \n\nThe ſecond, Exerciſe of Body. \n\nAnd let each ſtand in a Chapter by itfelE, \n\n\nCHAP. I \n\n\n* \n\n\nOf 7. emparence in Diet. \n\n| 5 \nXcellent and true was the Speech of Galen, Plures gula \nFeriere quam gladio, The Throat deſtroys more than the \n\nSword doth; Exceſs in either Meat or Drink cauſeth Crudi- \n\n\nties; Crudities cauſeth ill Blood; of ill Blood cannot be \n\n\nB | made \n\n\n* \n\n\n26 Culpeper's Midwife Enularged. \nmade good Seed, and by this means Parents often come by \nthe Death of their Infants, even in their Infancy, and know \nnot of it. | | \n\nThe Cure of Intemperaney is to be performed by Tempe- \nrancy, and they that uſe it ſhall find by Experience that it \nwill not only as a means under God, lengthen the lives of the \nChildren but alſo bring ſingular Benefits both to the Bodies \nand Minds of the Patents, for look how much difference there \nis in Purity between Water which is muddy, and Water which \nis clear, ſo much and more alſo there is between the Blood \nand the Seed of thoſe that keep a Temperate, and thoſe \nthat keep an Intemperate Diet. I ſhall be very brief in \nJaying down this, that fo I. may, as much as lies in my Pow- \ner, inſtruct you, and do you good, and not tire your Pati- \nence with a tale of a Cock and Bull; therefore conſider. \nI. That by a Temperate Diet, I intend that ſuch an ex- \n\nact quantity of Meat and Drink ſhould be taken into the \nStomach, as the Stomach is well able to concoct and digeſt \nperfectly, which ſufficeth the due Nouriſhment of the Body \ndifferently according to the Imploy ment either of the Body \ner Mind; the Meaſure of Food ought to be as much as poſ- \n Kbly may be proportionable to the quality and condition of \ntze Stomach, the reaſon is clear becauſe it is the Office of \nthe Stomach to digeſt it: Hence it appears. \n\n1. That ſuch as lead a ſtudious Life ought not to Eat fo \nmuch as thoſe that lead a laborious Life, becauſe the Di- \ngeſtion 15 not ſo good ; therefore their Meats ought to be leſs \nin quantity, and lighter of Digeſtion, \n\n2. The meaſure in reſpect of Quantity is not the ſame to \nall ſorts of People, but very different, and that three ways. \n\nFirft, In reſpect of the diverſity of the Air, for ſuch as \nhve in hot Countries muſt eat leſs Meat than thoſe that live \nin cold, and leſs in Summer than in Winter, in one and the \nfame Country. \n\nSecondly, In reſpect of the Perſons themſelves Eating: For \ndivers People are of divers Complexions ; and diverſity of \nComplexions requires a diverſe quantity of Food: The \nway for a Man to find out what Complexion he is of, and \n\n\nil - allo what quantity of Food is agreeable to that Complexion, \n\n\n__ > \n\n\n| Culpeper's Midwife Enlarged. 27 \n| is very plainly laid down in my Tranſlation of Galen's ant \nof Phyfic, to which J refer you. a | \nThirdly, In reſpe& of Age, for Youth requires à greater \nquantity than old Age; and fo do thoſe that are in ealth \nrequire a greater quantity than thoſe that are Sick: And \nhereby the way, IJ have wiſhed an hundred times, and do \nwiſh fill, chat one fooliſh Faſhion in this Nation were left, \nnamely, inciting Sick People to Eat much ; whereas if the \nDiſeaſe come out of Repletion, as moſt Diſeaſes do, Faſt- \ning is far better Cure for them than Feeding. : 5 \n3. Hence it comes to paſs that a greater quantity of ſome \nMeats is to be taken then of other ſome. Meats are more \nappropriated to one Stomach then another, and ſome Meats | \nare lighter of Digeſtion then other ſome. . | \n4. Such as uie bodily Exerciſe ought to take a greater \nquantity of Food, and ſuch as is harder of Digeſtion, then \nſuch as only lead ſtudions Lives, and exerciſe the Faculties \nof the Mind only; the reaſon is clear; for the Exerciſes of \nthe Mind hinder Concoction, becauſe they call up the whole \nPowers of the Spirit to ſuccour the Brain and Underſtand ing; \nhence it comes to paſs, that a Man that is intent upon his \nStudy, he regards not what he ſees, nor hears, not what his \ndeareſt Friends ſay to him but either he anſwers.them not at \nall, or elſe nothing to the purpoſe. This is the firſt Conſider- \nation. \nI Conſider that the greateſt Dfficulty lies in this ar. 1 \nfinding out the exact meaſure of Diet: This I ſhall labour \nto remove | 8 \n1. By ſhewing you the Grounds of this Difficulty, \n2. By giving you ſome Remedies to remove it. | \nI. The Grounds of the Difficulty ſeem to me to conſiſt in \nPleaſure; for Pleafure knows not the Bounds of Neceſſity, \nneither doth Luſt know where Neceſſity ends; for if you mind \nit you ſhall find. | „ \nFirſt, That Appetite is many times prolonged far beyond \nthe Satisfaction of Hunger or Thirſt, ſo that three or four \ntimes fo much as would fuffice Nature is thruſt into the \nBody af | Liquorifhnefs. _ | Sy \nSecondly, Appetite many times proceeds from the Appre- \nhenſion of the Fancy; Fancy conceives Meat to the de- \n; \"WY lightful \n\n\n— \n\n\n— \n\n\n—— — \n\n\n28 Culpeper's Midwife Enlarged, \nlightful and pleaſant, and Appetite ſollow's them, when \nReaſon itſelf teſtifies it to be hurtful. | \n. 2. I ſhall give you ſome Remedies or Rules whereby you \nmay find out the fit Meaſure of Meat and Drink; and they \nare theſe; _ * | | \nFir, If you take ſo much Food at a time, (be it Meat or \nDrink, it matters not) as makes you unfit for Study, or \nother Duties of the Mind, then it is apparent you have ex- \nceeded the due meaſure ; for it is very clear that all the Of- \nfence that proceeds to the Brain by way of Food, ariſeth \nfrom the abundance of Vapours which are ſent up from the \nStomach to the Head, which either would not be at all, or \nelſe ox be pure, if you had not either eat or drank too \nmuch. : \n_ Secondly, If you find a dulneſs, heavinefs and wearineſs \nafter Food, or a proneneſs to Sleep fo ſoon as you have \neaten, be ſure you have taken too much ; for Meat and \nDrink ought to refreſh the Body, and make it chearful, and \nnot to oppreſs it, and make it dull. | | \nThirdly, Avoid all forts of Food by which you afterward \nEnd Prejudice, tho' you delight your Palate never ſo much \nwhen you eat. them; for that which pleaſeth the Palate. \ndoth not always pleaſe the Liver; and if they agree not \nwith the Liver, they cauſe Curnidities, Cloudineſs and \nDizzineſs of the Brain, Wind, Diſtillation upon the Lungs, \nSo. \n.. Fourthly, I ſhall only give you one Caution more, and \nthat is this, ſubſtract from your exceſs in Diet by little and \nlittle; for Nature abhors all ſudden Changes, tho they be from \n10 to good; As ill Cuſtom got Poſſeſſion over Nature by \nleprees. | \n| o Come we now. to the laſt Conſideration, in which we \nſhall endeavour to prove, that Intemperance in Diet in the \nParents, cauſeth the Death of many of their Children in \ntheir Infancy, even before any Direction in their Nativities \ncome to cut them off: That we ſhall endeavour to do thus: \nFir, If it cauſe Corruption in the Blood and Seed of the \n+ Parents, it muſt needs haſten the Diſſolution of the Children; \n\nthe firſt cf which we ſhall prove thus: Almoſt all Diſeaſes \nhave their Original from Repletion ; vis. Taking = \n| 5 * eat. \n\n\n* —— \n\n\nn \n\n\n2 2 — \n: Ds of noe N \n1 T \n\n\n£2. — — 3 \n\n\nBody of the Parent conduceth to the Life of the Child, \n\n\nCulpeper's Midwife Enlarged. 29 \nMeat and Drink than Nature requires, or the Stomach can \nwell digeſt, as is excellently well laid down by the Wiſe \nMan, Eccleſ. 37, 29, 30, 31. Be not unſatiable in any dainty \nthing, nor too greedy upon Meats ; for exceſs of Meat bringeth \nSickneſs, and Surfeiting will turn into Choler. By Surfeiting \nhath many Periſbed, but he that taketh heed, prolongeth his Life. \nSecondly, Conſider, that all Crudities are nothing but an \nimperfect Concoction of Food; for when the Stomach re- \nceives more Food than it can digeſt, the Chyle made of ſuch \nMeat muſt needs be crude, becauſe the Stomach maketh a \nCorruption inſtead of a Concoction. Then conſider, \nThirdly, The Liver cannot turn bad Chyle into good \nBlood; neither can the Teſticles convert bad Blood into \ngood Seed, becauſe the ſecond Concoction cannot amend \n\n\nthe fault committed in the firſt, nor yet can the third amend \n\n\nthe Faults committed in the ſecond : Hence you ſee that it \ncomes to paſs that Men and Women give the occaſion of \nthe Death of their Children before they are begotten. \n\nFoaurthly, On the contrary, for contraries mightily illuſt- \nrate one another; from a 'Temperate Diet is good Chyle \ncauſed, ſuch as is agreeable to Nature from good Chyle is. \ngood Blood bred ; and from good Blood good Seed; and \nfrom good Seed, ſtrong Children, luſty and healthful, \nwhich according to the Principles of Nature are ſubject ta \nlive. And ſo much for this Chapter. \n\n\nK \nOf the Exerciſe of the Bech. \n\n\n\"Hat ever God ordain'd Men or Women ſhould live idly; \n\n\" 1 never yet read nor heard; and Zycurgus the famous \nSpartan Commander, being aſked the reaſon why he forced \nYoung Virgins to Labour? Anſwer'd very wiſely and diſ- \ncreetly, that thereby cleanſing their Bodies of evil Excre- \nments, they might bring forth luſty Children when they \nwere Married; a prudent Speech well beſ:eming: the Man \nthat uttered it, and very fit to be practiſed in every Come \nmon-wealth. But that I may ſhew how the Exerciſe of the \n\n\nconſider \n\n\n— \n\n\n> 3 A — \n22 iS . — \n— . ¶ rœ 8d . ͤGi— — — \n\n\n4 - \n— 1 = — — _ ) * o \n_- — — 3 * 2 2 ” * 0 — R \nn — — - 8 r N22 Ee A ͤ . — —8 — - — — my — ty Ae + —_ n _ = — . P ap ee — \n— — — —— * 8 * 1 — * — - * 2 — — * — dy — . N \n80 th — 9 r R J = > 5 \ni A by i 5 _—_ - -4 4 * w * - 7 D LO * '1 b 1 4 2 * I \nf R G 3 2 5 2 0 = = 2 g p . 4 - > DAS IG We g = 3 . ” \n* 2 rr ay Ag 1 . * ——— - A be net ® — 8 * — ** ALS . my - ES — 25 = ,, _ 4 \nF _ — — — Ge __ — - — —— — — SP — \n— — — — - ” * \n— - — — —＋—— — — a — . - — — — — — — — . * — . ST — , * \n95 8 CCC ˙˙2ꝓ2ͤ— %˙ͤÄqJ⁊ E er 1 — — — — — q \n= a * ＋ . * q a K 5 6. \n; N . : . . 4 \na * x . \n, 1 * a { o \"7 \n. * \nF * \n9 J \n' 4 \n2 # \n\n\n30 Culpeper per's Midwife Enlarged. \n\n\nconſider it ſtirs up natural Heat in them, there is as much \n\n\ndifference between 2 Man's Body when natural Heat is ſtir- \n\n\nred up, and when it is not ſtirred up, as their is between the \nEarth in V inter and Summer; when the Sun Rirs up natural \nHeat in the Element, the Earth rejoiceth and brings forth \nits increaſe ; when the Sun departs, and by his diftance can- \nnot fiir up natural Heat, then the Earth is diſmantled of \nthe Beauty which the Spring beſtowed upon her, and mourns \nlike the Frees in O?ober : 3 ſo in the Body of Man, if \n\n\nnatural Heat be capable of Concocting pure and goed Seed \n\n\nfor the Generation of Man, which it cannot do ſo long as \n# lies Suckling in his own Center, the Microcoſmical Sun. \n\n2. Moderate Exerciſe equally diſtributes the Spirits \nthroughout the Body; and if fo, then of neceſſity they \nmult needs be equally diſtributed in the Seed; thoſe that \nhave ſtudied Natura] Philofiphy, know well enough that it is \nthe unequal diftribution of the Elements which caufeth the \nDeath of all Things ; and the more they are unequally dif- \ntributed in a Thing, the fatter its Diſſolution haſtens; ſo that \nyou may reſt aſfuredly confident of the Truth of this, that \nthe more equally your Spirits are diſtributed in your Bodies, \nthe more equally will they be diſtributed in your Seed; and \nby conſequence ſo much the more probable are your Chil- \ndren to live. \n\n\n3. Moderate Exerciſe by opening the Pores, cleanſeth the \n\n\nBlood of thoſe fuliginous or footy Vapours which uſually \noffend it: And this is the reafon Sweating is ſuch a good \nRemedy in Fevers. Now then, if the Blood be cleanſed of \nwhat ofiends it, or corrupts it before it be ſent down to the \nTeſticles to be Wan ee into Seed, the Children bred of \nthis puriſied Seed muſt needs be ſtronger, and by conſe- \nquence more fubject to live. - | \nThus you fee what Reaſon faith to the Point, viz That \nmoderate Exerciſe of the Parents conduceth much to the \nLives of the Children. I ſhall call up my other Brother \nE. Doctor Experience, to Teftify the truth of this. | \nYou ſee, nay, you cannot but ſee, unleſs you are wilfully \nblind, that poor People fuch as work hard, and fare hard, \nand are ſeldom Idle, have more Children, and thoſe \nand luſtier of Body, and uſually longer lived than hich won \nIve \n\n\nn * \nn 8 \n{IE ES” . \n\n\nCulpeper's Midwife Enlarged. 2r \n\n\nlive Tdly, and fare deliciouſly ; tell me elſe what becomes of \nall our Citizens Children, there being ſcarce fo many of them \nto be found now, as may be proved have been born in half a \n\n\nYear's time? I am confident not ſo many of them are now © \n\n\nto be found of ſeven Years of Age : They that will - \nlet them be Wile. Rx, 5 y that will be Wiſe, \n\n\nA ND thus much fer my Firft Book, which contains the Anatomy \n\nof the Parts dedicated to the Procreation of Man, or at \nleaft of fo many of them as may ferve for a ground Work to the \nfollbauing Diſcourſe ; and this needs no Guide, as being itſelf the \nGuide and Baſis to ihe whole Work, \n\n\n— 4. a. a. i —_— * __— _T * 46 5 =_ — —_— — * = \n= „ Anm \n\n\nOf the Formation of the CHII D in be \n\n\n— 2 — Ml _ —_— _ — — — — \n\n\nBOOK H. \n\n\n— \n\n\nPROOEMIU M. \n1 Would willingly have omitted here to the proud Con- \n\n\nceits of the Learned Rabbies of our Age, to wit. That \n\n\nno Creature is Rational but Man (as intending to write of \nit hereafter in another Treatiſe) whereas indeed there is no \n\n\nnatural Wiſdom which Man hath found out by his Study, \n\n\nbut the ſame is naturally to be found in the Creatures taken \nin ſenſu conjuncto, nay, and far excelling Man, nay, the beſt \nof Men breathing, when they have ſpent their time, and \n\n\ntired their Brains in Study: it's poſſible a few Creatures (as \n\n\nHorſes, and Oxen, and Aſſes and the like) which Man \nhath brought up in Slavery, may not be io rational as their \n\n\nMafters. A Bird that has been brought up in a Cage, will \n\n\nfly into the Cage again, tho you take him out and ſet him \non the further fide of the Table; but a Bird that was brought \nup in the Woods, and ſo knows what Liberty is, if you \nnut him in a Cage, he will go near to die \n\n* 8 \n\n\n* \n\n\nSs \n\"RP \n* \n\n\ne a * \n\n\n32 Culpeper's Midwife Enlarged. \nThe reaſon is, becauſe the firſt knows not what Liberty is, \n\n\nbut by Bondage is in a fort deprived of Reaſon. Did not \nthe wiſeſt of Men ſay, Oppreſſion will make a wiſe Man mad? \n\n\nAnd is madneſs ought elſe but deprivation of Reaſon ? We \ncannot know whether Creatures at Liberty have any Religi- \n\n\non or Knowledge of God or not; we may gueſs from P/a/. \n104. If we do but mark what we read that they have ; \nhowever this 1s. certain, They never went together by the \nEars about it as we have done ; but as for an abſolute Com- \n\n\nmon-wealth, take it as a. Free State, or Monarchical, Man \n\n\ncomes as far ſhort of the Wiſdom of Creatures, as I do of \nthe Wiſdom of Solomon. 1 \n1. That ſuch of the Creatures that hold a Free State, and \n\n\nif -Agur may be believed, ſuch are Locus; The Loeuſts have \n\n\nno King, yet they go forth in Bauds; They have no Kings \ntherefore a free State ; they go out in Bands, therefore have \nthey Government. The Word (Band) ſignifies Government \nas well as Number; for Soldiers ungoverned, will ſooner \n\n\nmake a Rout than a Regiment. \n\n\n2. Take another Monarchical. State, and they are Bees, \nread but Butler's Book of Bees, written altogether from Ex- \nperience,. and you ſhall ſee what an admirable Martial Com- \nmon- wealth they keep, how patient in private Wrongs ; for \nif you abuſe a Bee in the Field ſhe will not iting you if ſhe \ncan poſſibly get away without, yet do but affront them at \nhome, then the Wrong is publick, then if you would fave \nyourſelf you muſt run for it. The Truth is, no Monarchy \nof Men throughout the whole Univerſe was ever compared \nto them, and yet they never read Et,ics, and are utterly un- \nacquainted with Machiawaliani/m, whereas Man for all his \nReaſon he brags ſo much of, and all his Reading and Learn- \ning could never frame ſuch a Monarchy, but may, nay hath \nundone itſelf even by Civil Wars, (the worſt of all other) \n\n\n| witneſs the Græcian and Roman Monarchies, that I may not \n\n\nſpeak one Word of England. 6; \nThe very Truth is, Man hath far more Pride than other \nCreatures (the Lord keep me from ſuch Reaſon) who have \ning torn a little Knowledge from one Creature, and a little \nfrom another, and by comparing what one Creature doth, \nwith what another dath, having a few of them bred up in \n\"os ſubjection \n\n\na at - n 1 1 8 \n\n\nſubjection and flavery that they can have no commerce one \nwith another, unleſs it be to pity one another in their ſlavery \n(for it's probable that Birds and Beaſts underſtand one ano- \nthers Language, though we underſtand but little of theirs \nthe Czc4ozv excepted) fo that for want of Liberty they gan- \n\n\nnot come to the knowledge of their own State; and then \n\n\nMan vapours that he is the only Rational Creature upon the \nEarth. Oh abominable Pride h \nI was ſomething the larger upon this Subject, - becauſe the \n\n\nknowledge of it is one means to move Men to look upon \n\n\nTeſus Chriſt, and expect his Spirit, and to long after an U- \nnion with God through him, when they do but ſee what \nmiſerable Creatures Sin hath made them: Beſides hereby a \n\n\nMan may ſooner come to the knowledge of himſelf, which \n\n\nis the greateſt of all Earthly Knowledge. \n\n\nJam come now to the matter, which js „ hew proud, though \nmiſerable, Man is formed in the Womb. \n\n\nHs matter being of great Importance not only in \nPhy/ic, but alſo in Plz:/ophy ; I ſhall be as Methodi- \n\n\ncual in it as I can, therefore I ſhall treat of it in a double \nWay. 5 \n\n\n1. Phyfically. \n2. Afiralogically. \nAnd let each ſtand in a Section by itſelf. \n\n\n2 s \nThe Phyſical way of Formation of the Child in the Wan. \n\n\nTHAT this may be orderly done (for all things look beſt \nwhen they are in Order, becauſe God is the God of \nOrder) I ſhall note, | \n1. The proper Parts of the Child, 1 \n2. The Formation of the Child and its Situation in the Womb. \n3. Anſiwer to ſome needful Dueftions, ; 1 \nAnd let each of theſe alſo make the Complement of one \n\n\nC H A P \n\n\nCulpeper's Midwife Enlarged. 20: \n\n\n: l \n: ; \n\n\n# \nU \n\n\n— RT - - | \nE \n\n\n„ \n— CT \n\n\n— — - — - —— - — \n98 dns” ar. eee det aRE \n\n\n> \n* \n: \n— P IN Pr ag \n; \nnn . n _ wal r 2 a \n7 « * \n1 4.4 \n4 \n\n\n—_— — \n* \n\n\nmuſt uſe Greek Words, elſe how ſhould we keep People in \n\n\n34 Culpeper's Mitwife Enlarged. \n\"CHAD. 1. \nOF the Parts proper to the Child in the Womb. \n\n\nCall thoſe Parts proper to the Child in the Womb only, \n* which help either to nouriſh it there, or to cloath or de- \nfend it there; and either caſt away, or are of no uſe, un- \nleſs perhaps Phyfical or Medicinal; it being Born. \n\nTheſe I ſhall divide into two Parts. \n\n1. The Unbikcars, or Navel-Ieffels. \n\n2. The Secuudine. 85 \n\nThe ft, ſerves for its internal Uſe. The fſcond for its \nexternal. The i nouriſheth it; the g cloaths it, and \ndefends it from Wrongs. \n\n\n© Of the Untelicer, or Nvel Vaſcli. \n\n\nThey are in Number Four; One Vein, Two Arteries \nand the Veſſel which is called Uraches ; of all which ap- \n\n\npart \n\n\n1. The Vein is the Nouriſher of the Infant even from \nthe beginning of the Conception, to the time of Delivery, \ntill it breath Air and Concoct its Food as we do. : \nIt ariſeth from the Liver of the Child; and when it hath \npaſſed the Navel it is divided into two Parts, and theſe two \nare again divided and ſubdivided, the Branches being up- \nheld by the Skin called Chorion (of which more anon) and \nare joined to the Veins of the Mother's Womb, from \n—_ they haye their Blood for the Nouriſhment of the \n2. The Arteries are two, one on each ſide, which proceed \nfrom the Thac Branches of the great Artery of the Mother; \nby theſe is the Vital Blood carried to the Child, being ready \nconcocted by the Mother. _ 3 \n3. A Nervous or ſinewy Production is led from the bot- \ntom of the Bladder of the Infant to the Navel, and this is \ncalled Urachos, and its ufe (as the Word fignifies, for we \n\n\nIgnorance) \n\n\nCulpeper's Midwiſe Enlarged 35 \nIgnorance) is to convey the Urine of the Infant from the \nBladder to the Allantois. \n\n\nI confeſs various are the Opinions of Anatomiſts concern- \ning this, ſome denying any ſuch things to be in the Delivery \n\n\nof Women, but only in Beaſts Some ſhew their Ignorance, \nothers their Skill in the Art of Piſputation, and ſome few \ntheir Experience, which I ſhall quote, Barthalozrenw Corbro- \nlius, a Chirurgion, and the ordinary Diſſector of the Ana- \ntomies to the College of Phyſicians at Montpelier in France, \nrecords an Hiſtory of a Maid whoſe Water being a long \ntime ſtopped ; did at laſt iſſue out through the Navel. \nJolm Fernelius, Pathol. Cap. 13. Records the like of a \nMan of 3o Years of Age, who having a Roppage in the \nNeck of the Bladder, his Urine iſſued out of his Navel \nmany Months together, and that without any Prejudice at \nall to his Health, which he aſcribes to the ill tying of his \nNavel, whereby the Urachos was not well dried. Felchier \nCoiter quotes ſuch another, in a Maid of 34 Years of Age \n\n\nat Noremberg in Germany; I confeſs there are but ſeldom, \nyet hereby may be proved ſuch a thing as an Urachos in \n\n\nMen. | \n\nTheſe four Veſſels, to wit, one Vein, two Arteries, and \nthe Uraches, do join near to the Navel, and are united by a \nSkin which they have from Chorion, and ſo become like a \nGut or Rope, and are altogether void of Senſe, and this is \nthat Women call the Narel-ftring. Women may if they \npleaſe, when they have cut it off, take the Pains to open it, \nand fee for their own Content, and thoſe about them, that \nwhat I have written here is the Truth. de e \n\nThe Veſſels are thus joined together, that ſo they might \nneither be broken being ſevered, nor entangled together z \ntheſe when the Infant is born are of no uſe ſave only to make \nup the Ligament which ſtops the hole of the Navel, and \n\n\nſome other Phyſical uſes, which I may happen to touch up- \n\n\non before the end \n| | Off the Secundius. \n\n\nTHE Greeks call this xd Nervig & rd S5ege, the Lating \nimitating them, call them Secundas, and n \n\n\n36 Culpeper's Midwife Enlarged. \nand our Women the Sccundine, After - birth, and \nAfter- burden. They are in Fumbe: held to be four, \nwhere here I ſhall only deſcribe and few their uſe, and let \nthe forming of them alone till I come to the next Chapter. \n\n1. The firſt is that which is called Placenta, a kind of \nLatin Word given to a Sugar-Cake. becauſe it reſembles the \n Formof a Cake; it is knit both to the Navel and to the \nChorion, and makes up the greateſt part of the Secund:ne, or \nAfter-birtn. 8 \nThe Fleſh of it is like that of the Milt or Spleen, ſoft, \nred, and tending ſomething to blackneſs, and hath very \nmany ſmall Veins and Arteries in it ; and certainly the \nchief uſe of it, is for the firmer containing the Child in the \nWomb. | \n\n2. Of the Chorion; this Columbus denies to be Skin; you \nſee acute Men may be miſtaken, and if ſo, What an ill-fa- \nvoured. Maſter Tradition is! whereas it is moſt certain that \nthe Chorion and Ammon involve the Child round, Both above, \nand underneath, and on both ſides ;. Allantois doth not io. \nThe Skin, Hippocrates commonly in his Book of the Diſeaſes \nof Women, calls the Secundine, or at leaſt gives this parti- \ncular Name, the Secundine in general (whereas C:/umbus \n\n\n; _— — — \n5 Ar > SY — 8 _ —— \n\n\n222 \n— \n\n\nop — \n\n\n— \n\n\nin the Placenta, very light and ſlippery. \n\nIts uſe is not only to cover the Child round about, but \nalſo to relieve and ſafely bind up the Root, and the Veins \nand Arteries, or Navel Veſſels before deſcribed. \n\n3. Of the Allantois: This ſome deny to be found in the \nBody of Man; and truly thoſe. that prove it to be there, \nprove it more by Reaſon than Experience. If I had ſo ma- \nny Children in Holland as I have had in Ergland, 1 could \nhave better certify'd you of. the Truth of it; for in \nHolland all Men are preſent at their Wives Labours : They \nare delivered upon their Huſbands Laps, and not upon a \nStool. Galen ſaid there was ſuch a thing in Women as well \n\n\n— — \n\n\n2 3 \n— 7 A 1.m2 4 \nty : \n7 - \n\n\n— md * — — * \n5 y i 1 — WM * — 5 * 3 4 1 \n. ——. — — — Y \n— — 1 - — — \n— 10 * Y * * \n\n\n— * \n—— \n\n\n— \n— \n— \n\n\n£2 ” > \n”7 Gn ———— — — \n\n\nCE W Lerner nn arr \n\n\nbeen no better than Galen's Apes, and yet Galen never ſaw \nMan-nor Woman Anatomized. However if it be, good \nWomen may find it if they look for it; it is, they ſay, \nä N | | | white \n\n\nmiſtook this for the Placenta) it is a Skin thick and white, \narniſhed with very many ſmall Veins and Arterics ending \n\n\nas in Beaſts, and the e part of our latter Writers have \n\n\n2 \n4 3 A * 1 \n2 r 8 2 88 \n\n\n** \n\n\nCulpeper's Midwife Enlarged. | 37 \n\n\nWhite and ſoft, and exceeding thin, and juſt under the Pla- \n\n\ncenta, Where it's knit to the Urachos, from which it receives \nthe Urine, and its Office is to keep it ſeparated from the \nSweat, that the ſaltreſs of it may not offend the tender Skin \nof the Child. 5 7 \n\n4. The laſt covering of the Child yet remains, which is \ncalled Amnois; it is white, ſoft, thin and tranſparent, nou- \nriſhed by ſome very ſmal! Veins and Arteries. \n\nIts ule is not only to enwrap the Child round, but alſo to \nretain the Sweat of the Child : the uſe of which Sweat, I \nfhall haply touch upon hereafter. | | \n\nAnd thus much for the firſt Chapter, wiz.. The Parts pro- \nper to the Child. 4 \n\n\nCH AF. \nThe Formation of the Child in the Wemb. \n\n\nHs ſpoken of the proper Part of. the Child, we \ncome next to ſpeak of its Formation ; but before I be- \n\n\nin this, give me leave to promiſe, that this is my difficul- \n\n\nteſt Piece of Work in the whole Book, nay in the whole \n\n\nStudy of Anatomy, becauſe ſuch Anatomies are hard to be \ngotten ; moſt Women that he on their Death- beds when \n\n\nthey are with Child, miſcarry before they die, if not all; \n\n\nbeſides, Galen never ſaw a Woman Anatomized in his Life- - \n\n\ntime, as I ſhall prove by and by (and yet our Anatomiſts \nfollow him as a little God-a-mighty, and his ie dixit ſerves \nthe turn; and ſo the Blind leading the Blind, you know \nwhat will become of them both) Columbus in the moſt rati- \n\n\nonal in this Point that I know; the reſt, ſome follow Galen, \n\n\nſome Veſalius, ſome their Fancies, and ſome Quibble about \n\n\nit. Myſelf ſaw one Woman opened that died in Child bed, \n\n\nnot delivered, and that is more by one than moſt of our \nDons have ſeen, yet they are confident as Afop's Crow was, \nthat he was an Eagle, but he was made a Mocking-ſtock to \nthe Boys for his Labour; and fo will they be ſhortly for \ntheir fooliſh Model of Phyſic, that I may give it no worſe \n\n\nAnd \n\n\nName. \n\n\n- r wy - : , - > Our: \nö — — * — 5 2). 7 7 \n— - dy _ 72 << * — y ö \n8 bo * — 8. tif \"> 4 \n>, * 43 2 2 — - — \n* N Ge . nf vas r Aa Oh \n332 N * * 8 1 \n> . \n* — . — 444609 nd. EO Ry \n1 RT * | \n\" — 8 ; r rr \n——— a \n\n\n38 Culpeper's Midwife Enlarged. \n\n\nAnd then ſecondly, I hope you will = me leave to be \na little Critical; for there is need enongh, if you knew but \n\n\nſo much as I; if I commit any Failings they are unknown \nto me : Let the; Honeſty of my Intentions. deface them with \na Deleatur. 2 | \n\n\n> \n\n\n7 \n\n\nNew. the Baſergb. \n\n\n1. The Tefticles or Stones of a Woman Womens Te/- \nare for Generation of Seed, where many times ticles, . hite. \n(if the Doors and Chirurgeons were not high \nbaſe and denied. your Admittance) you might ſee it in an \nAnatomy, white, thick, and well concotted. \n\n2. In the Act of Copulation, the Woman ſpends her \nSeed as well as the Man; and both are united to make the \nConception, \n\n3 The reaſon why ſometimes a Male is conceived, ſome- \ntimes a Female, is the ſtrength of the Seed: Why ſometimes \nFor if a Man's Sęed be ſtrongeſt, a Male is a Boy in Con- \nconceived; if the Woman's; a Female; the ceived, and \ngreater Light obſcures the leſſer by the ſame ſomemetimes a \n\n\n| Rule, and that's the Reaſon weakly Men get Girl. \n\n\nmoſt Girls, if they get any Children at all. \n\nThis ſhews a manifeſt Difference between Difference be- \nNature and Appetite: Nature ſtrives to be- tween Nature \nger its like, Men to beget Men, Women to and Apperite. \n\nget Women,; but for. Men to deſire Girls, \nand Women Boys, is Appetite, not Nature: And yet you \nſee the Wiſdom of moſt Men and Women, deſire to plea- \nſure Appetite and not Nature, and ſo plainly make them - \nſelves Slaves to their own Senſe. Experience ſhews us, \n\n\nthat a Girl of a Vear old fancies Men more than Women, \n\n\nand Boys of the ſame Age the contrary. If the Horſe or \nor Mare Trot, it were a Wonder if the Foal ſnould Amble; \n\n\nand yet you ſee alſo where Nature is ſtrong, it will vanquiſh \n\n\nAppetite, do it the wort it can. \n4 The Seed of both Sexes being united, the Womb in- \nſtantly ſhuts up, partly to hinder the extramiſſion or paſſing \n\n\nout of the Seed, partly to cheriſh the Seed by its unbred \n\n\nHeat, the better to provoke it to Action. And that's the \n5 | | 1 5 Reaſon \n\n\nbg hoped \n\n\n* \n\n\nReaſon Womens Bellies are ſo lank at their firſt Conception : \nThen inſtantly Nature goes to work. \n1. You muſt conſider, that the firſt thing which is Ope- \n\n\nrative in the Conception is the Spirit, whereof the Seed is \n\n\nfull: This Spirit Nature quickeneth by the Heat of the \nWomb, and ſtirs it up to Action. | \n\n2. The ſeed, though it ſeems to be but one Maſs yet \nindeed it conſiſts of very different Parts, of Which ſome are \npure, ſome are impure.: The internal Spirit therefore ſeve- \nreth thoſe Parts, thoſe that are thick, cold and clamy, from \nthoſe that are pure and more noble : Theſe are caſt to the \noutſides, and with theſe is the Seeds circled round, and of \ntheſe are the Membranes made, in which the pure Secd is \nwrapped re und, and defended from cold and other Acci- \n\n\ndents, and kept cloſe together, that ſo it may operate the \n\n\n8 \n\n\n3. You may more than gueſs at the Truth of this, if you \n\n\ndo but conſider the growth of Trees, which is a very fami- \nliar Example (though heeded by few) for if you do but \nnote it. \n\n1. The cold of Winter congeals and putrifies the Vital \nSpirits in the Trees, which is again reſolved in the Spring \nby the Heat of the Sun. Þ* \n\n2 By this Nature opens the Pores of the Trees, and diſ- \ntils Drops, always ſeparating the pure from the impure ; \nof the pure it makes Flowers; of the impure, Leaves; \nand of the groſs, Bark. But to return again to our Pcople. \n\n1. The firſt thing that is formed, is the Skin 4nmois, the \n\n\nnext the Chorion, and they enwrap the Seed round as a Cur. \ntain: To let the idle 1deas of Arantius his Brain alone (who \n\n\nwas of another Opinion) as not worthy of an Anſwer. \n2. Very ſpeedily after this (and yet this is done in a very \n\n\nhort time) leſt the Seed thus ſhut up fliould corrupt or \n> Which is moſt proper that it might not lie idle (for God and \n\n\nNature hate Idleneſs) is the Navel-Vein bred, which pier- \nceth thoſe Skins being yet very Tender, and carries a — \n\n\nof Blood from the Veins of the Mother's Womb to the Seed, \n\n\nof which Drop is formed the Liver, from which Liver is \nſoon bred the Yera Cava, or chief Vein, from which all \nthe reſt of the Veins that nouriſh the Body ſpring, and no \n\nLEA h \n\n\nCulpeper's Midwife Enlarged. 39 \n\n\n40 Culpeper's Midwife Enlarged. \nhath the Seed ſomething to nouriſh it, whilſt it performs \n\n\nPart of it to form the Fleſh. \n\n\nol it; you may take it, and walk a Fool in the Horn-fair \nwith it; for I aſſure you, he that builds his Faith upon Tra- \ndition all Day, may fit down in the Chimney-corner at \nNight, and ſcratch his Head with a pair of Fool's Nails. \nAnd I pray tell me, if it be not learned Divinity which \nyou ſhall ſometimes hear taught in Pulpits for Othodox, \n\n\nfinition of Ariſtotle, and the Peripatetichs, nor of all the \n\n\nſelf to Believers by the Perſon of Jeſus Chriſt. \n| Praſeutem mom ſtrat quelibet Herha Deum. \n\n\nhave no ſkill in if they can get Money, they have gotten their \nDeſtire. Let them tell me the Reaſon of the Antipathy be- \ntween the Herbs Rue and Baſil, that one will not grow near \nanother, and yet both Garden-Herbs ; but what do I talk \nto a learned College of Phyſicians of Magnetic Vertues ? Talk \nto them how they ſhall raiſe their Fees from Ten Shillings \nto Twenty. I proceed. ES | \n- 3. \"This Vein being formed the Navel Arteries are ſoon af- \nter formed, then the great Artery ; of which all other are \nbut branches, and then the Heart, and ſo according to Co- \nlumbus, all the Arteries are formed before the Heart, and \ngood Reaſon too, for I told you before, that the Body was \nquickned by the Arteries, and that the Navel-Arteries were \n\n\na 1734 \n\n\n„45775 \n\n\nthe reſt of the Work, and alſo Blood adminiſtred to every \n\n\nAnd now tell me I pray you, if this be not better Rea- \nfon, than to hold all the Members are formed together, as + \nMan contend ſtoutly for and they no nal Fools neither; or \nif you like Tradition better than Reaſon, I will not rob you \n\n\nThat the Heart lives firſt, and dies laſt, when the Liver lives, \nbefore the Heart is framed? I weigh not a ruſh the nier De- \n\n\nFools that dance after their Pipes; how that firſt a Man lives * \nthe Life of a Plant, then of a Beaſt, and after that of a a \nMan. They know what the Life of a Plant is, as much as \ndoth a Hobby-horſe, and but little more. \"Tis the Com- \n- munication of the God head to a Plant that makes it grow, | \nthough not in ſuch a ſpiritual Way as he communicates him- |? \n\n\nEvery Graſs ſhews God is preſent with it, and 'tis the \nwithdrawing of God that makes it wither ; this is that they \n\n\n3 \n* \n8 \n\n\n80 \n\n\n2 \n\n\n1 Thy \n\n\nOT.\" \n\n\nbred from the Arteries of the Mother; good Reaſon then \n\"5 hh | 5 that \n\n\n\" L410 4-SW45, + 0 Fg . Ga es 1D © 4 * — \n\n\nCulpeper's Midwife Enlarged. 41 \n\n\nthat they ſnould be formed next, to give the Seed vital Blood \nfor the forming and quickning of the Body; ſince now the \nLiver hath fitted them with Blood, as Matter to build up \nthis frail Houſe of Fleſh withal. \n\n4. The next of all, the Liver furniſheth them with Blood \nto form the Heart : for the Arteries are made of Seed, but \nthe Heart, as alſo all Fleſh, of Blood. | id \n\n5. After this the Brain is formed, then the Nerves to give 4 \nSenſe and Motion tothe Infant. | | \n\nHere Atifotle and the Peripateticks are an hundred | | \nAriſtotle's Miles from the Truth. Judge if they do not make 4 \nFoolery. a Saving Voyage, that will needs have the Heart ; \nformed firſt, and that the moſt noble Part of the 1 \nBody ; whereas the Brain is a more noble Part, as being the oF \nSeat of Reaſon, and it muſt be alſo the Fountain of Blood; and 9 \nmany other Falſities, which I have heard Miniſters deliver 2 \nin a Pulpit, as confidently as yp will eat Acorns: Are ſuch \nMiniſters of God, I pray, or A4r:/totle ? | \n6. If you aſk me which of the Bones be formed firſt, I an- \nſwer, the Vertebræ and Skull; of the Order of forming the \nreſt ; as alſo of forming the Fleſh I am ignorant; 4ri/otle was \nof Opinion the Yertebr were firit formed of all the Bones, \n\n\nand there the Man hit the Nail on the Head. F \nTo be a ſkilful Phyſician, ſtudy theſe Books of mine, viz. | \n\nPlaterus, Sennertus, Riverius, Riolanus, Bartholinus, Fohnſton, 4 \n\nVeſtingius, &C. | \n\n\n© AP: Ut, \n\n\nAn Anfwer to ſome needful Queſtions about the Formation of the \nhs Child in the Womb, : \n\n\n1 N anſwering theſe, 7 all anger ſome, and ſome 1 Shall | \nteach; I. Hall pleaſe others and not deſpleaſe myſelf. | 7 \nMany and large have the Diſputes of the Ancient and Mo- \ndern Writers been about 'Trifles in this Caſe, which I ſhall \npa: paſs by. As, | \n1. Whether the Seed be the efficient auſe of our Forma« \ntion or not? | -- \n2, Whether Women have 20 or not? \n\n\n$+ Whether : F \n\n\n42 Culpeper's Midevife Enlarged. \nWhether it act in Forming as well as the Seed of Man? \nWhether all the Members be formed together ? \nWhether the Heart live firſt ? 5 \nWhether Seed flows from all Parts of the Body ? \nWhether Seed of Sexes muſt be preſently. mixed or \n\n\nWITT 2 \n\n\nnot ? | \n8. Whether this active Power of Forming be in the Womb \nor not? With theſe and many other like frivolous Diſcourſe \nhave Authors 'for want of better Employment) blotted a \nCart-load of Paper with, and ſpent that precious time in \nuch needleſs Diſputes, which might have been better em- \nployed, for the 28 of their Brethren. Only ſome need- \n\nul Queſtions here are to be anſwered, which \n\n\nChild lies in, can. The firſt is this, What is the Form the \nIn the Womb. Child lies in, in tbe Womb ? In what Faſhion \n| doth it lie there? \nAbout this Authors cannot agree; not two of them in ten \nare of one Opinion. Vou ſee what a woful Maſter Traditi- \non is, and what a miſerable thing it is in Phy/ich, as well as \nDivinity, to pin one's Faith upon another Man's Sleeve, be \nhe never ſo learned. I ſhall give you firſt Hippocrates's \nJudgment, then Columbus, and lait of all a Figure out of \n\n\nSpigeltus. \n\n\nHippocrates in his Treatiſe De Natur. Pueri, \nAccording to affirms the Chill as he is placed in the Womb, \nHippocrates. to have his Hands, and his Knees, and his \n\n| Head bent down towards his Feet ſo that he \nlies round together, his Hands upon both his Knees, and \nhis Face between them, ſo that each Eye toucheth each \nThumb, and his Noſe betwixt his Knees. Of this Opi- \nnion was Bartholinus the younger. Columbus \nholds that the Figure of the Child is round in \nthe Womb, the right Arm bowed the Fin- \nrs thereof under the Ear, and above the Neck, the Head \nowed down, fo that the Chin toucheth the Breaſt, the left \n\n\nColumbus, \n\n\n3s propped up by the bending, of the right Elbow, the Legs \nare 1.ttcd upwards, the right of which is ſo lifted up, that \nthe Thigh toucheth the Belly, the Knees the Navel, the \n3 ; | | \"Foe! \n\n\n42: \n\n\n* \n\n\nThe Form the I ſhall perform as briefly and plainiy as 1 1 \n\n\nArm bowed above both Breaſt and Face, and the left Arm \n\n\n_ A \nn — \n\n\nJn Pn, DOE \n\n\n—_ Io Wa.» » PEE — 24 3 — — 9 Ix Ot 1 \n— , \\ is 1 2 — TAG 3 — \n5 1 Nr. — 8 * \"RES PL, x \nva. CR hg” AL —— 6 # £4 — \nyu % a * SID j! WW 74 — — ä \nAN * — o FE LL . \n( 7550 p ,., \n2 W : a SEALS \nff #1. 1th \"La Mar , 7 \n\n\n— ws 2 - * + \n4 CEA — — \n\n\n. a \n\n\n* — \n\n\n2 — \n\n\nR * \n* ** Wenn \n\n\n—— \"4 — \n— \n\n\n\"NC | Explication bY. Ne Figures, ſhewing the Diflibagce of the \nParts of a Child in the Womb, from thoſe in a Perſonof Years. \n\n\nThe Second of the Figures in this Plate, heros the Form the Child lies 5 in, in the \n\n\nWomb, according 70 the Opinion of Hippocrates and Bartholinus. | \n\n\ni rr \nFR The Deputy Kidneys, or Vice Kidneys, | => | \ncalled In Latin Renes Succenturiati. \nBB The true Kidneys, as yet di iſtinguiſhed, \n\nby divers Kernels; but ill expreſſed in point \n\ne Situation by the Graver*s miſtake. | \n\nC The great Arteria from which Branches go \nto the Kidneys and Capſulæ or Caſes. \n\nD The Feda cava, from whence ſpring the \nEmulgents, and the ſmall Twigs 1 the \nCapſulæ, or Caſe. \n\nF . I. \nShews the Situation of a Child in the \nWomb, howbeit in ſome it differs, \n\nA The Head bending forward, ſo as the \nNoſe may be hid between the Knees. \nBB The Buttocks, to wwpich the Heels are \n\ncloſe ſet. \n\nCC The Arms, \n\nD The Band or Rope cartied aleng by tbe \nNeck, and bended Þ-k upon the Forehead, \nand continued with e Placenta, expreſſed \nin the following Figure, at the Letter, D, \n\nEG. | \nAAA The Membrane Chorion divided. \nBB The Amnios Membrane, as yet cqve- | \nYing ihe Bard. \n\nCC The inner Concave part of the Placenta \nor Worm Cake, which lies next the Infant \nwith T wigs of the Veſſels, : \n\nD A Portion of the Band or twiſted Rope. \n\nPIE 3. IV, \n\nExpreſſes the Outfide of the Womb-cake, \nwhich cleaves to the Womb with(EEEE). \nthe Clefts and Chinks therein which vary \nin Reſpett of Number and * Mothers Womb , which in very many \n\n> 1: G6. IN. Particulars differs from that of a grown \n\n7 be Skeleton of a Child as i is in the the Perſon, as 15 apparent.” \n\n\nhe | The Form the Child lies ih the Womb, according to \n\n\n— \n\n\nthe Opinion of Shigelius. \n\n\nboth Proper and Common. \n\n\n; \na \n4 \nx \n1 \n7 \nö \n\n\n4 \n\n\n4 \n\n\nP 2 — * . 1 % > \n, . FP S544 £47 \n\n. . SLES AGES %%. \nN I e, of mae a —— F CLARE WY \nEx e I — 1 = LA 7 \n\n* , , 1 \n*. — \n—— \n7 \n* \n\n\n/ \n, EX \n” 7 * # / \n\n\nHU \nFI) \n. A 95 \n\n\ni, \n1H 4; . \n\n7 2 \n\n7 * \n\n\nBe This Table ſhews the Infant naked and diſrobed of all its Tunicles, \n\n\nAA The Prrtiens of the Cho- \nrion diſſected and removed \n\nfrom the proper Place, \n\nB 4 Portion of the Amnios. \n\nCC The Membranes of 7he- \n\n Fomb diſſettes, | \n\nDD The Placentia, being 4 \ncertain fleſhy Subſtance, 1n- \ndued with very many Veſſels, \nby which the Infant receives \nits Nouriſhment. | \n\nE The Varication of the Veſſels \nwhich make up the Navel- \nſiring. \n\nFF The Navel-ſtring, bywhich \nthe Umbilicar Veſſels are car- \nried from the Placenta 10 \nthe Navel. \n\n\nGG The Infant as it keth per- \n\n\nfect in the Womb near the \nTime of Travel. \nH The inſection of the Umbi- \nAcar Veſſels into the Navel \nof the Infant. \n\n\n4. \n\n\n—— ARS \n\n\n1 \n\n\n418 n according t to \n\n\nof Spigelius. \n1 and diſrobed of all its Tunicles, \n\n\nnd Common. \n\n\nn \n\n\neee TT OR \n\n\nAA The Pertions of the Cho- \nrion diſſecked and removed \n\nfrom the proper Place, \n\nB 4 Portion of the Amnics. \n\nCC The Membranes of the \nFomb diſſetted, | \n\nDD The Placentia, beirz a \n\n\ncertain fleſhy Subſtance, in- \n\n\naned with very many Veſſels, \nby which the Infant receives \nits Nouriſhment. \n\nE The Varication of the Veſſels \nwhich make up the Navel- \nfiring. \n\nEET. i yewous \n\nre car- \nita 70 \n\n\nPer- \nthe \n\n\ntz - \nvel \n\n\n„ \n\n\n— \n\n\nCulpeper's Midwife Enlarged. 43 \n\nHeel toucheth the left Buttock, and the Foot is turned back \nand covereth the Secrets, the left Thigh toucheth the Belly. \nand the Leg is lifted up to the Breaſt ; the Back lies out- \n\nward. An n n 07 5075497 | ; e FIST \n\n8 Laſtly, J here inſert you the Figure taken \n\n{ out of Sprgelins, who quotes it but of a Child Sprgelrus. \n\nö prepared for the Birth, or when the Birth is | | \n\ni near, and as far as I remember, that which I ſaw was like \n\n\nthis. | \n\n15 Mauꝛnuert the Figure here. | \nMy ſecond Queſtion is, How. the Child is nouriſhed in the \n\nomb ? 1 \nAuthors differ as much about this: I ſhall quote ſome of \nthem, that none ſhould think I am critical | \nwithout Cauſe againſt Antiquity, which our Here rourifped \nNation, for want of more Wit, have ac-\" mm the Womb. \ncounted Venerabe. | 12 \n\nAlmeon thought the Infant drew in his Nouriſhment by \n\n\n— \n\n\nf F his whole Body; becauſe it is rare and ſpungy, as a Spunge \n\n0 ſucks in Water on every Side; and fo he thought it ſucked \n' Blood, not only from the Mother's Veins, but alſo from the \nWomb | | | „ N \n\n5 N Democrates and Epicurus, recorded by Plutarch, that the / \n\n£ Child ſuck'd in its Nouriſhment by its Mouth. And af \nHippocrates, Lib. de Principiis, affirms, That the Child ſuck d : \n\n; 1 both Nouriſhment and Breath by its Mouth from the Mo- \nther when ſhe breathed, (though in his other Treatiſes he \n\n- \"| ſeems to deny it) yet there he brings two reaſons for it: 1. \n\n9 | Becauſe it ſacks ſo ſoon as it's Born, therefore it needs muſt \n| have Learned before. 2. Becauſe there are Excrements \n\n| f found in the Guts of it fo ſoon as tis born 3 \n\n8 > To the firſt I. anſwer thus, It learns to ſuck” by Natural | \n\ne 4 inf, Take a young Cat that never ſaw her Daty catch - \n3 a Mouſe, yet will ſhe catch Mice ſo ſoon as ſhe is able: \n\n3 3 Muſt ſhe needs therefore fuck Mice from her Dam when ſhe \n\n] was in her Belly? And yet this Argument of _ Hippocrates, \n\n\nwill ſerve for ſuch a Prieſt as denies - any ſuch thing as Na- \ntural fine (of which I know ſome) to teach in the Pulpit \nfor Authentick. . e \n\nn C z To. \n\n\nʒ113m.ꝙ.:üũü4c4≅4 \n\n\n„ \n\n\n44 : Culpeper's Mideife Enlarged. \n\n\nTo this ſecond Reaſon I anſwer thus, That theſe are not \nExcrements of the firſt Concoction; and that I prove, be- \n\n\ncauſe they ſtink not, but are the thickeſt Blood convey'd. \n\n\nfrom the Veſſels of the Spleen to the Guts, and there driven \ninto that Form. All theſe being as far off from the Truth, \n\n\nas Dover is from the Lizard Point : We muſt find anew Way \n\n\nfor the Child's Nouriſhment ; and the Truth is, all Modern \nWriters agree, the Child receives its Nouriſhment by \nits Navel; but what the natural Nouriſhment of the \nChild, they alſo keep an old pother about, and defend and \nprove about, like Lawyers, and all to no purpoſe in the \nWorld. | \n - Ariſtotle and the Peripateticks, and Magrius from them, \nheld it to be nouriſhed in the Womb by the Woman's Men- \nftrua's. : | \nOthers, as Columella, Pliny, Columbus, and Fernelius, they \ndeny the Child to be nouriſhed by Menſtruous Blood; and \ntheir reaſons are, becauſe it is impure, and this Impurity \nthey. prove, becauſe it kills tender Herbs, makes Trees bar- \nren, and Dogs:mad, and hurts the Women themſelves, ma- \nny ways cauſing Pains, Swelling, Vomiting, loſs of Appe- \n-tite, Vertigo, the Fits of the Mother, 3 over ſharp and \n\n\ncruel Diſeaſes of the Womb; and therefore being thus evil, \n\n\nthey are not fit Nouriſhment for the Child. A very learned \nDiſpute for a couple of Boys of ſeven Years old a piece to \ndecide. For, | : \n\n1. This Blood which a Woman voided once a Month, \nis not ſo bad as they make it to be; nay, ſimply in its ſelf \nconſidered, not bad at all, but very good ; for if the Wo- \nman's Body be.in good Temper, the Blood muſt needs be \nyouu; and the reaſon why ſhe voids it, is, becauſe it of- \n\ns in quantity, not becauſe it offends in quality; but if \nthe Woman's Body be vicious, the Blood which remains in \nit is vicious, as well as what is caſt out. \n\n\n2. It is not ſimply the Merfiraa's which produce thoſe \n\n\ndangerous Effects they talk of; but the Menſlrua's ſtopped \nbeyond their due time, and by Stoppage corrupted, and by \nCorruption are theſe ill Effects they taſk of produced; and \nthis is a better Argument to prove them very good _ \n\nan \n\n\nCulpeper's Midwife Enlarged. 45 \nthan very bad; for the beſt of Things when corrupt, prove \n\n\nthe worſt. But, \n\n\n3. What need all this quoil have been? We all know that \nit is called ¶ Menſtrua s] becauſe it is caſt out Monthly; and \nwe know that Women have them not the greateſt Part of \nthe time they go with Child, nor moſt Women when they \ngive ſuck : And if the Child be not nouriſhed with the \n{ame Blood in the one, and it be converted into Milk in the \nother, what becomes of it? It ſeems then this cavelling is \nrather about the Word [ Meftrua's] or about the Blood re- \ntained above a Month before Conception, than about any \nmaterial thing in the Buſineſs : But I have done. \n\nI come now to the Anſwer of the Queſtion, and yet let \nme tell you firſt of another of Hippocrates his Abſurdities, \nvis. That the latter time of the remaining, or the Child in \nthe Womb after it is quick, it is nouriſhed partly by the \nMother's Milk; you may find in his Book De Natura Pueri; \n\n\nit deſerves not an Anſwer, being juſt as probable as that a. \n\n\nMilſtone can ſwim. 1 \nThe Truth is the Child is nouriſhed in the Womb by ve- \n\n\nry pure Blood, conveyed into the Liver by the Navel- Vein, \n\n\nwhich is a Branch of the Lena Porta, or Gate-Vein, and \npaſſeth to the ſmall Veins of the Liver: Here this Blood is \nmore purified, and the thicker and rawer part of it is con- \nveyed to the Spleen and Kidnies; the thick Exerement of it \nto the Guts, which is that Excrement found there fo ſoon as \nthey are born, The pure part is conveyed to the Vena Cava, \nor hollow Vein, and by it diſtributed throughout the Body \nby the ſmall Veins, which like ſmall Rivulets paſs to every \nPart of it. This Blood is accompanied with a certain watry \nSubſtance, as all Blocd is better to convey. it through the \nPaſlages it is to run in, which, as in Men is breath'd out-by \nSweating, and contained in the Aunois, as I told you before. \nI have done with this Queſtion, after I have ſhew'd you \nthat there is a certain watry Subſtance in white Blood is ſent \n\n\nto the Kidnies, and from the Ridnies is this ſent by the U- \n\n\nreters to the Bladder : Neither doth an Infant void his Urine \nby his Privities, but it is conveyed to the Allantois by the \n\n\n' Uraches, (which I deſcribed beiore) which is long and \n| bloodleſs, and paſſeth from the Bottom of the Bladder to \n\n\nC 3 the \n7 : \n\n\n46 Culpeper's Midwife Enlarged. \nthe Allantis; neither hath it any Muſcle belonging to it, \nſeeing no time unſeaſonable to the Infant in the Womb to \nvoid its Water, whereas we have Muſcles at the Root of the \nYard, to ſtop and open, that we might follow our: Buſineſs, \nand not always be Piling. | | | #4 \n\n| And thus you have, \n\ni. In what Form the Child hes. \n\n2. How it is nouriſhed in the Womb. \n\n\n8 \nThe Formation of the Child in the Womb Aſtrologically handled : \n\n\n1. IT cannot be denied, but that the Stars and Elements \nhave a mutual Sympathy one with another, becauſe \nthey are produced out of one and the ſame Chaos. \n2. The Elementary Bodies are in Subjection to the Ce/eftial \nbecauſe, Obedience is to be found in the Elementary World. © \n3. That there muſt needs be Mzicroco/mical Stars in the Bo- \ndy of Man, becauſe he is an exact Epitome of the Creation. \n4. That this Microcoſinical Sun, Moon and Stars, muſt be \nactive, and the Elementary Part of the Body of Man paſſive, \nappears, becauſe the Cæleſtial Bodies are not changed, \nbut remain the very ſame. Now there were at the Creati- \non but Elementary Bodies always increaſe or decreaſe, and \nnever ſtand at a Stay; hence then it will come 10 paſs, \nwhich all (unleſs Cavillers) will confeſs, that as the Cæleſtial \nBodies in the Microceſin induce the Form, and the Elementary \nWorld ſubminiſters Matter for this Form; ſo alſo they muſt \nof Neceſſity do in the Mzcroceſm. © \n5. 'Fo preſent this more clearly before your Eyes as a \n\n\nTruth, take notice, that the Womb of a Woman is under \n\n\nScorpio; for under Firgo it cannot be, becauſe Virgo is a bar- \nren Sign: And here by the way, that few or no Writers \nthat ever vet could fead, could give any Reaſon why Scorpro \nis a fruitful Sign; they tell you a long Tale of a Tub con- \ncerning the reſt of the Signs, as that Les is a barren Sign, \nbecaute Lions ſeldom bring forth Young. But why ſhould \nnot Taurus be a barren Sign? for Bults never oring forth \nYoung ; and Ates is not Fruitful, becauſe is it tha . \n\n5 Zzars, \n\n\nee ee * — \n\n\nn \n\n\nCulpeper's Midewife Eularged. \n\n\n47 \n\n\n\"Mir and why then ſhould Scorfio, which is the Houſe of \nMars alſo? The Truth is (to let the Fictions of Authors paſs) \n\n\nSrorfro is a fruitful Sign, becauſe it rules the Womb : And \nCancer and Piſce, are fruitful, becauſe they are of the ſame \n\n\nTripli \n\n\ncity, \n\n\nBut to proceed : \n\n\nThat every Planet hath Influence in the Generation of \nMan, re by this Table. \nLet them that wobtld be learned Phy ficians, read thelc \nBooks of mine, viz. Platerus, Sennertus, Riæerius, Riolanus, \nBa tholinus, Fohn fen, Jetiugius, &C. \n\n\n= \n\n\nThe Table 15 25 \n| | | | Br, \ne | x | © @ 4a | » \n\n_Yis Tr YT mT |KCaSS MT \ne EVM \nTR a r= rx \n% Z MT AS 7 II D \nDr \nDD Ae & [YRS & 6 IL \n=+£ Vis m XxX . my PER \nI j e N TS [= tp. IF. \nFFF \nF n r [xn Af; \nNN \nll . Im- ieee \n\n\nN \n\n\nEvery Planet is ſaid to rule particular Parts of the Body, \nand ſeveral Parts, according to each Sign he is in. All Au- \nthors have left Tables of this, and all falie, I at firit defiring \n2 Reaſon of this Table, found out in about half an Hour's \nical , that every Planet ruled the Head when he was in bis \n\n:: Hiouſe, and the Neck in the Houſe ſucceeding; b ut this, \n3 J could not find it agree with the Writings of other \nAuthors (with their Tables of Nature I mean \n\"A lictle ſtand ; conſidering a Man had as good put hisWits an \n\n\nC4 \n\n\n) 1 was firſt at \n\n\nA PPr entice \n\n\n. „ „ WIC er 4 oO Eats ere \n\n\n— \n\n\n48 Culpeper's Madwife Enlarged, \nApprentice to a Man of Bealam, as make them Slaves to Tra- \ndition, I drew out a Table in another Form, which preſently \ngave me as much Satisfaction as I deſired; ſo. much as be- \nlongs to my preſent Argument I ſhall here quote. You ſhall \nfind that cvery Planet in Scorpio governs the Parts of the Body \nwhich are under the ſame Signs which he is Lord of, the Lu- \nminaries excepted, which do it by Reception, is an evident \nTeſtimony that they have Influence in forming the Child in \nthe Womb ; as alſo there is a mixture of the Influence of \nthe Luminaries in that Action. 46 \nLet this ſuffice to have proved, that the Planet have an \n\nInfluence even upon the Conception in the Womb ; we \ncome now to ſhew you. \n\n1. What Authors ſay concerning the thing. \n\n2. What indeed the Truth is. \n\n1. What Authors. DT \n\nThe firſt Month of the Conception they give to Saturn, . \nby whoſe Influence and retentive Faculty they ſay the Seed . \nis faſtned in the Womb. I \n\n2. The ſecond Month they attribute to Jupiter, by whoſe \nInfluence they ſay the Foundation of Growth, Senſe and \nUnderſtanding is laid ; whereas the Foundation of all is laid | \nIn the Commixture of the Seed in both Sexes ; the Man is | \nthen formed in Jap; in poſe, though nat in ee. Fi \n\n3. The third Month they give to Mars, and he they fly _ \ngives Heat and Motion to the Child; but if it wanted Heat \nbefore, how could it live till that time? T's but a frigid \nArgument, to think Life can be maintained by cold. \n\n4. Then the Sn challengeth the fourth Month they ſay, \nand he furniſheth the Child with vital Spirit, but Mars gave \nit Motion a Month before ; and was ever voluntary Motion \nto be known without vital Spirit ? \n\n5. Then comes Venus, and ſhe in the fifth Month gives \nthe Child Comelineſs and Beauty; but by their Leave, if \n\nthey take comelineſs for faſhion of Body, that it hath lon \nbelles ; for the Body is faſhioned in thirty or forty Days as al \n\nhold; but if for clearneſs of Skin that appears not till the \n; Child be of ſome Age, namely a Year or mere. \n\n6. Mercury, he hath the ſixth Month appropriated to him \n\nin which time they fav, he ſeparates and diſtinguiſheth the \n\n| To Members \n\n\n3 | . \\ \nPers, . rem wiac,th — — 1 © > \n2 . . 8 5 * \n\n- +7 Ez * \n2 \nFe * * n 8 \nE Fo * — * * \n- — r N EIS — r — \\ \n8 \"RAY \n\nvo Xt * 4 N S n — \n\n3 PRO SY” * — << 2 r * b - \"WY \nf \n\n\n= — \n— \n\n\nwu \n\n\na \n365 \n4 \na \n\\ \n» TY \n* \n4 \nÞ \n1 \n1 \n1 \n\n\nOO aw wie CY \n\n\nyo ep %% \n\n\n* 553 os th; n , \nn =. : \n\n\nJ r \nn * \n\n\nCulpeper's Midwife Enlarged. — \n\n\nMembers of the Child, which were before connexed; This \nis ſuch a peice of Buſineſs Man knows not what to think of, \nmuch leſs what to make of; if they mean by diſtinguiſhing \nthe Members, the breaking of theſe Skins which wrap the \nChild round in the Womb, wiz. the ve d, they are not \nbroken before the time of the Woman's Labour; if they dream \nthat the Members or Limbs of the Child are in a Chaos before, \n\n\nthis is but a Dream waking ; and as ſimple a Buſineſs as it \n\n\nis to believe that they are tied together by Ligaments &c. (for \n\n\nto write like a Scholar, for I write now to Aſtrologers, who \n\n\nſhould be Scholars if they are not) it is ridiculous, and de- \nclines as much from the Truth, as the Poles of the World do \nfrom the Equator, that any one ſhould think that thoſe Limbs. \nof the Child that now are ſeparated, ſhould formerly be joined \ntogether, either by Erarthrofis, Arthrodia, Gynglymos, Harmonia, \nSutura, Gom phoſis, Sinchondroſis, Sinneuroſis, or Syſjarcofts. \n7. And then the Moon muſt come to make up another Er- \nror in the Work, and ſhe muſt have the ſeventh Month be- \nitowed upon her, in which they ſay compleats the Child, \nwhich was juitas compleat five Months before. \n2. To ſhew you the Truth of the Buſineſs. - \"5-4 \nAuthors fail not ſo much in the Operation of the Planets, \nas they dorn the time in allotting the Planets what they mult \ndo every Month ; whereas indecd they all operate together, \nat the ſame time, but if all the reit of the Planets ſhould lie, \ntall while one works, what a mad peice of Work would they \nmake? A Man had as good affirm, that eyery Planet moveth. _ \nhis Month, and all the reſt ſtand ſtill the while. Philoſophy \nteacheth Men that Motion is the Cauſe of Change; for it is \nthe Motion of the Sa, or elſe of the Earth that cauſes Dax \nand Night. But that we may be Methodical in laying down \nthe true and genuine Operation of the Planetary Influence in \non Af of conception: We ſhall ſpeak of each Planet by \nIt ſelf. - | \n1. The Sun, is well known to every one, gives Heat to \nthe World: And if ſo, then alſo to the Body of Man, be- \ncauſe our Life conſiſts chieflyj by Heat, which animates the \nMoiſture, fo that the dun muſt needs be the Author of Life, \nand Father of all living creatures, and therefore muſt of ne- \nceſſity be firſt formed in the Seed of both Sexes, being mixed \n. | Co in \n\n\n50 Culpeper's Midwife Enlarged. \nin reſpect of Order, if not in reſpect of Time: He is formed \nin the very midſt of the Seed, ſrom whence he quickens, in- \nipires, and moves every Part to its particular Action. Indeed \nwhat Aristotle attributes to the Heart in the Generation of \nMan's very true, if he had ſpoken of the Microco/ſmical Sur, \nand therefore ſome real PhiloGphets ( I ſearce dare reckon \nNriftotle in the Number of them) having 'imagined that the \nSeat of the Microco/micel Sun in the Body of Man was the \nHeart; yet I can ſcarce be of that Opinion that the Microce/- \nical Sun and Moon, which Reign like King and Queen in the \nBody, ſhould be confined to any particular Place, however \nthe Office of the Microco/mical Sun both in and after concepti- \non is to give vital Spirit, and ſtir up all things to Motion \nand Action. ee e \n2. As the Water moiſtens the Earth that ſo it might not be \n\n\nMicrocoſmical- moon adds Moiſture to the Conception from the \nvery beginning of the Embryo, even to the utmoſt term of \n\n\nmiliar Ferm amongſt all Phy/icians, yet underitood by very \nfew. Some Philosophers are of Opinion, that the Microcoſimicul- \nmoon keeps her Reſidence in the Brain, and that's the Reaſon \nAriſtotle's earthly, dull Philoſophy, held that the Brains coot- \ned the Heart; but how or which way, neither himſclf, nor \nany Body elſe ean tell. Tis ſome inviſible buſineſs which had \nits Original from the Brain- ſick Humour of an idle Philoſo - \npher. Bur out of queſtion, the Microcaſinicalmoon is not con- \nfined to any one Part of the Body, but is univerſally in it as \nRadical-moifiure is, Indeed the truth is, as the Sun / des Heat, \n1d the Moon gives Moiſture: And that is the Reaſon the Ge- \nneration of Things is held to be from Heat and Moiſture ; \nand if ſo (Which is moſt certain) what an admirable fantaſ- \ntical Dream was that of A4ri/tozie, that the Brain was cold \nand moiſt? | 7 \n3. There muſt be ſomething to counterpoiſe the Heat of \nthe Sun, and Moiſture of the Moon, and this muſt be by a \nPlanet contrary to them both, elſe it could not be done, \nwhich Office Saturn performs ; for he fixes and ftays the \n-- Beams of the Microcoſinical Sun and Moon, that ſo Generation \nmay be made. You knew Shoemakers nail on their Shoes wo \n5 8 the \n\n\nburnt up by the ſcorching Heat of the Cæleſtial Sun; fo the \n\n\nLife; and this is that which. they call Radical-mcifture, a fa- \n\n\nn 8 \n\n\n* \n\n\nthe Laſt before they can ſow them; the bones are alſo \n\n\nCul peper's Midwife Enlarged. 51 \n\n\nframed by his Influence,” by which this frail conception is \nupheld and Ned After it is ben \n\n4. There can be no Generation without PutrefaQtion , \ntherefore what Rays the Lunaries let fall upon the Seed, \nand Saturn hath fixed Jutiter, by his Heat and Moiſture pu- \ntrifies and concocts, and by his equal Temper preſerves a \n\n\n. \n\n\nHarmony in it. | 3 \nF. As all things are bred by Heat and Moiſture, and \nfixed by coldneſs and dryneſs ; ſo the Generation of Man, \nthere muſt needs be ſome exſuperance and abounding ; this \nMars heats, exhales and converts both into Excrements, \nand alſo hardens into coverings of the Fulryon: Indeed his \nHeat is a drying, burning, calcining Nature ; for all things \nare made better and purer by Calcination; fo indeed is the \nEmbryo in the Womb made fit for growth by the Heat of \nMrs 8 \n6. We told you all Generation was performed by Heat \nand Moiſture, therefore as Mars. Heats and Calcines the \nFrbryo, fo Venus moiſtens it. And here you have the Rea- \nſous. \n1. Why Venus being a cold and moiſt Planet ſkould be the \nAuthor of Generation, ſeeing all Generation is performed \nby Heat and Moiſture ; indeed ſhe doth but only add Moiſ- \nrure to the Heat of Mars. | * ONT \n2. Conſidering what Antipathy there is between Mam \nand Venus, and yet what a Sympathy they have in the Ge- \nneration of Man; and ſee the Reaſon of that Sympathy and. \nAntipathy of things generated. \n3..Secing all things are generated by a Corruption of \nthe contrary Qualities, you need not aſk the Reaſon why \nMan being fo generated muſt in time come to Corruption. \n4. You ſee here the Reaſon of thoſe Poetical Fiftions \nthat Mars and Venus were ſo often found in Adultery, be- \ncauſe they perform the very ſame Office un. the Generation \n„ | \n5. It is Proof enough to me, that Mart and Fenus do \nperform this Action of the Conception of Man, becauſe \ntheir Bodies in the Heavens are neareſt of all the five Pla- \nnets of the Globe to this our Terreftial Star. | \n\n\n6. Mercury: \n\n\n— Culpeper's Midwife Enlarged. \n\n6. Mercury being of a mutable Nature, often applying to \nthe Suu and Moon, and the Planets ; Mercury maketh the \nſenſible, and (ſome ſay; rational Part in Man, and ſo \nbeſtows Senſe and Reaſon upon the Embryo; in Deed and \nTruth, he beſlows ſuch a penetrating and acute Humour \nupon the Enbryo, which flirs up to Contemplation, inquir- \n\n\ning after the Reaſons of Things; for he cauſeth that inbred. \n\n\nDeſire of Knowledge which is in the Sons of Men: Only \nhere is one thing which ſecms worth the Anſwering, which \nis, That thoſe that are born in the ſeventh Month, may live \nby Reaſon of the Complement, fulfilling of the Planetary \n> > Wo ; but ſuch as are born in the eighth Month, are ei- \nther born dead, or live but a very little while, becauſe the \n1141 poem or Government of the Conception is turned \nback to Saturn, who (they ſay) is inimical to Nature in all \nkis Qualities. \n\n\nTo this 1 Anſwer ; \n\n\n1. Satwrn is inimical to none but to ſuch as know not his \nQualities for he cannot endure ignorant Puppies. \n\n2. Tis not the Complement of ſeven Planets that makes \na Child live, born at the ſeventh Month, but the perfection \nof the Number [Sever ] which, if I were writing Divinity, B \ncould prove by Scripture to be the perfecteſt Number that \n15, | \n\n3 Hippocrates may be miſtaken in his Book De Principiis, \nand in that De Odtimeſtri Partu, and in that De Alimento ; in \n\n\nall which he goes about to prove, That a Child born in the \n\n\neighth Month cannot live, Galen, Ariftotle, Plutarch, and \nothers, that wrote the ſame things after him, might be but \n\n\nhis Apes; for the Writers of Egypt, Spain, and thoſe of \n\n\nNaxuz, they affirm, that Children born in the eighth Month \nhave lived: Set one againſt the other. ; | \n\n4. There may be Rate difference about Hippocrates his \nMonths, viz. Whether they were Solar or Lunar. A Solar \n\n\nMonth is the Time in which the San is transfiting one of the \n\n\nSigns of the Zodiac, and is very near thirty, or thirty one \nDays throughout the Vear. \n\n\nF \n\n\n* «== \n_ \n\n\n| \n| \n| \n| \n\n\nN \n| \n\"I \n54 \n5 \n\n\nns \n\n\nCulpeper's Midwife Enlarged. 33 \nA Lunar Month is the time that the Moor traceth through \n\n\n\" 8 \n\n\nthe Zodac, and confifteth of 27 Days, ſome odd Hours, \n\n\nand ſome odd Minutes. \n5. The Women they wrote of, might be a Month miſ- \ntaken of their Reckoning; that is as eaſily done, and as \n\n\noften by ſome, as a Woman can miſtake one Shoe for ano- \n\n\nther in the dark. \n\n6. If the Office of Saturn be to retain the Seed in the \nWomb the firſt Month, who cauſeth the Expulſion of the \nChild in the eighth, which they attribute to him alſo? Is \n\n\nSa turn fo old that he has loſt his retentive Faculty? \n\n\nThey that would be knowing Phyſicians, let them ſtudy \n\n\ntheſe Books of mine, viz. Platerus, Sennertus, Riverius, Rio- \n\n\nanus, Bartholinus, Jobnſton, Veſtingius, Rulandus, Fernelius, \n\n\nHanctor. \n\n\n2 =, \n\n\n\"BOOK MM \n\n\nOf what hinders Conception, together with its Re- | \n\n\nmedics. \n\n\nT is moſt certain, that all Men and Women deſire Chil- \ndren, partly becauſe they are Bleſſings of God, and fo \nSaints deſire them, P/al. 127. 3. Lo Children are an Heritage \nof the Lord, and the Womb is his Reward. As alſo Pſal. 128. \nfrom the beginning to the latter end, prove it. Or elſe be- \n\n\n>, cauſe they are pretty things to play withal, every like deſir- \n\n\ning to play with its like. Or lattiy, and moſt probably, \n\n\n7 Luft is the Cauſe of begetting more Children than the deſire \nof the Bleſſings of God; for where the deſire for Children \n\n\nmoves one to the Act of Copulation, the Pleaſure in the \n\n\n| \n| \n| \n\n\nAct moves an hundred, and ſuch corrupt Principles gon \nuſually Baſeneſs in the middle, and Bitterneſs in the latter \nend, to thoſe that uſe them. It being apparent by the Curſe \nof God upon Eve, I will exceedingly multiply the Conception, \nthat many Children come into the World as a Curſe, mo \n\n\n„ Culpeper” 8 Mitecife E alarged \n\n\nT am: not now to act the part of a Divine but of a os fcian, \nand therefore to the Purpoſe in hand. \n| What hinders. Conception, cafeth Rs 96. \n| 1. Natural... | \nBarrenneſs is & 2. Acc dental. \nty Se 3. A lgainſt Nature. \not each of eſe in a Section 85 itſelf, \n\n\nUt nd cr op REY 0 \ni of Natural 1 T \n\n\nNATURAL eee I call that which cauſeth Bar- \nrenneſs in a Woman; the Inſtruments of Generation \nbeing perfect in both herſelf and her Huſband, no prepoſ- \nterous or diabolical Courſe uſed” to cauſe it, yet the Woman \n\n\nremains naturally barren ; neither Age nor natural Detect, \n\n\nand Diſeaſes impediting, yet the conceives not. \nTo find out all the *Reatons of this, requires a ſtronger \nHead- piece than I have; yet what the Lord bath! imp: arted \n* me, I ſhall freely impart to you. \n\n. The Man and the Wife that are both of one Complcx. \nag ſeldom have Children; and the Reaſon is clear from \n\n\nthe univerſal courſe: of Nate. which being formed by an \n\n\nAll-wiſe God, of a compoſition of Contraries, cannot be \nincreaſed by a Compoſition of likes; and although to find \n\n\ntwo People juſt in every particular of a Complexion, go 3 \n\n\nSyſtem happily too rare to find, or very ſeldom found; \nif they be very near of a Complexion, my Reafon will. Bold \nuu and I knew no Remedy for it; unleſs they ſhould \n\n\n1 \n> \n\n\nart; for if the main cauſe of Marriage be the Procreation | \n\n\nof Children, I know not but that Marriage which denies \nthis may be unlawful. The Truth is, Marriage is the great- \neſt natural Aion of Man's Life, and he that waits upon \nGod for his Direction in it, ſhall not do amiſs. \n\n2. Want of Love between Man and Wife is another \ncauſe of Barrenneſs. That there is an eſſential, vital Spirit \nin the Seed: of both Sexes is without all Queltion : (And \nthat made up the Baſis of Ouans Sin mentioned in Scrip-- \nture, in ſpilling his Secd; the other as ci cumtances, did \n\nbu 3% \n\n\ntw 2” WHOM 0 \n\n\nWo \n2” \n\n\n1 \n\n\nCulpeper's Midwife Enlarged 63 \nbut aggravate it, for this God ſlew him. I believe God \nhath been more merciful to many in England in the ſame \ncaſe, yet he is as juſt now as he was in Ozan's Days. Then \nſecondly, that this Seed participates of the Nature of both \nSexes, is very clear, by Mens begetting their like, ix. \nMen and Women beget Men and Women ; then if their \nHearts be not united in Love, how ſhould their Seed unite \n\n\nto cauſe conception? It is reported of two Theban Princes, \n\n\nEteocles and Polynices, both Brothers, yet a mortal Hatred \nbetween them, that having ſlain one another in Battle, \nwhen their Bodies were burned 12 in thoſe Days and Places | \nthey burned the dead Corps, and entombed only their Aſhes) \nthat the Fire partcd in the middle and went up in two Tops, \nand if there were ſuch a mummial Hatred in their Dead \ncorps, greater muſt the Hatred be in the Seed of two diſa- \ngreeing Sexes, becauſe it hath more Spirit in it; and this is \nthe Reafon there never comes conception upon Rapes. \n\nIt is a ſad thing Men ſhould take Women for their Friends \nthat did love them, and then hate them: And as fad, \nthat Women when they are Married, ſhould either through \nPride or Folly, or ſomething elſe, fo forget themſelves, \ntheir Huſbands, and their God, that they cannot hve quietly \nwith them; and worſe than either (if worſe can be) is that \ntrick of Parents, to compel their Children to Marry againſt \ntheir Minds; ſuch corrupt beginnings, uſually bring Sorrow | \nenough to all Parties that uſe them, or have a Hand in them; \nand that they all know by that time they have counted the \nmiddle and both ends. DS \n\n3 A third cauſe of natura] Barrennefs is, the letting ef \nVirgins Blood in the Arm before their courſes come down: \nTheſe come down in Virgins uſually in the fourteenth Year \nof their Age, ſeldom before the thirteenth, never before \nthe twelfth : And becauſe uſually all young Virgins are out \nof frame before they firſt break down, the Mother takes the \nDaughter's Piſs, and away to Doctor Dance runs ſhe, who \n\n\n. knowing ſomething by her Water, as much as he could if \n\n\nhe looked in a Crow's Neſt, and gathering by the Mother's \nTalk, and by ſecing the Party, that fulneſs of Blood of- \nfended, ſtraight preſcribes Blood- letting in the Arm {Bleed- \n\n\ning and Purging, and Purging and Vomiting, being all the \n\n\nMedicines \n\n\n> \n\n\n56 Culpeper's Midwife: Enlarged. \n\nMedicines that many country Phyſicians to my Knowledge \nhave Skill in, or commonly uſe). they go whip Diſeaſes out \nof the Body, as Sextons whip Dogs out of the Church, \n(this is done, and then ſhe is well for a time, the ſuperflu- \nous blood being taken away; the next Year (if ſhe ſtay ſo \nlong) the falls in the ſame caſe, then the other bout of bleed- \ning, and in three or four times ſo ſerving, eſpecially if the \nMaid uſe much exerciſe, the blood comes not down to the \nWomb as it doth in other Women, but the Womb dries up, \nand becomes for ever barren, . \n\nFor preventing this for time to come, let no Virgin be let \nblood in the Arm before their Meuſtrua's come well down \n(caſes of Neceſſity excepted) but rather in the Foot ; for \n\n\nthat provokes the blood downward, and by that Means it 9 \n\n\nprovokes the Terms. \n\n4. A fourth cauſe of natural barrenneſs, is loſs of carnal \nCopulation; Men and Women come to the School of Venus, \neither not at all, or ſo frigidly, that as good never as whit, \nas never the better. 1 f \nThis is perpetually cauſed of a cold Diſtemper, and muſt \nbe cured by ſuch things as heat and nouriſn. \n\nFor the cure. Let ſuch eat and drink of the” beſt ; Sire \nCerere & Libero friget Venus, faith the Latin Proverb : With- \n\n\nout good Meat and good Drink, Venus will be frozen to \n\n\n—_— \n\nWholeſome Food for ſuch, are Cock-ftones, Lamb-ſtones, \nSparrows, Partridges, 'Quails, Pheaſants-eggs; and \ntake this for an Aphoriſm of Truth, both in this Diet, \nand all other parts of Phyſick ; }hatfcever any crea \nture is addicted extremely to, they move the Man that eats them \nto the lite by their mummial Virtue. Therefore Partridges, \nQuails, Sparrows, Sc. being exceedingly addicted to Vene- \nWo they work the ſame in thoſe Men and Women that eat \n\nem. 3 5 f \n\nI will give you another, Look in what parts of the Body the \nFaculty which you would frengthen lies, and take the ſame part of \nthe Body of another Creature, in whom the Faculty is flreng, as \nMedicine. For Example, the Virtue procreates lizes in the \nTeſticles, therefore Cock-ſtones, Qc. are Medicinal for this \nDiſeaſe, | Ts \n\n\nI \n\n\n2 \n\n\nCulpeper's Midwife Eularged. 37 \n\nI have written enough of this to wiſe Men; but \nbecauſe all Men are not ſo, neither do I know Remedy. \n* they will, I ſhall quote ſome few Receipts. | \n\nLet ſuch often eat windy Meats, eipecially ſuch \nas nouriſh much, as Parſneps, Alexanders, Skirerts, Pine- \nnuts, Ec. \n\n2. Let them take a Dram of the Electuary Diaſayrion every \nMorning. You may find the way how to make it in my \nTranſlation of the London Diſpenſatory. \n\n3. The Stones of a Fox dried to Powder, and a Dram \ntaken every Morning in Muſkadel. \n\n4. A Dram of Satyrion Roots taken in the like Manner. \n\nBut becauſe I ſhall touch much upon this in the next \nBook, I pals it here. And thus much for this Section. \n\n\nS.E C T. Ih \nOf Accidental Barrenmeſs, \n\n\ncall that Accidental 3 which comes by Reaſon \n\nof ſome caſual Infirmity upon the body of the Man or \nhis Wife at a time, which being taken away, the Effect \nceaſeth. | \n\nThis is ſometimes cauſed by the Man's part, but moſt \ncommonly on the Woman's. \n\nThen what I am here to ſpeak to is, Barreneſs c ſed by \n\n* /ome cauſe which may eaſily be Corrected and Remedied.. » © \nAuthors have left ways to know, whether the caſe of has: \nrenneſs lie in the Man on in the Woman, and Hypfoerates \nwas very buſy about it; hut becauſe I cannot confide in his \nJudgment, I ſhall paſs it by in ſilence. \n\nThe mod rational way of Knowledge in this Point that \never I read in this caſe, I ſhall quote, and give my Reaſon \nfor it; if it do hold true, well and good; if not, I cannot \nhelp it, for I never tried. It is this; \n\nTake a Handful of Barley (any other Corn that \"will \nquickly grow will ſerve the turn as well) and ſteep half of \nit in the * of the Man, and the other half in the Urin \nof the Woman, the ſpace of four and twenty Hours, then \ntake it out and ſet it, the Man's by itſelf, and the W 8 \n\n3 \n\n\n58 Culpeper's Midwife Enlarged.” \nby itſelf, ſet it in a Flower-pot or ſomething elſe where you \nmay keep it dry, then Water the Man's every Morning with \nhis own Urine, the Woman's with hers, and 'that which \ngrows firſt is the greateſt ſign of Fruitfulneſs, if one grow \nnot at all, they are naturally barren, fay Authors ; for my \nPart I do not bind any Man to believe it, yet this J ſay, all \nMen and Women deſire to be Fruitful, and the Urine of one \nthat is Fruitfal (probably) is more likely to make a Seed \ngrow, than the Urine of one that is not Fruitful, becauſe \nthere is a Principle of Fruitfulneſs in the one, not ſo in the \nother; and every Man knows (that doth but know his 8: \nRight Hand from his Left) that Urine is eſſential to the | Pt \nBody of every one: And if it can ſhew Diſeafe, why not as | \nwell Fruitfulneſs and its contrary ? \n\n\nBut to proceed ; | \n\nBarrenneſs Accidental 1s either common to both Man and V \n\nWife, 1. e. either of them may be troubled with the Infirmi- \nty, or elſe it is proper to the Woman only, this (as I told be \nyou) is moſt frequent; neither is it my Purpoſe kere to ſpeak th \n\nOf Diſeaſes incident to Men, which may cauſe Barrenneſs for \nthe time being, but of ſuch as properly caule it; for the ha \nInſtruments of Generation in Man being perfect, his Diet BI \nand Exerciſe according to Rule, which the firſt Book hath be \n\nalready, and the next Book ſhall further inſtruct you in. I \nknow no accidental Cauſe of Barrenneſs in him, if his Bo- Pe \ndy be in Health. | | th \nThe chief cauſe of Barrenneſs in a Woman lies in her b \nWomb, and its Infirmities, which what they are, their lit \nCauſe, Signs and Cure, you ſhall find in Order preſented to | a \nyour View. FE Fes FF th \n1. Of fopping of the Menflrua's. | ; 2h] Be \n2. Of everfiewing of the Menſtrua's. | Bre \n\n3. Of the Flux of the Ii mb. 2 \n4. Of falling out of the Womb. | | | itſ \n5. Of Infiamation of the Ii cb. | \n\n6. Of l indineſi of the Womb. | \"> | \n7 Of Heat and Drineſi of the Womb. | 13 \n\n\nee . del 1:75, MBit In Order. 1 \n: | - OC MAP. thi \n\n\n2 \n\n\n. Midwife Bind . 59 \n\n\nCHAP. 1 \nOf the floppage of le Menſtrua J. \n\n\nT* HE Mw ey s ſtop: in a Woman. \nNatirally. \n| Hhain oft Nature. \n\nTo know he Difference between theſe, y ou 3 ooh re- \ngard to the Age of the Party: In many the Menſfrua's ap- \npear not till after the fourteenth Year, in few before, in \nnone till after twelve. \n\nThey ſtop naturally in ſome Women about the 5oth Year \nof their Age, in ſome before; they continue in very few \nWomen after the five and fiftieth, \n\nWhen they ftop through Age, the Woman is paſt Child- \nbearing, not before, for then it ceaſeth to be with her after \n92 Cuftom of Women. \n\nSuch as uſe themſelyes to ach. Exerciſes, \nhave but few of them, but thoſe few are very good Cauſes. \nBlood; and the Reaſon why they have but few, is \nbecauſe the Blood is conſumed by Exerciſe. \n\n2. Again many times, they are ſtopped in 3 fat \nPeople, for their Veins are narrow, and that little Blood \nthey have is turned into Fat. \n\nSuch as are waſted by continual Sickneſs, have but \nlittle ſuperfluous Blood in them. \n\n4. Sometimes they are ſtopped by reaſon the Woman hath \nthe Hzmorrhoids or Piles at the Time. \n\n5. Sometimes they fly up to ſome Sore or . Ulcers in the \nBody, as happens to ſuch Women as have a. Canker in their \n| Breaſts. Theſe I note but by the by. But \n\n6. Sometimes either a hot or cold N of the Womb \nitſelf cauſeth it. And | \n\n7. Care, Fear, Sorrow and Grief cauſe it. \n\nMy preſent Scope is only to ſpeak of the two latter, and \nmore particularly of the laſt ſave one, for the Cauſes of the \nlaſt being taken away, Effects ceaſe. \n\nThe general Signs of a Woman moleſted: with Signs 25 \n\n\nthis Diſeaſe are Heavineſs of the whole Body, mzeral. \nPronenefs \n\n\n. \nFLY. . * \n1 \n\n\nbo Culpeper's Midwife Enlarged, \n\n\nProneneſs to Vomit, Loathing of Meat, and certain Tremb- \n\nlings, ſuch as happen to Women with Child, Pains in the \n\nBack, and ſometimes in their Stomach and Neck, and \n\nBreaft, the hinder part of the Eyes, and the fore part of \nthe Head, and ſometimes their Body ſwells. \n\nThe diverſity of the Caſe may be partly \n\nParticular. known by the relation of the Sick. A cool \n\nDiſtemper is known by Dulneſs, Sleepineis, \n\nSlowneſs in Moving, a Pale, Whitely, Leaden Colour. A \n\n\nhot Diſtemper is known by the contrary Signs. I am no \n\n\nway ignorant of the ways the Ancients uſed for the cure of \nthis Diſeaſe in Women; becauſe I like them not, I ſhall \nmake bold to leave them out, and inſert my own, for which \nI ſhall give my reaſons. Conſidering that the ſtopping of \nthe Menſtrua's come thro' default in the Womb uſuaily, the \nbeſt way to help it, is by ſtrengthening the Womb. I ſhall \ngive you firſt the way of Cure. af | \n_ Secondly, Cautions in uſing it. \n\n1. Let the Patient fo. grieycd Sweat; for that \n\n\nCure. opens the Pores. The belt way is to Sweat in a \n\n\nFot-Houſe. | | | \n2. Let the Womb be ſtrengthened by drinking a draught \n\n\nof White-wine, wherein an handful of ſtinking Arach being \n\n\nfirſt bruiſed, hath been boiled; the Herb is common, it \n| wo almoſt upon every Dung-hill throughout the Nation, \n\nt by a ſecret, Magnetic Virtue ſtrengthens the Womb, and \nby Sympathy removes any Diſeaſe thereof. Ow Bees \n\n3. If there be together with this Infirmity Pains in the \nHead, as uſually there is, for there is great Sympathy be- \ntween the Head, and the Womb, and that's the reaſon all \nCephalic Herbs almoſt ſtrengthen the Womb, add a handful \nof Vervain to it, which by a like Magnetic Virtue ſtrength- \nens both Womb and Head, \n\n4. This being uſed two or three Days, if they come not \ndown : Take 7 Calaminth, Pennyroyal, Thyme, Mother of \nThyme, Bettony, Dittany, Burnet, Feather-few, Mug- \nwort, Sage, Piony-roots (the Female are beſt in this caſe, \n\n\nlet Man part their Pleaſure) Juniper-berries ; half an hand- \n\n\nful of theſe, or ſo many of them as can be gotten, boiled in \nBeer, and drank for ordinary Drink. ; \nBN TT wu . | 5. Take \n\n\nCulpeper's Midwiſe Enlarged, 6¹ | \nTake one part of Gentian, two parts of Centaury: 10 \nDia them with Ale in an Alembec, eee have bruiſed | \nthe Gentian roots, and infuſed them well: This water is an \nadmirable Remedy, not only to provoke the Terms, but al- | \nſo to refilt the Peſtilence, to help ſtuffings in the Stomach, 1 \nthe Spleen, to Purge not only the Womb, but alſo the bo- 1 \ndy of Choleric and Corrupt, Humours. If ſo be you have | | \nnot this Water in a readineſs, Take a dram of Centaury, \nand half a dram of Gentian Roots, beat them to Powder, \ntake it in the Morning in White wine; or you may boil an \nhandful of Centaury, and half a handful of Gentian Roots \nbruiſed, and boil it in Poſſet drink, and brink a draught of \nit at Night going to bed. | \n6. The Seed of wild Navew beaten to Powder, and a \ndram of it taken in the Morning in White-wine, doth the \nlike. | | \n6. Alexander, roots bruiſed and boyled in the like man- \nner, perform the ſame Office ; other Simples which are \nMedicinal, are the roots of Parſly, Fennel and Lovage, \nAngelica-roots, the Herbs of Chervil, Maſter-wort and \nSage, perform the ſame : you may uſe them at your Diſcre- \ntion. | | | 1 | \nIf this do not the ded, you mult let them Blood in the \nLegs. | | | \n\n\nE \n\n\n© — \n\n\n8 \neee \n\n\n* \n\n\nDr 3 \n\n\n— —— \n\n\nN . e ME fa CONE 3 \n\n\nn \n\n\nCAUTIONS. \n\n\n— \n\n\nCaut. 1. Give not any of thoſe to any that is with Child, \nleft you turn Murtherers, wilful Murther ſeldom goes un- \npuniſhed in this World, never in that to come. | \n\n2. Give your Medicines a little before the Full Moon, \nor between the New and full Moon, for then blood encreaſ- \neth, but never in the Wane of the Moon; for if you do, \nyou had as good give them to an Oak The Moon hath \ngreat influence upon all Elementary bodies, but more upon \nWomen than Men, becauſe they are of her own Sex. \n| 3. Let the Patient uſe much Exerciſe. 8 1] \nTe 4. If the Body be troubled with evil humours, let them 13 \nbe purged out. The third Chapter will inftru& you how. 1 \n\n; 5. Sometimes | \n\n\n* \n* \n\n\n: [} \nLT 1 \n\n: LE \nk \n\n\n— ( :::n!?:e:!: \n\n\n— — — \n\n\n. \n\n\n— — — — — \n7 \n\n\n——— \n— \n\n\n— \n— \n— \n\n\nDT — a \n— : PRE. n \"_ \n- ——— 4 \n\n* . \n\n\n1 \n\n\n— \n\n\n— \n\n\nF nd > OE RF TIES RIES \n* * _ 3 = \nOP IST. — * * 1 * E — \n\n\n— _ \n\n\nSs nn = \n—ͤ—ſ—EPZ 40 ies ce Carat \n* — \n\n\nTOY \n” \n\n\n[ \n\n\n62 Culpeper's Midwife Enlarged \n\n\nSometimes (though but ſeldom) they are ſtopped \nthrough fulneſs. This is known by vehement Pains about \ntheir Reins, their Veins are ſwollen, and they are ſuch Peo- \nple as live idly, and abound in blood. \n\nSuch muſt be cured by ble geding i in the Arm, for fulneſs \ncauſeth diſtention or richig | and diſtention hinders ex- \ntramiſſion And bleeding in the Foot makes the diſtention \ngreater, as was well noted by Dr. Ri. Verius, Phy ſician to the \nFrench King. \n\n592 let chis be done with W 6 Ache. and ert War. \n_ 7” 1 | \n\n\n* 0 e 4 3% : \ns % 118: HA id .: \n\n\nWe « Kar beg gr $f 5 \n\n\nOf the Owe flowing of the dels. \n\n\n„Tur: are ſaid to overflow, when they continue lon- \n\n\nger than their uſual time; their uſual time of con- \n\n\ntinuance is two or three Days; in ſome Women that give \nthemſelves to no Exerciſe, four or five Days. \n\n\n2, When they come oftner than the Legitimate time. \n\n\nTheir Legitimate time is, the time that the Moon Travels \nthrough the twelve Signs of the Zodiac, that is Twenty Se- \nven Days, ſome odd Hours, and odd Minutes. 1758 \nIt is cauſed. \n1. By Rupture of ſome Veſſel. \nCauſe. 2. By immoderate Purgation. \n3. By ſome concording Humour. \n4. By hard Labour in Child- bed, ar unkind hand- \n7 ling in it. \nSigns. Tf the Veſſels be broken, the blood guſheth \nabundantly 3 in heaps... | \nIf ſome gnawing Humour, they are not much 3 in quanti- \nty, but come with much Pain. | 14 \nTue other are eaſily to be n \nCauion. Such Women as are ſubje& | to this Diſeaſe, \n| ſuffer Abortion upon every {light occaſion. - \nLet them abſtain from Exerciſe. and moving as much as \nmay be, and from all: cold Drinks, - LESS lk \nBecauſe \n\n\nCulpeper's Midwife Enlarged. 63 \n\n\nBecauſe this Diſeaſe weakens the Womb much, ſtreng- \nen it as you are taught in the Chapter before. \nAnd here I confeſs I differ from all Phyſicians that ever \nrote, for they all unanimouſly hold that the Diſeaſe is firſt \nbe cured before the Part grieved be ſtrengthened ; where- \n] counſel to ſtrengthen the Part firft, that ſo Nature may \n> able to help on this Cure; the Work will be better and \noner done with Nature's help than without. Having firſt \nrengthened the Womb, proceed to the Cure thus; \nCure. 1. Anoint the Reins of the Back with Oyl of Ro- \nſes, Oyl of Myrtle, or Oyl of Quinces, which you \neaſe. I ſuppoſe the laſt mentioned to be che beſt ; do thus \n4 Night, and when you have ſo done, wrap a piece of \n\n\nhite Bays about your Reins, the Cotton fide next your ſkin, \nd keep the ſame Bays always to it. | oe OO \n2. To inject the Juice of Plantane into the Womb, is an \n\nmirable Remedy | | \n3. Sage, the roots of Diſtort and Tormentil, Cinque- \nyie, Knotgraſs, Comfry, Sannicle, Ladies Mantle, Gel- \nn Rod, Looltrife, Meadſweat, Archangel (that blaſphe- \nous Name our Thyſicians give dead Nettles). Mouſe-ear, \nlomon's Seal, Purſlane, Sorrel, Red-Beets, Shepperd's- \nrſe, Red-Roſes, Acorn-cups, the bark of Oak-Trees, \nC0, Maſtich, are Medicinal, boiled in your ordina- \nDrink. | \n\n\nu cannot expect I ſhould travel all over the Nation to teach \nu; you ſee what ignorance the Learned College of Phy- \nans hath trained you up in; inſtruct you one another as \nell as you can, know that you were not born for yourſelves \nlone, and I will do what J can to inſtruct you in the know- \ndoe of the Herbs before I am half a Year Older. \n\n4. Above all, I commend this Medicine to you: Take \n\n\nhandful, boil them well (being ffi bruiſed) in Ale, and \nink a good draught of it now and then ; this (with the Bleſ- \nof God) will help gau, tho\", the Mouth, of the Veſſels. be \n\n\nen \n\n\nwrb, White Pepper, Call anum, of each one dram: Diſlve \n| the \n\n\n1 \n- aca ad ett agate, Loaf F centre uber ere onthe Seb 4 Ad did. Moo :* ho Ae \n* \n\n\nI could wifh from my Heart you knew all theſe Herbs; \n\n\ncomfry Leaves, or Roots, and clowns Wound-avort, of each \n\n\n5. Take Cinnamon, Caſſia Lignea, Opium, of each two drans.; \n\n\nWL $64 +. \n* \n\n\n8 \n— Y ek orgies it >\" ig \nPaldgar” , 4 - , ” — \n\n\n2 \n\n\nAVER noe . ———— bore obs \n\n\n62 Culpeper's Miduife Enlarged. \n\n\nSometimes (though but ſeldom) they are ſtoppe \nthrough fulneſs. This is known by vehement Pains abo \ntheir Reins, their Veins are ſwollen, and they are ſuch Pec \nple as live idly, and abound in blood. \n\nSuch muſt be cured by ble ceding in the Army for fulne \ncauſeth diſtention or ſtrecchin's 80 diſtention hinders en \ntramiſſion : And bleeding in t Net Foot makes the diſtentio \ngreater, 'as was well noted by Dr, Riverius, Phyſician to th \nFrench King. \ng. let this be done with Tons A ik. and Sant War \nne : ale ö \n\n\n9939 \n} \n\n\n6. rag ih Hud b T0 ß . 3 \nale Ou, of the Menfrua'« \n\n\nPans are ſaid to overflow, when they continue lon \nger than their uſual time; their uſual time of con \ntinuance is two. or three. Days ; in ſome Women that giv \nthemſelves to no Exerciſe, four or five Days. \n2, When they, come oftner than the Legitimate time \nTheir Legitimate time 1s, \"the time that the Moron Travel \n\n\nthrough the twelve Signs of the Zodiac, that is Twenty Se \n\n\nven Days, ſome odd Hours, and odd Minutes. \nIt is cauſed. \n. By Rupture of ſome Veſſel. \nCauſe. 2. By immoderate Purgation. \n3. By ſome concording Humour. \n4. By hard Labour in Child- bed, or unkind hand \n| ling in it. \nSigns, If the Veſſels be broken, the blood guſhet \nabundantly in heaps. \n\n\nIf ſome gnawing Humour, they are not much in quant \n\n\nty, but come with much Pain. \n| The other are eaſily to be known.” \n\nCaution, Such. Women as are ſubje& to this Diſeai \n9 ſuffer Abortion upon every fight occaſion. - \nLet them abſtain from Exerciſe. and moving as much \n\nmay be, and frem all cold Drinks. 5 \n\nBecat \n\n\n2 \n\n\nCulpeper's Midwife Enlarged. 63 \n\n\nBecauſe this Diſeaſe weakens the Womb much, ſtreng- \nthen it as you are taught in the Chapter before. \n\nAnd here I confeſs I differ from all Phyſicians that ever \nwrote, for they all unanimouſly hold that the Diſeae is firſt \nto be cured before the Part grieved-be ſtrengthened ; where- \nas I counſel to ſtrengthen the Part firft, that ſo Nature may \nbe able to help on this Cure; the Work will be better and \nſooner done with Nature's help than without. Having firſt \nſtrengthened the Womb, proceed to the Cure thus; \n\nCure. 1. Anoint the Reins of the Back with Oyl of Ro- \n\nſes, Oyl of Myrtle, or Oyl of Quinces, which you \npleaſe. I ſuppoſe the laſt mentioned to be che beſt ; do thus \nevery Night, and when you have ſo done, wrap a piece of \nwhite Bays about your Reins, the Cotton fide next your ſkin, \nand keep the ſame Bays always to it. | „ \n\n2. To inject the juice of Plantane into the Womb, is an \nadmirable Remedy. 5 | \n\n3. Sage, the roots of Diſtort and Tormentil, Cinque- \nfoyle, Knotgraſs, Comfry, Sannicle, Ladies Mantle, Gel- \nden Rod, Looltrife, Meadfweat, Archangel (that blaſphe- \n\n\nmous Name our Phyſicians give dead Nettles) Mouſe-ear, \n\n\nSolomon's Seal, Purflane, Sorrel, Red-Beets, Shepperd's- \npurſe, Red-Roſes, Acorn-cups, the bark of Oak-Trees, \nRed-Coral, Maſtich, are Medicinal, boiled in your ordina- \nry Drink. | \n\nI could with from my Heart you knew all theſe Herbs; \nyou cannot expect I ſhould travel all over the Nation to teach \nyou; you ſee what ignorance the Learned College of Phy- \nficians hath trained you up in; inſtruct you one another as \nwell as you can, know that you were not born for yourſelves \nalone, and I will do what I can to inſtruct you in the know- \nledge of the Herbs before I am half a Year Older. \n\n\n4. Above all, I commend this Medicine to you: Take \nof comfiy Leaves, or Roots, and clowns Wound-wort, of each \n\n\nan handful, boil them wvell (being h bruiſed) in Ale, and \ndrink a good draught of it now and then; this (with the Bleſ- \nfing of God) will help yo, tho\", the Mouth, of the Veſſels. be \nopen. 5 | 5 \n5. Take Cinnamon, Caſſia Lignea, Opium, of each two dranu; \nMyrrh, White Pepper, Galt anum, of cach one drani: Diſſolve \nthe \n\n\n; . Ts \n54 ln WY — CC ———_— C7 III \n, : Fr —— A — — —— \n* \n\n\nee m \n— — 1 {4 \n\n\n4 rr ** \n4 Wr — << 2 - \n. \n\n\n64 Culpeper's Midwife Enlarged. \nthe Gum and Ofium in White wine, > oof the reft to Powder ; \nthen make them into Pills by mixing & * exattly , and \n\n\ntet the Party Difeaſed tate two Pills every Ns going to Bed ; \n| tet not 1 wer: contain above the Weight of. Mie Grains. \n\n\nCHAP. III. \nof the Flux of the Womb. \n\n\nDęſcrip- I. UX of the Womb is a continual Diſtillation from \ntion. that part of the body for a long time together, \nNature carrying out the Excrement that way which ſhould \nbe voided ſome other way. 5 \n\nThe Form and Colour of what is voided, ſhews what \nhumour offends, (if I had written to Scholars, I would \n\nhave faid the peccant humour) for, \nIn ſome it is Red, like putrified Blood, and that \n\n\nCauſe. proceeds from blood putrified. \n\n\nfrom Flegm. \n\nIn ſome Vellowiſh, and that ſignifies Choler. \n\nIf pure bloed come on, if a Vein were opened, either ſome \nCorroſion or Gnawing of the Womb is to be feared, or elſe \nſome Laceration or tearing in her laſt Delivery, and it is to \nbe feared the Midwife acted not her part either like an ho- \n\nneſt, or like a knowing Woman. | \n\nAll of them are known by theſe Signs : The \n\nSign. place of Conception is continually moiſt with the \n\nHumours, the Face is ill coloured, ſhe diſtaſteth \n\nand abhorreth her Meat, breathes difficulty, the Eyes are \n\nſwollen, ſometimes with pain, ſometimes without. ; \nThe Cure is different as the Cauſe ; For, \n\nN If Pure Blood COme out, you mult let blood i In \n\nCare. the Arm in the firſt Place, and the Cephalick or Head \n\nVein is the fitteſt; for unleſs you draw back the \n\n| Blood, you can never ſtop it, as you'muſt Pump out the Wa- \n*, ter of a Ship before you can ſtop the Leak. \n\n1 Then uſe the latter Medicines in the laſt Chapter, made \n\n\nof * and Wound - wort, \n| The \n\n\n) \n1 \n1 \n\n1 \n\n\nIn ſome it is white and pale, and that proceeds | \n\n\noY % A 7-7 \n\n\n8 \n\n\n2 \nbn YE. —_ & THR WERE TW Ys PLE \n\n\n— ——_—_— — — . —— —_— ů — \n\n\nCulpeper's Midwife Enlarged. 65 \n\n\nThe Juice of Plantain injeQcd into the Womb is good ; \nand if you add the Juice of Comfry to it, it were better. I \nhave taught you how to keep theſe Juices all the Year in \nmy Engliſb Phyfician Enlerged, the laſt Edition. \n\nIf Flegm be the cauſe, let Cinnamon be a Spice uſed in \nall her Meats and Drinks, and let her uſe her body to hot \nAntidotes, as Venice-Treacle, Mithridate, &c. to take a \nlittle every Morning. | \n\nLet her take of Coſtmary, Agrimony, the bark of com- \nmon Elder, Dwarf Elder, Caraway-Seed bruiſed, Liquoriſh, \nof each a handful ; which boiled in a pottle of White-wine \n(or for want of it Rheniſh Wine) to a Quart, drink half a \nPin: of it every Morning, adding half a dozen drops of Spi- \nrit of Caſtoreum to it, and an Ounce of Syrup of Roſes \nwith Agarick. | \n\n\nLet her boil Burnet, Mugwort, Fetherfew and Vervainin \n\n\nall her broths. \n\n\nLet her, if ſhe pleaſe, purge her body with Pills of Am- \nber (you may find them, and the way how to make them, \n\n\nin my laſt Edition of the London Diſpenſatory) ſhe may take \n\n\na Scruple at Night going to bed, they will not work till \nnext Day, and uſe this divers Nights. \nHalf a dram of Myrrh taken every Morning, is an excel- \nlent Remedy for this Infirmity. N \nIf it come of Choler, let them take Borrage, Bugloſs, \n\n\nRed Roſes, Endive and Succory Roots, Lettice, White \n\n\nPoppy-Seeds, of each a Handful. Boil them in White \nWine, from a Pottle to a Quart; let her drink half a Pint \nevery Morning, to which half Pint add Syrup of Peach \n\n\nFlowers, and Syrup of Cichory with Rubarb, of each an \n\n\nOunce. It will gently purge her, you may find the way \nhow to make them in my laſt Eaition of the London Diſpen- \n\n\nfatory. \n\n\nAfter the uſe of this ſome Mornings, let her take the \nPowder of Ivory and Miſleto of the Oak, of each one \nScruple, mix'd -with half an Ounce of Conſerve of Roſes, \n\n\nevery Morning for a Week together (I never knew any \n\n\nAuthor could give a reaſon why Miſleto, of the Oak, \n\nſhould be better than any other Miileto, neither do I \n\nbelieve it is.) | 9 + \nD Laſtly, \n\n\n66 Culpeper's Midtoiſe Enlarged. \n\nLaſtly, If it comes of putrified Blood, having firſt let \nblood in the Foot, ſtrengthen the Womb as you were taught \n\nI know all Writers hold Melancholy to be one cauſe of \nthis evil, but J am of a contrary Opiniofi, unleſs (as many \ndoj they take the aduſt Choler and aduſt Blood to be Melan- \ncholy, for Melancholy is altogether retentive, and how can \nthat cauſe Expulſion? | \n\n\nmake much of them. \n\n1ꝗ. Let the Patient forbear violent Motions, Paſſions and \n\nPerturbations of Mind. - \n\n2. Let them forbear all ſharp and ſalt Meats, and ſuch \n\ntungs as provoke Urine. 9 \n3. Of dead Nettles (which our Blaſphemous Phyſicians \n\neall_Arch-Angels, whereas the word Michael, who is the Arch— \n\n4 * ſignifies as God) there are three ſorts, White, Red \n\nand Yellow, iz. their Flowers are of that Colour; the \n\n\nwhich way you pleaſe. \nTo cure all Diſeaſes read my Platerus, Sennertus, Ri perius, \n\n\nNiolanus, Bartholinus, Johnſton, Veſtingius, &c. \n| CHAP. Iv. \nOf the Falling out of the Womb, \n\n\nDeferip- \"THE Womb is ſaid to be fallen out when it is ſo \n| turn d down that it ſticks out, for it is never clo- \nſed from its Ligament. \n\nCauſe. Tt may be cauſed by ſome Fall, by a Blow, by \nOverlifting, by vehement Trouble of Mind, by ſore \n\n\nCareleſs when ſhe turns Midwife. | \n| i The Diſeaſe is obvious to the Eye, and that is \nSigns. Sign enough. | 5, \n— The vulgar way of Cure is to put it in again with \na hot Cloth, and there it will ſtay as long as a Cat \ntied to a Pudding; and if it be ſwell'd that it will not up, \n| | bathe \n\n\nI ſhall conclude this Chapter with three general Rules, | \n\n\nWhite-Flowers help the White, the Red help the Red, and \nthe Yellow the Yellow Flux in Women, You may uſe them \n\n\nLabour in Child-birth, by unſkilful drawing out the Child, \neſpecially if it be Dead, or of the After-birth, by Mother \n\n\nCulpeper's Midwife Enlarged. 67 \n\n\n| bathe it with a Decoction of Mallows, Linſeed and Fenu- \n\n\ngreek - ſeed boiled in Water; and if this do it not the firſt \ntime, uſe it the ſecond; and When you have got it up, let \nthe Woman lie with her Legs obs together; for fear ſhe \nſhould not, tie them together with a ſwathing Band; they \nſhould ſtop it with a Cork, and tie a Bladder over it alſo. \nLet her uſe Odoriferous things to her Noſe; ſuch be \nCivit, Galbanum, Sytrax Calamitis, Wood of Aloes, Ec. \nlet her apply ſtinking things to her Womb, ſuch be Aſſa- \nfœtida Oil of Amber, the ſmoak of ker own Hair being burnt. \nThis is moſt certain, that the Womb flies from all ſtink- \ning things, and applies to alt ſweet Things, therefore theſe \nare good; as alſo to apply a Plaiſter called Hyſtericum (you \nmay find in my laſt Edition of the Di/pen/atory) to the Belly, \nin the middle of which Plaiſter, place ſome Cotton, and \nupon the Cotton four or five Grains of Civet, and let the \n\n\nCivet lie juſt upon her Navel. \n\n\nBut my own Magnetic Cure is this: \n\nTake a common Bur- leaf (you may keep them dry if you pleaſe all \nthe Year ) and apply to her Head, and that will draw-the Womb \nwpavards In the Fits of the Mother, put it under the Soles of her \nFeet, and it will draw it deumwards, Bur-ſeed beaten into \n\n\nEo der will do the like, they command the Womb which way you \n\n\n{eaje, and by orderly uſage will cure any Diſeaſe it. \n\n\nTis a Plant of Venus, and is beſt gathered when ſhe is \nAngular and ſtrong in her hour, and the Moor applying to her. \nIf it will not readily go up, by reaſon of Careleſneſs in \nnot uſing the Remedy time enough; you may bathe it as you \n\n\nare told, | \n\n\nA 4 3 \n\n\nOf the Inflammation of the Womb. \nHE Womb is inflamed by. many Cauſes, Canes. \n. By a Blaw, \nZy flopping of the Terms, \nBy Abortion. \n. By Ulceration. \nBy Immoderate Letchery, \nBy overmuch walking, \n\n\n. By Cilds. \n\n\n=} On ob 2 8 „ \n\n\nD 2 Sign \n\n\n— \n\n\n68 Culpeper's Midwife Enlarged. \n\n\nSigns, Its Companions are an acute Fever, pain in the \nHeads, eſpecially about the hinder part or Root of \nthe Eyes, Cramps in the Arms, Fingers and Neck; the \nWomb is vex'd with panting Pains: If all the Womb be \ninflam'd, it will be Pain'd all over; if but part, the Pain \nwill be where the part inflamed 1s; For, if the hinder Part be \ninflamed the Back is ſtrained moſt, and then they cannot go \nwell to Stool, becauſe the right Gut is preſſed together; or \nif not ſo, tis diſtemper d. \nIf the forepart be Inflamed there is pain about the Blad- \nder, and the paſſage of Urine is hindred; they make Urine \n_ with difficulty, becauſe the paſſage is on the Fore- part of \nthe Womb. | SES \nIf any of both fides be Inflamed, the Leg next the In- \nflamed fide, moves but ſlowly and heavily. \nIf it be in the Neck of the Womb, the paſſage is cloſe \nand burning hot. \nFor Cure, Firſt ſtrengthen the Womb, as you \nCure. were taught before; for this may cure it by Sym- \npathy. If youcan do a thing by fair means, never \nattempt it by foul: | \n11 Endive and Succory- roots are commended by Authors in \nFT this Diſeaſe, being boiled in clariſied Whey. But my own \ni Directions are theſe few. ; | \n+ 1, Clarifie your Whey, then boil Plantain Leaves or \nRoots in it, and drink it for your ordinary Drink. Then, \n2. Inject the Juice of Plantain into the Womb with a \ns Syringe: If it be m Winter, when you cannot get Juice, \n. make a ſtrong Decoction of the Leaves and Roots in Water, \n; and inje&t that up with a Syringe, let it be but Blood- \nwarm. This Medicine is worth a Thouſand. \n3. If the Body be Coſtive, uſe a Clyſter. | \nbe, 8 Let them avoid movings of Body and Troubles of \nMind. x | FI \n1 ſeldom preſcribe Diets to Women, becauſe they have \ngotten ſuch a trick they will keep none; yet becauſeſit is very \nrobable there are ſome wiſe Women (it were a hard caſe \nelſe) I ſhall intreat them to ule a very ſlender Diet, and let \nit Þe of ſuch Food as 1s cold and Moilt. Barley Broth is an \nadmirable Remedy for them; it were very well if they could \nFe | | latisty \n\n\n——— —— 9 \n* * \n\n\n. . Ac r — \n* * * \n3 . N 2 \n\n\n— — aa \n\n\nCulpeper's Midwife Enlarged, 69 \nſatisfy themſelves with it, and Panada. As for Drink, let \nthem forbear all Wine and ſtrong Beer, much more Strong- \n4 Water. | | \n4 In all Inflammations eſpecially if the Inflammation be \n\nreat, Blood-letting is an excellent and admirable Cure, as \n| alſo very ſpeedy. In this caſe the beſt way, is to bleed them \nin the Ancles, becauſe of the immediate paſſage between \nthe Vein Seh ena and the Womb. ES” \n| 6. Outwardly apply to the Region of the Womb, Wool \nmoiſtened in Vinegar of Roſes. | f \n7. If the Inflammation be near the neck of the Womb \nmake a Peſſary of Wool, dip it in Juice of Plantain, et \nJuice of Purſlane, or Juice of Sengreen, and put it up \nthe Privities, | \n\n\n. \n| Of Windineſs of the Nemb. \n\n\nHE Womb is ſometimes afflicted by Wind, or puffed \nup; and this ſometimes appeareth to the Eye of Senſe, \nand ſometimes it cannot be difcerned but by the Eye of \nReaſon. | | 2 K 0 \nAuthors differ much in the Cauſe, and as much in the \nCure; however, they ſay, the Signs are Swelling in the \nbottom of the Belly, pricking Pair in the Stomach, Back \nand Head, Diſtention of the Sides: And ſometimes they \nſay, Women feel wind coming out of their Privities, (if you \nwill beleive them). ; \nTs tell you the truth, my Opinion is, that the Diſeaſe \nyou call the Fits of the Mother, is nothing but a windineſs of \nthe Womb, which becauſe it hinders not Conception that I \nknow of, 1 have nothing to ſay to it at this time; however, \nit any Woman will not believe me, I cannot help it; tis \nbut forbearing windy Meats, and taking ſuch things as ex- \npel Wind, and ſtrengthen their Womb, as they were taught \nbefore, and then it (together with Nature) helps itſelf. \nAs for moiſtneſs of the Womb, which many ſpeak and \nN write of, how the Womb when it is over-moiſt will not re- \n| tain the Seed, the thing is very propable, but the very fame \n| with a Flux of Flegm, and to be cured the ſame way. \n| D 3 | CH AF \n\n\n—— - - K \n* 9 \n\n\n*1 NY \n\\'; \n\n\nfor I write to help you, not to trouble you. \n\n\nCulpeper's Midwife Enlarged. \nCHEST YH. \n\n\nOf the Heat and Dringſ of the Wink. \n\n\nT HE Signs were ſhewn you before 'The Diſeaſe moſt \n\n\nincident to Women of a Cholerick Complexion, \n\nAs for Remedy, ſuch Herbs as cool and moiſten are very \nMedicinal, of which ſtinking Arrack (uſed as you have been \ntaught before) ſeems to bear the Preheminence. \n\nNeither are Plantain and Mallows much inferiour to it, \nuſed as before, eſpecially Plantain. \n\nGoats Milk often drunk with Honey or Sugar, is a very \nExcellent Drink for Women troubled with this Diſeaſe; and \nif ſo, other Milk cannot be bad. | \n\nAnd many other Herbs are Medicinal for this Infirmity ; \n\n\nall which or fo many of them as you can get, you may boil \n\n\nwith a Sheeps Head till you have boiled all to pieces, and \n\n\n- uſe the Decoction either as Drink or in Pottage. \n\n\nThe Herbs are theſe, Vine-leaves, Willow-leaves, Endive, \nSuccory both Rotts and Leaves, Violet-leaves Strawberry- \nleaves, Raiſins of the Sun, Borrage, Bugloſs, either Leaves \nor Flowers. | | \n\nIf you pleaſe, in ſuch Decoction you may take ten or \ntwenty Grains of Red Coral, mixed with as much Cinna- \nmon. Swe my Engliſh Phyſician for this more at large. \n\nIf your Body need Purging, take ſuch Medicines as Purge \n\n\nCholer, and without cool theiReins, or elſe you were as good \n\n\ndo nothing. Of which Caſſia Fiſtula newly drawn, ſeems \nto me to be the beſt: Vou may take an Ounce of it when \nyou go to Bed. Never fear the following of your Buſineſs \n\n\nthe next day. \n\n\nLaſtly, Appiy to your Navel a Cere- cloth, which you \nmay find in my laſt Edition of the London Diſpenſatery called \n\n\nby Name Ceratum Santalinum. Other Remedies you may \nfind in this Book more at large, to which I refer you. \n\n\nI confeſs I could have preſcribed many other Medicir ss, \nas other Authors have done before me, as Peſſaries, Baths, \nFomentations, &c. but theſe, if rightly uſed, are enough, \n\n\nCulpeper's Midwife Enlarged. \nSECT. III. \nOf B arrenne/s againſt} Nature. \n\n\nFT is not one Phyſician's Opinion alone, that many Wo- \nmen are made Barren by Diabolical Meanes. \nI do not call them Diabolical, becauſe they cannot bz \nacted without invocation of evil Spirits, but becauſe they \nare done by abuſe of Nature; for as the right uſe of Natu- \n\n\nral Things is from God, fo the abuſe of them is from the \n\n\nDevil. And fo many unworthy Creatures are wont to ſerve \nMen and Women at the very time of their Marriage, that \nthe Man can never (before! it is remedied) have to do carnally \n\n\nwith his Wife, which is all Publick Marriages are good for : \n\n\nSome, altho' the Scripture (that I know of) give no publick \nRule for Marriages yet we all know Marriage is a civil thing; \ntherefore ought more properly to belong to the civil Magit- \ntrate, than to the Cler y-Man ; but the Clergy get Money \nby it, that's the Key of the Buſineſs. | | \nHowever, to prevent ſuch Miſchief, Authors have left \n\nwares As, \n\nTo carry St. 7 rt about them which for that \n\n\n: canes is called Fugee Deemonum, a driver away of Devils. | \n\n\n2, To carry a Loadſtone about them. \n\n3. A Plaiſter of St. John's-Wort laid to the Reins. \n\n4. A whole Swill hung over the Bed. \n\nX yu heart of a Turtle Dove carried about then, Cum \nmuitis ali. \n\nBut ſuppoſe the Miſchief be already done, and the Man \ncannot give his Wife due Benevolence, how may it be help'a? \nIn this I will tell you no more than I have known tried. \nThe Cure is eaſie, and was done by the Man only making \nWater thro* his Wife's Wedding Ring, ſo theye was one \nSuperſtition helped another, \n\nSuch as would be ſkilful Phyſicians, let them read theſe | \nBooks of mine, viz. Platerus, Sennertus, Riverius, Riolanus, \n\n\nown; wo ? J. Viftingius, Rulandus, Fernelins, Sandor, \nCole, &c. \n; D 4 B O OK. \n\n\nY \nL 22 , \nn 1 — voir \n— —— — \n\n\nCulpeper's Miazife Enlarged. \nBOOK IV. \n\n\n07 what hinders Conception, \n\n\n7 1 Shall deliver py mind in this, \n\n\n. By way of ordering the Body \n2. By waz of Medicine, \nAnd let each of theſe ſtand in a Section * itſelf. \n\n\n: $A OT I \nHew a Woman that would hade Childten (mould irder her Body. \n\n\n. IK Women would be fruitful, let them give themſelves \nto exerciſe, Idleneſs is hateful to God, and deſtruc- \ntive to the Creation; and that's the reaſon ſuch Women \nlive idly (as moſt of our City Dames do } have ſo few Chil- \ndren, and thoſe they have ſeldom live, but are troubl'd with \nunſuperable Diſeaſes till they die: Or if they live, they are fo \nſpoil'd by apiſh Education, that they ſeldom come to good: \nWhereas poor Men and Women that labour hard, have ma- \nny Children uſually, and they are ſtrong and luſty. \nI ſhall {to pleaſe you good Women) give you a ſhort Para- \nPhraſe upon n Exercije and Re, yea, ſuch a one, that if \nyou mean to be wiſe, you may know what is mot fitting for \n\n\nyour own Bodies: But if you never intend to be wiſer, you \n\n\nihall not blame me when you whine for lack of Children, or \nfor the Death of thoſe you had. \nExerciſe is either Moderate or Immoderate, \n\nMederate is neither tos much, nor too Little. \n.. ſmmogderate is either V. lemons or Exceffroe. \n\nModerate E A r \n\n. Stirs up Natural Heat. \n. Quickens the Spirits. \n. Opens the Pores. \nWaſts the Excrements of the third Digeſtion. | \n6. Makes the Body, Senſes and Spirits ſtrong, and that's \nthe way: to have ſtrong Children. \n\n\nS bv we \n\n\nhy Comforts \n\n\nCulpeper's Midwife Enlarged. 73 \n6. Comforts all the Limbs. - \n7. Helps Nature in all her Exerciſe, which Procreation \nof Children is none of the leaſt, \nImmoderate Exetciſe (which is a thing our City-Dames are \n* unacquainted wth unleſs it is Exerciſe their Tongues.) \n. Waſts, Dries, Conſumes, Wearies both Body and \n\n\n| Spirits \n\n\n2, Hurts the Body in every part. \n2. Overthrows Nature's Actions. \nReſt is Moderate or Immoderate. \nModerate Reft. \n1. Comforteth and refreſheth Nature, \n2. Recruits a Tired Brain, \n3. Maintains Health \n\n4+ Strengthens both Body, Senſes and Members, \n\n| Immoderate Reſi or extream Idleneſs. \n\nDulls both Minds Senſes and principal Inſtruments of \nthe Body. \n\n2. Cauſeth Crudities, evil Humours, evil Excrements, \nCold, Sickneſs, infinite Infirmities, above half the Infirmities \nthat accompany the Body of Man and Woman, and there. \nfore it was nobly done of Lycurgus the Spartan, to ue 5 \nevery one to work four Hours in a Day. \n\nIt haſtens old Age. \n\nIt cauſeth Deformity. \n\nHark, you Women, if you would be Young and Fair \nuſe yourſelves to Labour. \n\nAnd now, if you can ſind any of theſe accidents i in your \nſelves, you know both the Cav/e and the Cure. \n\nSecondly, Diſcontent wonderfully hinders Conception, and \nC_ furthers it as much. \n\n. I ſhall ſpeak of Content, in which conſider. \n\nContent of red Dilates the Heart and Arteries where- \nby the vital Blood or Spirit is ſufficiently diſtributed through- \nout the Body, and thence ariſe ſuch affeQions as Pleaſe, Re- \ncreate and Refreſh the Nature of Man, as Hope, Joy, N \nGladneſs, Mirth, Sc. \n\n2. They Comfort and Strengthen not only the parts of the \nBody, but alſo the Operations and Imaginations of the Mind: \nPor it is —_ upon by all Authors, yea, the truth it ſelf \n\n| D 5 hath \n\n\n74 Culpeper's Midwife Enlarged, \n\n\noperates moſt forcibly in the Conception of the Child. How \n\n\nmuch the better then were it for Women to lead contented \n\n\nLives, that ſo their Imaginations may be pure and clear, that \nſo their Conception may be well Formed, than to Vex Fret \nand Fume, Fling and Throw, Murmer and Repine, and fill \ntheir Minds full of diſtracting Cares and Fears, as an Egg is \nof Meat, making a Tumult in the Spirits, and bring all \ntheir Thoughts into ſuch a Confuſion, that they look more \nlike Beaſts than Women, ſo that if they could but ſee them- \nſelves, they could not but be aſham'd, to ſee how like An- \n\n\nticks they are. The beit Medicine I can preſcribe them in \nthis Diſeaſe, is this, that they would give their Mind often \n\n\nto read that excellent Book of Mr. Jerremiah Burroughs En- \ntituled Chri/tzan contentment, where I am confident they ſhall \nfind all their Objections anſwered; and a Women ſeldom \nwants Objections, if ſhe do but look upon her Apron-ftrings. \n\nAs fer Diſcontent, I ſhall give you my Judgment. \n\n1. Ms a Phyſician. \n| 2. As a Divine. \n\n1. A. a Pzgyſician. \n\n1. It ſtirs up ſuch affections in the Body as are Inimical both \nto Body and Mind, and therefore muſt need either kill or \nſpoil the Child in the Womb: Such are Anger, Paſſion, Ha- \ntred, Fear for things to come, Fear for things paſt, Sorrow, \nSighing and Grief of Mind. All theſe Corrupt the very \nNouriſhment wherewith the Child is nouriſned in the Womb, \nand oftentimes kills the Fruit in the very Bud. \n\n2. It diverts the vital Heat from the circumference to the \nCenter, thereby conſuming the vital Spirits, by which means \nthey come very flowly, or not at all to the Child. | \n\n3. It Deſtroys, Overthrows, Murthers both Body Mind. \n\n4. It haſtens old Age and Death, by conſuming the Ra- \ndical Moiſture. \n\n2. AM a Divine. \n\n\nT beſeech you to let my councel be acceptable to you, \n\n\nconſider what you do. | \n\n\n1. When you have been diſcontented twenty four Hours, \nyou are never the wiſer, never the nearer to the obtaining \n\n\nof what you deſire; ho by taking care can add a Hair's Bread!th \n\n\nto his \n\n\nhath ſet its Seal to it, that the Imagination of the Mother \n\n\n| \n\n\ne . 7 Wt WB. \n\n\n2 \n\n\nCulpeper's Midwife Enlarged. 73 \n\n\nto his ſtature? And what a fooliſh thing it is to do your ſelves \n\n\nſo great a miſchief without the leaſt hope of doing your \n\n\nſelves the leaſt good? . \n2. Diſcontent keeps you from the good you defire. You \nwill not give your Children a thing while they cry, neither \nwill God you, while you are Diſcontented. | \n3. It makes your Evil worſe: Becauſe others wrong you, \nyou will wrong your ſelves; becauſe you want temporal \nthings, you will want Health alſo. — 5 Eg \n\n4. All things come by the Providence of God; and what- \nſoever Mans end be, his ends are always good, Are not tabs \nSparrows ſald for a Farthing, and yet not one of them falls to the \nground without your Father? If God takes care for the Spar- \nrows, one of which is worth but half a Farthing, will he \nnot take care for you? \n\n5. It ſtews your Spirits linked to the World, and not ri- \nſen with Jeſus Chriſt; for if Diſcontent for things of this \nWorld take up your Thoughts, tell me what of you is riſen \nwith Chriſt? He that is riſen with Chrift, minds the things that \nare above, | \n\n6. It ſhews you are little provided for Death; if you know \nyou muſt leave the World, why are you Diſcontented that \nit leaves you? | 3 \n\n7. You deny Eternity; for if you knew the World ſhould \nbe conſumed, you would uſe if to tread upon, not to fill your \nPockets with. | \n\n8. Your Intereſt in Chriſt is but little; for achere the Car- \ncaſs is, thither auill the Eagles gather together. | \n\n9. How juſtly may God withdraw his Protection from \nſuch as cannot reſt upon it without Diſcontented Hearts. \n\n10. You put away your own comfort. All true comfort \ncomes from the Holy Ghoſt the Comforter ; and the Holy Ghoſt \nſeldom or never reſts upon a ſad Soul. And therefore the \nProphet E/;a called for Muſic to chear his Spirits before he \nwas fit to receive the Spirit of God. Conſider theſe things \nand you ſhall ſee what a folly and madneſs Diſcontent is. \n\nThat you have two Ways, or Means of Fruitfulneſs, \n\n1. Exerciſe of Body. \n2. Content of Mind, | \n| D 6 I Thavg \n\n\n* \n\n* : \n. \n{Bi} \n\n7% \n* # \n\n1 * Vf \n\n| \n\n19 \n1 | \n2 'v \n4 . \n\n% \nN \n\n\nBy away of Caution. \n\n\n76 Culpeper's Midwife Enlarged. \n\n\n1 have but one more, and that is, to preſerve the Womb in \n\n\na due decorum. I note is here only, becauſe People are very \n\n\nignorant in Phyſic; The former Rules will help you if you \n\n\nwould have Children, ſee that the Menftrua's come down in \ngood order, the Colour of them will ſhew you what Humour \n\n\noffends; purge it out; the former Rules will direct you. I \n\n\nmean thofe in the laſt Book, in the Chapter, Of Flux of the \nWomb. If they come down Difcoloured it ſhews ill Diet. \nIf pure Blood comes down, be ſure that Woman is very \nProne to concerve with Child. \n\n\nJo Cure all Diſeaſes, read my Placerus, Sexnertus, Riverius, \n\n\nRiolanus, Bartholinus, Fobnſton, V eftingius, &C. \nSH \"S © =o): wh -& \n| Medicines for a Woman that wwould have Children. \n\n\n12 H IS I ſhall deliver to you. \nn 1. By =vay of Cantion, \n2. By away of Precept. \n\n\n= \n\n\n1. Ule not the act of Copulation too often: Some ſay it \n\n\nmakes the Womb ſlippery : I rather think it makes the Womb \n\n\nmore willing to open than ſhut. Satiety gluts the Womb; \nand makes it unfit to do its Office, and that's the reaſon \nWhores have ſeldom Children: And alſo the reaſon why \nWomen after long abſence of their Huſbands, when they \ncome again, uſually ſoon conceive. | \n\n2. Let the time be convenient; for fear of ſurprize hin- \nders Conception. po 1 \n\n3. Let it be after perfect digeſtion, let neither hunger nor \ndrunkenneſs be upon the Man or Woman. \n\n4. Let the deſire of Copulation come Naturally, and not \nby Prevocation, the greater the Woman's deſire of Copulati- \non is, the more ſubject is ſhe to Conceive. \n\n5, Women are more ſubject to Conceive a day or two \nafter the Monthly Terms are ſtayed. \n\n6. Avoid Eating, or Bearing about you all ſuch things as \neauſe Barrenneſs: Such be the Bones of a Stagg's Heart, \n\n\nEmeralds, Sapphires, Ivie-Berries, Jet, Burnet-Leaves and \n\n\nRoots Karts, Tongue, Steel-Duſt, Mints, Sc. \n\n\n2 \n\n\n7. Apiſa \n\n\n55 Culpepet's Midwife Enlarged. 77 \n7. Apiſh ways and manners of Copulation hinder Con- \nception. n 8 \nBy away of Precept. \n\n1. The Runnet of a Hare mixt with a little Cotton and \n\n\nput up into the Womb as Paſſary, and remaining there @ \n\n\nDay, is an excellent Remedy: But let it be done preſantly \nupon the ſtopping of the Menſtrua's and tied up in a Linnen \nCloth, and a ftring tied to it, that ſo you draw it out again, \nelſe you will make mad work. | \n\n2. It the Woman's Body be too hot, letting Blood in the \nVein Saphera, profiteth much. 1. Becauſe it cools, 2. Be- \ncauie it cleanſcth the Womb. | \n\n3. A Loadftone carried about the Woman, cauſeth not \nonly Conception, but concord between Man and Wife. \n\n4. The Heart of a Male Quail carried about the Man, \nand the Heart of a Female about the Woman, furthers \nConception exceedingly, and cauſeth mutual Love. \n\n5. The Root of Eringo, Piony and Satyrion, being eaten, \ncauſe Conception. So p \n\n6. Exerciſe your Bodies before you taxe Counſel of the \nunder Sheet; go to the School of Mars before you go to the \nSchool of Venus. | | — \n\n7. A Plaiſter of Labdanum ſpread upon Leather, and \napplied to the Region of the Womb, mightily diſpoſeth it \nto Conception. \n\nTheſe Rules are excellent. I confeſs many other may \n\n\nbe added in reſpect of Food, Diet and the like; for which \n\n\ntake this general Rule, 4/7 Creatures that are fruitful, being \neaten, make thoſe fraitful that eat them, as Crabs, Lobfters, \nPrauns, Sc. a | \n\nLikewiſe the Ancients have left many xvays. You may take \nthem as Meats or Medicines; ſime of which are theſe: © \n\n1. Caſtoreum in Powder, take half a dram, or a ſcruple \nin Malmſey in the Morning. | \n\n2. The Womb of a Hare beaten to Powder, and taken \nin like Manner. N \n\n3. A ſeruple of Galangal taken every morning in Powder \nrids the Body of ſuch infirmities as cauſe Barrenneſs. Take \nWhite-Wine. And truly I believe for very moiſt Women \nthere 1s ſcarce a better Remedy. \n\n\n# \n\n\n78 Culpeper's Midwife Enlarged. \n\n\n4. The Stones of a Fox dried and beaten to Powder, and \na a dram taken in the Morning in Sheep's Milk. \n\n5. The Stones of a Boar uſed in the like manner. \n\n6. The Brain of Sparrows and Pigeons eaten, and (for \nought I know) you may eat Fleſh and all, for they are very \nfruitful Creatures. | \n\n7. The Pizle of a Bull dried and grated to Powder, and \na dram taken at a time. \n\n- . 8. To hold ſweet things to the Place of Conception, \nbefore the a& of Copulation, becauſe they draw the Womb \n\ndown; but after the act, to the Noſe, to draw the Matrix \n\nup. | \n\n\\ Theſe, with many others, too tedious here to relate, have \n\nbeen quoted by Authors. | \n\nSuch as would cure all Diſeaſes, let them read theſe Books \nof mine, viz. Platerus, Sennertus, Riverins, Riolanus, Bar- \ntholinus, Johnston, Veſlingius. Rulandur, Sandor, Cole, &C. \n\n\n— \"_ \n\n\n» — \n\n\n10. \n\n\nA Guide for We omen in Conception, \n\n\nOme Women are ſo ignorant, they do not know when \nthey are Conceived with Child, and others ſo coy they \n\n\n| will not confeſs when they do know it, I ſhall labour to \n\n\nhelp the former. The latter if they will learn to be a little \nwiſer, may help themſelves. | \nI ſhall then divide this Book into theſe Chapters, \n1. Signs of a Woman conceived with Child. \n2. Whether a Male or Female be concetved. \n3. Conception of Twins, and the Reaſons. \n=o Authors Confuted. \n4. Of imperfe Children. \nAuthors Opinion, \nMy own. | \n| CHAP. \n\n\nCulpeper's Midwife Enlarged. 79 \nCAN \n\n\nSigns of Conception, \n\n\nM ay are the ways Authors have left for Women to \nknow whether they be with Child or not, which hap- \npens true in many Women, but not in all; ſome of which I \nſhall quote, vix. \n1. A coldneſs and chilneſs of the outward parts after Co- \npulation, for the heat retires to make the Conception. \n2. The Belly waxeth very flat, becauſe the Womb cloſeth \nit ſelf together to nouriſh and cheriſh the ſeed. \n3. Wringing or Griping Pains like Cramps happen in the \nBelly about the Navel. | 4 \n4. Loſs of Appetite to Victuals, and ſour belchings, ex- \nceeding weakneis of Stomach. \n5. Divers Appetites and Longings are ingendered, \n6. If cold Water be drunk, a coldneſs is left in the Breaſt. \n7. The Tops of the Nipples look redder than formerly. \n8. The Breaſts begin to ſwell and wax hard, not without \npain and ſoreneſs, | \n9. The Veins of the Breaſts are more clearly ſeen, than \nthey were wont to be, . \n10. The Veins of the Eyes are clearly ſeen, and the Eyes \n. ſeem ſomething diſcoloured, as a Looking glaſs will ſhew \nyon: This is a good ſign. | \n11. The Body is weakned and the Face diſcoloured. \n12. The Excrements of the Guts are voided painfully, \n\n\nbecauſe the Womb ſwelling, thruſts the right Guts together, \n\n\nTheſe be the Vulgar Rules, or at leaſt the beſt of them. \nGive me leave to deliver what I have known to be true, \n\n\nand never yet failed me, \n1. If under the Eye the Vein be ſwelled, I mean under \n\n\nthe lower Eye-lid, the Veins in the Eyes appearing clearly, \n\n\nand the Eye ſomething diſcolour'd, if the Woman have not \nher Terms upon her at the time, nor watched the Night be- \nfore, you may certainly conclude her to be with Child: And \nthis appears moſt plainly juſt upon her Conception, and the \nfirſt two Months. I have told many Women of it before \nthey have been with Child a fortnight and never failed. \n\n\n2. Stop \n\n\n8 \n\n\n78 Culpeper's Midwife Enlarged. \n\n\n4. The Stones of a Fox dried and beaten to Powder, and \n\n\na a dram taken in the Morning in Sheep's Milk. \n\n\nThe Stones of a Boar uſed in the like manner. \n\n6. The Brain of Sparrows and Pigeons eaten, and (for \nought I know) you may eat Fleſh and all, for they are very \nfruitful Creatures. \n\n7. The Pizle of a Bull dried and grated to Powder, and \n\n\na dram taken at a time. \n8. To hold ſweet things to the Place of Conception, \n\n\nbefore the act of Copulation, becauſe they draw the Womb \n\n\ndown; but after the act, to the Noſe, to. draw the Matrix \n\n\nu \n| Theſe, with many others, too tedious here to relate, have \n\n\ndeen quoted by Authors. \n\n\nSuch as would cure all Diſeaſes, let them read theſe Books \nof mine, viz. Platerus, Sennertus, Riderius, Riolanus, Bar- \ntholi nut, Johnston, Veflingius. Rulandus, e „Cole, &c. \n\n\n* \n\n\n— \n\n\n1600 TY, \n\n\n8 — \n\n\nA Guide for Women in C onception, \n\n\nOme Women are ſo ignorant, they do not know when \nthey. are Conceived with Child, and others ſo coy they \n\n\nwill not confeſs when they do know it, 1 ſhall labour to \n\n\nhel the former. The latter if they will 3 to be a little \nwiſer, may help themſelves. \n\nI ſhall then divide this Book into theſe Chapters, \n. Signs of a Woman conceived with Child. \n2. Whether a Male or Female be conceived. \n3. Conception of Twins, and the Reaſons. \n4. \n\n\nAuthors Confuted. \nOf imperfe? Children. \nAuthors Opinion, \nMy own. \n| CHAP. \n\n\nCulpeper's Midwife Enlarged. | 79 \nCHN. ;&, \n\n\nSigus of Conception. \nMI Any are the ways Authors have left for Women to \nknow whether they be with Child or not, which hap- \n\npens true in many Women, but not in all; ſome of which I \nſhall quote, vix. | \n\n1. A coldneſs and chilneſs of the outward parts after Co- \npulation, for the heat retires to make the Conception. \n\n2. The Belly waxeth very flat, becauſe the Womb cloſeth \nit ſelf together to nouriſh and cheriſh the ſeed. \n\n3- Wringing or Griping Pains like Cramps happen in the \nBelly about the Navel. | 6 \n\n4. Loſs of Appetite to Victuals, and ſour belchings, ex- \nceeding weakneis of Stomach. | 5 \n\n5. Divers Appetites and Longings are ingendered. \n\n6. If cold Water be drunk, a coldneſs is left in the Breaſt. \n\n7. The Tops of the Nipples look redder than formerly. \n\n8. The Breaſts begin to {well and wax hard, not without \npain and ſoreneſs, \n\n9. The Veins of the Breaſts are more clearly ſeen, than \nthey were wont to be, > \n\n10. The Veins of the Eyes are clearly ſeen, and the Eyes \nſeem ſomething diſcoloured, as a Looking glaſs will ſhew \nyon: This is a good ſign. | | \n\n11. The Body is weakned and the Face diſcoloured. \n\n12. The Exc:cments of the Guts are voided painfully, \nbecauſe the Womb ſwelling, thruſts the right Guts together, \nTheſe be the Vulgar Rules, or at leaſt the beſt of them. \n\nGive me leave to deliver what I have known to be true, \nand never yet failed me, \n1. If under the Eye the Vein be ſwelled, I mean under \n\n\n* \n\n\nthe lower Eye-lid, the Veins in the Eyes appearing clearly, \n\n\nand the Eye ſomething diſcolour'd, if the Woman have not \nher Terms upon her at the time, nor watched the Night be- \nfore, you may certainly conclude her to be with Child: And \nthis appears moſt plainly juſt upon her Conception, and the \nfirſt two Months. I have told many Women of it before \nthey have been with Child a fortnight and never failed. \n— 85 | 2. Stop \n\n\n80 Culpeper's Midwife Enlarged, \n\n\n2. Stop the Urine of the Women cloſe in a glaſs thres \n\n\ndays, and then ftrain it thro” a fine linnen cloth; if you ſhall \n\n\nfind ſmall living Creatures in it, ſhe is moſt aſſuredly con- \n\n\nceived with Child; for the Urine which was before part of \n\n\nher own Subſtance, will be generated as well as its Miftreſs. \n3. Take a handſome green Nettle, and put it into the U- \n\n\nrine of the Womrn, cover it cloſe, and let it remain in a \n\n\nWhole Night; if the Woman be with Child, it will be full \nof red ſpots on the Morrow; if not, it will be blackiſh. \n\nAnd thus much for Prognoſticks, whether a Woman be \nwith Child or not. = | \n\n\nCH AF. HI. \nWhether a Woman be conceived of a Male or of a Female. \n\n\nErein alſo I ſhall, | \nI. Deliver you the Opinions of Authors. \n2. What I bade found to be true by Experiences. \n* Authors give theſe to be ſigns of Conception of a \nK. | \n\n1. The Woman when ſhe riſeth up from a Chair, or the \nlike, doth ſooner ſtay her ſelf upon her right Hand than on \nthe left. 2 | | \n\n2, The Belly lies rounder and higher than when it is a \n\nemale. N 81 \n\n3. The Child is firſt felt to ſtir on the right ſide, becauſe \naccording to Hippocrates, the Male Children lie on the right \nſide of the Womb. | | | \n\n4. The Woman breeds Boys eaſier and with lefs pain than \nGirls, and carries her burden not ſo heavily, but is more \nnimble in moving. | \n5. The right breaſt is more plump and harder than the left \nand the right Nipple redder. 6 \n\n6. The colour of the Woman is more clear, and not ſo \nſwarthy as when ſhe conceives a Girl. © x54 \n\nThe contrary of theſe are ſigns of Conception of a Female \nit were but loſs of time and blotting of Paper to quote them. \nI Theſe are ſome of the vulgar Rules, and the beſt of them; \n\nI never knew theſe fail. * | \n\n\n_—_ \n\n\n* If the \n\n\n. \n— 3 as \n\n\ninnen, 2» 4 \n\n\nCulpeper's Midwife Enlarged. 81 \n1. If the circle under the Woman's Eye, which is of a \nwan blew Colour, be more apparent under the right Eye, \nand the veins more apparent in her right, and that moſt diſ- \ncolour'd, ſhe is with Child of a Boy; if the marks be molt \napparent in the left, judge her to be with Child of a Girl. \n2. Let her milk a drop of her Milk into a Baſon of fair \nWater, if it ſinks to the Bottom as it drops in, round in a \ndrop, it is a Girl ſhe goes withal; for if it be a Boy, it will \nſpread and ſwim at top; this I never new fail, tho' it be con- \ntrary to all Authors that I ever read. \n\n\nCHAP. 1, \nOf the Canception of Tawins. \n\n\nA Uthors make ſome flutter about the conception of Twins \nand what the reaſon ſhould be; as alſo how many \n\n\nchildren a Woman might naturally have at one Birth. \n\n\nThe Ancients held a Woman might naturally have ſeven, \nthree Boys, and three Girls, and one Hermaphrodite; and their \nOpinion was grounded upon another as Childiſh (for one \nError uſhers in another) becauſe they conceived a Woman \nhad ſeven cells in her Womb, but long ſince. Anotomiſts be- \nginning to grow pretty perfect in their manual Operation, \nhaving Pars out that the Womb had but one Cell, this re- \ndiculous Opinion was quickly exploded. \n\n\nOthers hold a Woman can naturally have but two Chil- \n\n\ndren, and their Reaſon is, becauſe ſhe hath but two Breafts : \n\n\ni Tknow no Reaſon but why they may as well hold a Woman \n\n\ncan go but two Miles, becauſe ſhe hath but two Legs. We \nknow well enough, that whatſoever is againſt Nature, is mi- \nraculous: And we know as well that tis no: Miracle for a \nWoman to have three Children at one Birth. - 27 ne \nIn Ægypt many times Women have five or fix Children \nat one Birth; the reaſon is ſuppoſed to be the Fruitfulneſs \nof the Place, and if fo (as is propable) then let Women \nthat would be fruitful, live in Fuitful Places. | \nAriflotle quotes a Woman that brought fourth twenty \nperfect Children at four Births, ©» . | \n| | | Tragus \n\n\n- \n\n\n» \nö \n5 } \n. \nN. \n4 \n& \n13 \n= © j \nK 1 \n14 \n3 1 \n1. \nn \n8 ö \n3 \n4 \n1 \n. \n= \n5 \n= \n5 \n1 7 4 \n3 \nwr \n4 & \n- \nBy \n4; \n— > \n1 \n* \n2 . \non” | \n= j! '4 \n\n\nN — — \n— the e ⁰— . ei ae \n7 \n\n\n92 Culpeper's Midwife Enlarged. \nTragus tells a Story of another in Ægipt that had fever! \nChildren at one Birth. | | \nAll this is nothing to what Albertus Magnus talks of for he \ntells of one Woman who had twenty-two perfect Children \nin her Womb at one time, and miicarried of them all; and \nof another who had an hundred and ſifcy at once, all as \nbig as a Man's little Finger. | \nBefides, they ſay in a Monaſtery in Holland, there remains \na Tomb of one Margaret, a Counteſs of Holſtead, who had \nthree hundred fifty four living Infants born at a Birth; and \nall Chriſten d. I urge no Man or Woman's Faith to believe \ntheſe things: But come, \n\n\nFirſt, To the Cauſe of Conception of Twins, or more Children \n\n\nthan one at once. \n\n\nSecondly, Whether Tavins be Conceived at one and the \n\n\nfame Time. \n\n\n1. The Cauſe why Twins are Conceived. \n\nHerein Authors are Various: 8 5 \n\nAvicenna and Haly Abbas, held the Cauſe to divers Cells \nin the Womb: but that as I told you, hath long ſince been \nfound out as falſe, as what is falſeſt. . \n Empedecles, attributes it to the plenty of Seed, which is able \n\n\nto procreate more than one. \n\n\n Efelepiades, to the ſtrength of the Seed by the ſame reaſon. \n| Ptolemy, tothe Poſition of the Stars, at the time of Copulation. \n\n2. About the ſecond, which is the greater Queſtion of the \ntwo, Authors differ much. | \n\nSome of the Ancients, and almoſt all modern Writers hold \nthem to be conceived at one and the ſame act of Copulation; \nthe Seed not being ejaculated out all at once. is divided in \nthe Womb, and ſo more than one Child conceived. This \nthough it ſeems ſomething plauſible, yet it will not hold Water. \n\nAnother Reaſon they give is, becauſe the Womb having \nreceived the Seed, ſhuts ſo cloſe that it cannot give intermii- \nſion to any more Seed; and this is as weak as the other. \nFor anſwer to the firſt. ; \n\nThe beginning of the Conception is not the caſting of the \nSeed into the Womb; for then a Woman muſt needs con- \nceive every time ſhe hath carnally to do with her Huſband ; \nbut the Exquiſite mixture of the Seed of both Sexes, is the \n\nvery \n\n\no \n\n\ne \n\n\nF as __ \n\n\nv — \n$ \n\n\nCulpeper's Midwife Enlarged, 83 \nvery beginning and cauſe of Conception, and that the Womb \nhaving but one Cell, can exquiſitely mix Seed in two Places- \nin that Work cloſing it ſelf ſo cloſe, that no vacuum is left, \nis incredible, To the ſecond I anſwer. \n\nThe Womb ſhuts not ſo cloſe, but what Seed is ſuperſiu. \nous, hath a Place to be let out, \n\n2. It is the Delights of Venus that opens the Womb at all \ntimes, for it opens the Muſcles, therefore voluntarily; and. \nwhy can it not open the Womb at one time as well as at another? \n\n3. Neither do all Authors agree, that Twins are conceiv- \ned at one and the ſame time, for Eraſſtratus a famous Phy ſi- \ncian, and all the Stoic Philoſophers, were of my Opinion, \nwiz, that they are conceived at divers times. | \n\n4. All things are brought to paſs by a due Limitation of \n\n\ntime; and two Children conceived at onee,. muſt needs be \n\n\nborn at once, which is impoſſible; he that would know \nmore of this, let them but Peruſe the Trutina of Hermes, one \n\n\nof the wiſeſt of Men and let him but underſtand what he \n\n\nreads, and it is poſſible he may tell you (having the Nativities \nof both Twins) the very Hour and Minute when they were- \nConceived. Let no Afrologer object to me, that the Tratina \nof Hermes is not exact to a Minute; but let them know, that \nif there be a Truth in it th a Sign aſcending, there muſt needs \nbe a Truth to a Degree, and Minute, and Second; for Truth \ncomes to a Pun, and the Failing man be in their non-under- \nſtanding of him. | K-35 \n\n5. All Authors hold a kind of ſtrange thing they call \nSuperfertation, in Women: Superfetation, as the Word figgt- \nfies, is a Woman's Conceiving of a ſecond Child, after ſhe \nhas conceived of the firſt. | \n\nAuthors are very frequent in Proof of this, and ſome ſuch \nhave been known in London. \n\nI ſhall let paſs what Poets ſay of Alcmene's bringing forth \nHercules and Iphyclus, one at the end of the ſeventh, the other \nat the end of the tenth Month (they that wou'd read it, may \nfind it in Plautus his firſt Play, Amphytrio,) and come to the \nrelation of more ſober Authors, and ſuch as are fide digmores. \n\n| Hippocrates writes of a Woman of Larija, who brought \nforth two living and perfect Children, forty Days diſtant the \none from the other. | | \n. Ariſtotle, \n\n\n1 Culpeper's Midwife Enlarged. \n\n\nſome of the Births were two Months diſtant. \n- Rhafis and Awicenmna hold, That all Women that have \n\ntheir Terms, during the Time of their Going with Child, \n\nare ſubject to conceive again. | \n\nPliny gives divers Examples of it, Dodoncus in his Obſerva- \ntions, many more. And the like you may read in Laurentius. \n\n\na Woman to perfect a fecond Conception aſter ſhe is conce1- \nved at the firſt; and if fo long after, as Authors ſay, then \nmuch more likely ſooner, before the Womb is filled with the \ngrowth of the firſt. But to make the matter beyond all diſ- \npute, whereas our Tranſlation ſaith, Gen 42. And ſhe concei- \nved AGAIN and bare his Brother Abel: \"Thoſe that have Skill \nin the Original know, that it ſhould be tranſlated, She Con- \necived upon Conception, and bare his Brother Abel, Let \nthis put an end to the Diſpute. | \nAnd then, if the Tratina of Hermes, be true, (I have heard \nmany cavil at it, but never any diſprove it, nor bring a bit of \nwile Reaſon againſt it) there you may find a reaſon why two \nChildren may be conceived at a month's diſtance, and yet \nborn in one Day; and if two Children, lying in the ſame \nWemb at the ſame time; be at any time conceived at twice, \nis it moſt propable they are ſo always? However, this is ap- \nparent, that by Teſtimony of all Authors, yea by the Judg- \nment of that prudent Phyſician Dr. RE ASON, a Woman \nmay miſcarry of one Twin, and yet go out her whole time \nWith the other, as Hippocrates quotes in his Book, De Natura \nPuer. Nay, both Ariſtotle and he, quote Women who brought \nforth two Children at one Birth, and a third fifteen weeks \nI after : Then it follows, that they are little better than Mur- \nbl derers, who force away the ſecond Child the firſt being born \n. before tis time; eſpecially, if the flux of Blood be not great \n\n\n* \n\n\nnor ſigns of Labour appear. \n\n\niy Women defere the Act of Copulation after they have Conceived, \n3TH 2 5 ewhen Beaſes do not. | \n\n= Popper the Daughter of Agrippa the Roman, a wanton Laſs, \n4 YA being aſked the Queſtion: Why Beaſts did not deſire it as \n| f well as Women ? Anſwered, becauſe they are Beaſts. 7 \nN | \n\n1 g 1 2 \n\n\nTELL % 5 \n\n\n© Ariflotle, de Hiſtoria Animalium, abounds in Examples; and \n\n\nThus then you ſee by this Argument, That 'tis poſſible ior . \n\n\nN \n75 \n5 \nbt \n\n\nW n 8 \n\n\n1 Li \n\n\nMt re e \n\n\nf \n\n\nCulpeper's Midwife Enlarged 85 \n\nThe Anſwer was acute 'tis eonfeſt, and acuter, becauſe not \npremedirated, and our own Writers give no wiſer ; for they \n\nſay 'tis a Prerogracive and Virtue God hath only given to \nWoman. Alaſs, poor Fools. that make a Vertue, of a Vice. \n\nThe very truth is, the Curſe of God for Adam's firſt Sin \n\nlies more heavily upon Man than. it doth upon Beaſts, and \n\n\nLuſt is a greater part of this Curſe ; and the Propagation of \n\n\nmany Children at once, an Effect of that Intemperancy: \nAnd that J ſuppoſe to be Hippocrates his Reaſon of forbidding \nCopulation to Women with Child. For my own part, far be \n\n\nit from me to forbid it; for I know well enough the Nature \nof Men are ſo vicious, that he mutt have to do with his Wife, \n\n\nor ſome other Body elſe in that time, or do that which is \n\n\nworſe than either. However, hereby you ſee the Fruits' of \n\n\nOriginal Sin, and what Cauſe you have to be humbled in \nthc preſence of God for it, and require his Aſſiſtance againſt \nthe wretched Effects it produceth. \n\n\nCHAP. IV. \nOf the Imperfed? Children. \n\n\nANY are the Forms which Authors have left to Poſte- \n\nrity, of Monſtruous Births; ſome altered in reſped of \n\nSex, as Hermaphrodites, ir. Form as Beaſtial, ſome double. bo- \ndied, ſome maimed, and many others which would do me \nno good to write of, and you as little to read it. e \nAuthors differ much in this Cauſe. _. \n\nThe Divine refers it to the Jadgment of God alone, which \nif true without the help of Nature, then is every Monſter \na Miracle. „ \n\nArologers, they refer it to the Stars, and the Poſition of the \nMoon in deficient degrees, at the time of Conception. \n\nJ cannot cloſe with any of both theſe, neither altogether \nwith a third, which are more propable, although perhaps \nthe Judgment of 4/tre/ogers may concur. | = \n\nSome hold the Imagination of the Women to be a great \nCauſe, by beholding either ſuch Monſters or ſuch Pictures; \nand that's the Reaſon, they ſay, that they are ſo frequent \nin Zgypt, So alſo you may read of one that brought — \n\nac \n\n\n86 Culpeper's Midwife Enlarged. \nBlack-more, the Woman beholding the Picture of a Black- \nmore hanging in her Chamber. And of a Woman at Pa, \nthat broug 12 a Child full of Hair like a Camel, becauſe \nſhe was ſo ſuperſtitiouſly wiſe to kneel every Day to the Pic- \nture of John: the Baptiſ cloathed in Camels Hair. Alſo I my ſelf \nkno\n…[truncated]", "summary": "By Nicholas Culpeper, Gent. Student — f 4 4 ö DIRECTORY 1300 MIDW I a8 Or, A Guide for W OM E N, Conception, In their Bearing, and Suckling their Children. The Firſt Part contains. The Anatomy of the Veſſels of Generation. The Formation of the Child in the Womb. What hinders Conception, and its Remedies, What furthers Concepticn. A Guide for Women in Conception. Of Miſcarriage in Women. Guide for Women in their Labour. A Guide for Women in their Hing…", "source_url": "https://archive.org/details/bim_eighteenth-century_a-directory-for-midwives_culpeper-nicholas_1755", "pdf_url": "https://archive.org/details/bim_eighteenth-century_a-directory-for-midwives_culpeper-nicholas_1755", "doc_date": "1755", "case": "hesperian", "sub_case": "Culpeper, Nicholas.", "tags": ["hesperian", "Language & Literature", "Literary And Political Reviews", "General Interest Periodicals--United Kingdom", "Law", "Philosophy & Religion", "Fine & Performing Arts", "Social Sciences", "History", "History--History of North And South America", "Books"], "page_count": 0} {"title": "A BOOK FOR MIDWIVES", "content": "A Book for Midwives \n\nCare for pregnancy, birth, \nand women's health \n\n\nSusan Klein, Suellen Miller, \nand Fiona Thomson \n\n\nHesperian \n\n\nBerkeley, California, USA \n\n\nThe Hesperian Foundation and the contributors to A Book for Midwives do not assume \nliability for the use of information contained in this book. \n\nAll health workers have a responsibility to be honest with themselves and the people they \ncare for about the limits of their skills. This means: only perform the procedures you are \ntrained to. Find help from other, more experienced health workers when a woman needs a \nkind of care that you are not experienced with. Seek the advice of local health workers and \nmedical authorities about the safest ways to practice in your area. This manual can help \nyou learn new skills, but no book can take the place of hands-on training with a skilled and \nexperienced teacher. Keep watching, reading, listening, and learning more whenever you \nhave the chance. \n\nCopyright © 2004, 2009, 201 0 by the Hesperian Foundation. All rights reserved. \n\nFirst edition: December 2004, 2nd printing 2009, update 201 0 \n\nPrinted in USA \n\nISBN: 978-0-942364-23-1 \n\n\nLibrary of Congress Cataloging-in-Publication Data \n\nThe Library of Congress has already cataloged the 1 0-digit ISBN as follows: \n\nKlein, Susan, b. 1 948. \n\nA book for midwives : care for pregnancy, birth, and women's health / by Susan Klein, \nSuellen Miller, and Fiona Thomson.-- 1 st ed. \np. ; cm. \n\nIncludes index. \n\nISBN 0-942364-23-6 (pbk.) \n\n1 . Midwifery. 2. Midwives. 3. Pregnancy. 4. Childbirth. 5. Women-Health and hygiene. \nI. Miller, Suellen, 1 947- II. Thomson, Fiona, 1 974- III. Hesperian Foundation. IV. Title. \n[DNLM: 1 . Midwifery. WQ 1 65 K635b 2004] \n\nRG960.K56 2004 \n618.2— dc22 \n\n2004060651 \n\n\nThe Hesperian Foundation encourages others to copy, reproduce, or adapt to meet local \nneeds any or all parts of this book, including the illustrations, provided that the parts \nreproduced are distributed free or at cost — not for profit. Any organization or person who \nwishes to copy, reproduce, or adapt any or all parts of this book for commercial purposes \nmust obtain permission from the Hesperian Foundation. \n\nBefore beginning any translation or adaptation of this book or its contents, please contact \nthe Hesperian Foundation for suggestions, updates on information here, and to avoid \nduplication of efforts. Please send us a copy of any materials in which text or illustrations \nfrom this book have been used. \n\n\nHesperian Foundation \n\n1 91 9 Addison Street, #304 \nBerkeley, California 94704, USA \nwww.hesperian.org \n\n\nnesperian \n\n\nThis book con be improved with your help. We \nwant to hear about your experiences, traditions \nand practices. If you have any suggestions for \nimproving this book , or making it better meet \nthe needs of your community, please write to us. \nYour comments will help make future editions \nmore useful. Thank you for your help. \n\n\nCredits \n\nProject coordination: Fiona Thomson \n\nDesign and production: Sarah Wallis \n\nCover design: Sarah Wallis \n\nAdditional writing and editing: \n\nDarlena David, Todd Jailer, \n\nJane Maxwell, Susan McCallister, \n\nSarah Shannon, Kathleen Vickery, \n\nSarah Wallis \n\nArt coordination: Fiona Thomson \nand Sarah Wallis \n\nAdditional production: Lora Santiago \n\nArtists: Namrata Bali, Jennifer Barrios, \n\nSara Boore, Heidi Broner, \n\nMay Florence Cadiente, Barbara Carter, \nGil Corral, Elizabeth Cox, \n\nRegina Faul-Doyle, Christine Eber, \n\nInaki Fernandez de Retana, \n\nSandy Frank, Deborah Green, \n\nSusie Gunn, Jesse Hamm, Haris Ichwan, \nAnna Kallis, Delphine Kenze, \n\nSusan Klein, Joyce Knezevich, Gina Lee, \nJune Mehra, Naoko Miyamoto, \n\nJeanne Muller, Mabel Negrete, \n\nGabriela Nunez, Kate Peatman, \n\nSara Reilly-Baldeschwieler, \n\nDiana Reiss-Koncar, Petra Rohr- \nRouendaal, Leilani Roosman, \n\nLucy Sargeant, Mona Sfeir, \n\nAkiko Aoyagi Shurtleff, Chengyu Song, \nFiona Thomson, Dovile Tomkute- \nVeleckiene, Sarah Wallis, Lihua Wang, \nDavid Werner, Christine Wong, \n\nAllan Woong, Mary Ann Zapalac \n\n\nField-testing and networking: Starr Amrit \nCopy editing: Rachel Markowitz \nIndexing: Ty Koontz \nProofreading: Sunah Cherwin \n\nMedical review: Ellen Israel, Lisa Keller, \nMelissa Smith, Judith Standley \n\nEditorial and production management: \n\nSusan McCallister \n\nCover photographs: \n\n1 \n\n\n2 \n\n\n1 . India by Starr Amrit \n\n2. Nepal by Curt Carnemark/World Bank \n\n3. Mexico by Rick Maiman/David and \nLucile Packard Foundation, courtesy of \nPhotoshare \n\n4. Democratic Republic of Congo by \nGilberte Vansintejan \n\n5. Tunisia by Curt Carnemark/World Bank \n\n6. Burma (Myanmar) by Peter Williams/WCC \n\nBack cover: Mexico by Rick Maiman/ \n\nDavid and Lucile Packard Foundation, \ncourtesy of Photoshare \n\n\nThe first edition of this book was imagined, written, and illustrated by Susan Klein. \nSadly, she died before it was published. This new revision is still carried largely by her \nwriting, her drawings, and we hope, her vision — that A Book For Midwives would be a \ntool enabling all those who attend women in childbirth, regardless of their \neducational background, to exercise independent judgment and to make the best \npossible decisions at each birth. \n\n\nCredits for the 2009 edition and 201 0 update: This updated, corrected printing relies \nheavily on the generously offered, wise counsel of midwives Ellen Israel, Ellen Lapowsky, \nSuellen Miller, Judith Standley, and Sarah Wallis; and Drs. Reuben Granich, Lisa Keller, \nScott Oesterling, Linda Spangler, Amy Stenson, and Lorna Thornton. Todd Jailer \ncoordinated the reprint with editorial and design assistance from Shu Ping Guan, Jane \nMaxwell, Susan McCallister, Kathleen Tandy, Dorothy Tegeler and Fiona Thomson. \n\n\nwww. nespcnaii.org \n\n\nThanks \n\n\nOnly with the collaboration of hundreds of advisors, reviewers, writers, artists, and others \nwas it possible to create this book. \n\nEvery staff member, intern, and volunteer here at the Hesperian Foundation helped bring \nthis book into the world, including those who raise funds, manage finances, publicize our \nbooks, and pack and ship them around the world. Outside our office, dozens of reviewers \nhelped decide what this book should cover and how to do it. Groups of midwives and \nmidwifery students in 1 0 countries critiqued early versions to make it as useful, appropriate, \nand accurate as possible. Midwives, doctors, and other health workers, trainers, and \nspecialists volunteered their time to ensure the accuracy and clarity of the material here. \n\nAlong with our tireless medical editors, we called on a few reviewers over and over \nagain, and they deserve special mention here. Thank you Deborah Billings, Lisa de Avila, \n\nRuth Kennedy, and Karen Strange. \n\nThe following organizations contributed time, resources, and critical thinking: Averting \nMaternal Death and Disability (AMDD) in the US; ASECSA in Guatemala; The Bangladesh \nWomen's Health Coalition; The Berkeley Midwives Study Group in the US; El Centro Para los \nAdolescente de San Miguel de Allende (CASA) in Mexico; Centre For Rural Studies and \nDevelopment in India; El Centro de Atencion Integral de la Pareja in Mexico; The International \nConfederation of Midwives; The Integrated Midwives Association of the Philippines; \nInuulitsivak Maternity Center in Canada; Ipas in the US, Ghana, and Kenya; Ixmucane and \nMidwives for Midwives in Guatamala; Jamkhed Comprehensive Rural Health Program in India; \nKampot Hospital Maternity Center in Cambodia; the Maryknoll Sisters and the VEMA training \ncenter of Tanzania; Pathfinder in Peru; and the Reproductive Health Research Unit at the \nUniversity of the Witwatersrand, Chris Hani Baragwanath Hospital in South Africa. \n\nThanks to the following publishers who gave us permission to use drawings: Family Care \nInternational, from Healthy Women, Healthy Mothers; Freedom From Hunger; and Pesticide \nAction Network Asia and the Pacific, from Breaking the Silence! Plantations and Pesticides. \n\n\nOur deep gratitude goes to everyone who gave their time, thoughts, and knowledge \nso generously, both to the original edition of A Book for Midwives and to this revision. \n\nYour commitment to health for all is what brought this book into the world. Thank you: \n\n\nHilary Abell \nDee I Afroze \nArthur Ammann \nJana Anderson \nSusan Anderson \nShoba Arole \nLeonor Bahena Erazo \nAlison Bastien \nNaomi Baumslag \nDenise Bergez \nErik Bergstrom \nAlan Berkman \nGinger Bhakti \nDeborah Bickel \n\n\nJudith Bishop \nLisa Bohmer \nBill Bower \nJenny Bowers \nKate Bowland \nIsabel Brabant \n\nBarbara Briggs- \nLetson \n\nSandy Buffington \nColin Bullough \n\nRaquel Burgos \nMedina \n\nAugust Burns \nPauline Butcher \nSarah Buttrey \n\n\nAna Maria Camarillo \nKristen Cashmore \n\nTeresa Cerezo \nGonzalez \n\nRebecca Chalker \nBarbara Clifford \nDavida Coady \nRani Coelho \nTimothy Coen \nJeff Conant \nPeggy Cook \nMaureen Corbett \n\nAntonia Cordova \nMorales \n\nMaricruz Coronado \n\n\nJennie Corr \nKyle Craven \nJane Crawley \nAlice de la Gente \n\nMaria de la Paz \nPuebla Alvear \n\nBarbara de Souza \nDavid de Leeuw \nKim Dickson-Tetteh \nMilka Dinev \nFrance Donnay \nPeg Donovan \n\nCarol Downer- \nChatham \n\nJane Drake \n\n\nA Book for Midwives (201 0) \n\n\nwww. nesperian.org \n\n\nJ.T. Dunn \nEdith Eddy \n\nSylvia Estrada- \nClaudio \n\nAryn Faur \nSusan Fawcus \nJuliet Fleischl \nNina Frankel \nCarmen Frazier \nFrances Ganges \nTracy Gary \n\nMarlene Gerber- \nFried \n\nJulie Gerk \nZafarullah Gill \nRuth Goehle \nFisa Gonzalves \nNadine Goodman \nSuzan Goodman \nKristen Graser \nJames Green \nSadja Greenwood \nCindy Haag \nBarb Hammes \nMarcia Hansen \nRoxanne Henderson \nGriselda Hernandez \nKathy Herschderfer \n\nSarah Jane \nHolcombe \n\nDiana Hoover \nNap Hosang \nJennifer Houston \nMary Clare Hubert \nKathleen Huggins \n\n\nPamela Hunt \nRobert Hurst \nPeter Ivey \nNuriya Janss \nChristine Johnson \nMary Johnson \nRalph Johnson \nJohn Kadyk \nAngela Kamara \nRobert Keast \nChristie Keith \nBeverly Kerr \nMary Kroeger \nRaven Fang \nB.A. Faris \nBrian Finde \nJulie Fitwin \nDavid Foeb \nRoxane Fovell \nRonnie Fovich \nDeborah Maine \nForraine Mann \nAlan Margolis \nMargaret Marshall \n\nAlberto Martinez \nPolis \n\nFuyanda Mavuya \nNicky May \nJunice Melgar \nJose Fuis Mendoza \nElena Metcalf \nFaura Miranda \nIris Moore \nSyema Muzaffar \n\n\nPapa Djibril Niang \nSandy Niemann \nBesem Obenson \n\nDeborah \n\nOttenheimer \n\nFauri Paolinetti \nBill Parer \nJuana Payva \nNimal Perera \n\nFucille Pilling de \nFucena \n\nMan Poon \nJennifer Potts \nPaula Quigley \nSumana Reddy \nMary Ann Reiger \n\nMarina Rodriguez \nPalma \n\nJudith Rogers \nForraine Rothman \nSabala and Kranti \nShelly Sala \nJason Sanders \nShira Saperstein \nMerrie Schaller \nKatherine Sear \nJohn Sellors \nKatharine Shapiro \nFonny Shavelson \nTheresa Shaver \nMira Shiva \n\nChristine \nSienkiewicz \n\nJael Silliman \n\n\nIrene Sotelo \nAlvarez \n\nJennifer Stonier \nSusan Sykes \nMichael Tan \nVijayalaxmi Taskar \nJoe Taylor \n\nPetra ten Hoope- \nBender \n\nCarol Thuman \nFinda Tietjen \nJan Tritten \nGreg Troll \nMina Tulugak \nFaura Turiano \nGilberte Vansintejan \nElmar Vinh-Thomas \nDonna Vivio \n\nClaire Von \nMollendorf \n\nDavid Werner \nSharon Wilconson \nJudith Winkler \nMerrill Wolf \nJuliana Yartley \nKaren Zack \nFisa Ziebel \n\n\nAdditionally, the incredible patience and support of our families and friends during the \nlong process of producing this book allowed us to see the project through. \n\n\nFinally, thank you so much to the individuals and foundations who financially \nsupported this project: Allan S. Gordon Foundation; Anna Falor Burdick Program of the \nFalor Foundation, Inc.; Averting Maternal Death and Disability Program, Heilbrunn Center, \nMailman School of Public Health, Columbia University; Compton Foundation, Inc.; \nConservation, Food and Health Foundation, Inc.; David and Fucile Packard Foundation; \nDorothy and Jonathan Rintels Charitable Foundation; Erik E. and Edith H. Bergstrom \nFoundation; Ford Foundation; International Confederation of Midwives; Jadetree \nFoundation; Jeanne Kemp; Salt-Bush Fund of the Tides Foundation; Ruth Sherer; and the \nUnited Nations Population Fund. \n\n\nWWW \n\n\n1 1* T \n\n*1 HR'S} MUM. # II or \n\n.nespenan.org \n\n\nA Book for Midwives (201 0) \n\n\nHow to use this book \nFinding information \n\nTo find information, use the Contents, the Index, or the Tabs. \n\nThe Contents at the beginning of this book list the name of each chapter in the \norder in which it appears. Contents of each chapter are also listed at the beginning \nof that chapter. \n\nThe Index, or the yellow pages at the back of this book, lists all the topics \ncovered in this book in the order of the alphabet (a, b, c, d...). \n\nEach page in this book has a number at the bottom. To find a chapter or topic \nin this book, find it in the contents or index, and then turn to the page number \nlisted next to it. \n\nTabs on the right-hand pages separate most of the book into 5 sections. \n\nYou can quickly find the information on staying healthy, infection prevention, \npregnancy, labor and birth (including postpartum), and on other health skills, \nby turning to the sections labeled with those tabs. \n\n\nWarnings, medicines, and notes \n\nWarnings, medicines, and notes are separate from the main text. \n\nWarning boxes show very important information. When you see this kind of \nbox, you must take action to avoid danger. \n\nWARNING! Do not insert an IUD for a woman who has \nsigns of infection. The infection can spread to the womb. \n\n\nMedicine boxes show how to give medicines. \n\nRead these boxes very carefully, and always look in \nthe green medicines pages starting on page 463 \nbefore giving a medicine. \n\n\nThese pictures show how \nthe medicines in the box \nare given — in this case \nas tablets. \\ \n\n\n0 \n\nTo lower a fever \n\n• give 500 to 1 000 mg paracetamol by mouth, every \n\n4 to 6 hours. \n\nNotes show information that is useful, but not directly connected with the \ninformation around it. \n\nNote: Clean hands do not stay clean for long. If you touch anything \nother than the mother's genitals, you must wash again. \n\nA Book for Midwives (201 0) \n\n\nnesperian. ore \n\n\nUnderstanding pictures of the body \n\nHow we show the outside of the body \n\nWhen we draw a person, we try to draw her whole body. If we do not have enough \nroom, we only show part of her body. \n\nIf it is important to see \nthe baby's head and the \nvagina more clearly, we \nwill show only that part \nof the body, so we can \nmake the picture bigger. \n\n\nThis picture \nshows a mother \npushing her baby \nout of her vagina. \n\n\nHow we show the inside of the body \n\nSometimes we need to show what is happening \ninside a woman's body. So we include pictures that \nshow what a woman's body would look like if you \ncould see inside of her. \n\nUsually, we use thick lines to show the outside \nof a woman's body, and thin lines or dotted lines \nto show what is happening on the inside. \n\n\nthe womb, \ninside the \nmother's body \n\n\nthe baby, \ninside the \nwomb \n\n\nA note on language \n\nMedical and technical words Throughout this book, we try to use easily \nunderstood words for parts of the body and things that the body does. We also \nexplain the medical words we use. If there is a medical or technical word you do \nnot understand, you can look it up in the index and see if it is explained in the \nbook. Or you can look in the glossary on page 503, which lists some medical and \ntechnical words that are useful to know. \n\nHe and she When talking about babies, we did not want to say \"he or she\" each \ntime because it can be awkward. So sometimes we say \"she,\" and sometimes we \nsay \"he.\" \n\n\nGetting help \n\nThe information in this book is not always enough to help you solve a health \nproblem. When this happens, get help! Depending on the problem, you should: \n\nGet medical advice. A skilled health worker or doctor should be able to help you \ndecide what to do. This is not usually an emergency. \n\nGet medical help. The woman or her baby need to see a skilled health worker or \ndoctor for tests or treatment as soon as possible. \n\nGo to a medical center or hospital. There is an emergency. Take the woman or \nher baby to a hospital right away for surgery or other immediate help. \n\nwww. nespenan.org \n\n\nA Book for Midwives (201 0) \n\n\nContents \n\n\nIntroduction \n\nChapter 1: Words to mid wives \n\nLearning is lifelong 1 \n\nShare what you know 3 \n\nRespectful and compassionate care .... 6 \n\n\nChapter 2: Treating health problems \n\nFinding the causes of health \n\n\nproblems 13 \n\nFinding the best treatment 16 \n\n\nChapter 4: Helping women stay healthy. \n\nEating well 33 \n\nCaring for the body for good health . . 42 \n\nChapter 5: Preventing infection \n\n\nPreventing infection saves lives 49 \n\nPrevent infection by keeping \ngerms away 52 \n\nClean your hands and wear \nprotective clothing 53 \n\nPREGNANCY \n\nIntroduction \n\n\n1 \n\nWork to improve women's health 8 \n\n\nWork for the joy of it 11 \n\n12 \n\nFinding root causes of \nhealth problems 21 \n\nMidwives can make change 25 \n\n\n,26 \n\n29 \n\n\n32 \n\nThings to avoid during \npregnancy and breastfeeding 45 \n\n48 \n\nClean the space and bedding 57 \n\nClean and sterilize tools 59 \n\nGet rid of wastes safely 67 \n\n\n70 \n\n\nChapter 3: A woman's body in pregnancy \n\nA woman's sexual and How women become pregnant \n\nreproductive parts 27 \n\n\nChapter 6: Common changes in pregnancy 72 \n\nChanges in eating and sleeping 73 Changing feelings and emotions .... 82 \n\nBody changes and discomforts 76 \n\n\nChapter 7: Learning a pregnant woman's health history \n\n\nQuestions in a pregnancy \nhealth history 86 \n\nDoes she have signs of pregnancy? ... 86 \n\nHow pregnant is she now? \n\nWhen is the baby due? 88 \n\nHas she had any problems with past \npregnancies or births? 93 \n\n\nMalaria \n\nHIV and AIDS \n\nWhat else in her life might affect \nher pregnancy and birth? \n\nMaking a transport plan \n\n\n..84 \n\n. 98 \n. 99 \n\n104 \n\n106 \n\n\nWWW. \n\n\nnespenan.org \n\n\nA Book for Midwives (201 0) \n\n\nChapter 8: Prenatal checkups \n\nTalk with the mother 109 \n\nCheck the mothers body 116 \n\nCheck for signs of anemia 116 \n\nWeigh the mother 118 \n\nCheck the mothers temperature .... 119 \n\nCheck the mother's pulse 120 \n\nCheck the mother's blood pressure . . 122 \nCheck for signs of pre-eclampsia. ... 125 \nSigns of bladder or kidney infection. .128 \n\nLABOR AND BIRTH \n\nIntroduction \n\n\n108 \n\n\nCheck the baby 130 \n\nMeasure the mother's womb 130 \n\nFind the position of the baby 135 \n\nListening to the baby's heartbeat. ... 139 \n\nWhat to do if you find \nwarning signs 142 \n\nAfter the checkup 144 \n\nRecord of prenatal care 145 \n\n\n146 \n\n\nChapter 9: Getting ready for labor and birth 1 48 \n\nSigns that labor will start soon 149 What to bring to a birth 151 \n\nWhen to go to the birth 151 Sterilize your tools and wash up ... . 153 \n\n\nChapter 1 0: Giving good care during labor and birth \n\nWhat happens during labor Be ready for emergencies \n\nand birth 155 Keep a record of what happens \n\nCare for the mother during labor ... 157 during labor \n\n\nChapter 1 1 : Opening: stage 1 of labor \n\n\nWhat happens during stage 1 167 \n\nWhen you first arrive 168 \n\nHelping the mother relax in stage 1 . 169 \n\nSigns for the midwife to check \nin stage 1 170 \n\nThe baby's position 170 \n\nThe baby's heartbeat 172 \n\nThe bag of waters 174 \n\n\nChapter 1 2: Pushing: stage 2 of labor \n\nWatch for signs that stage 2 is near \n\n\nor starting 195 \n\nWhat happens during stage 2 197 \n\nHelp the mother have a safe birth ... 199 \nWatch for warning signs 202 \n\n\n154 \n\n163 \n\n164 \n\n166 \n\n\nThe mother's pulse 178 \n\nThe mother's temperature 178 \n\nThe mother's blood pressure 180 \n\nBleeding during labor 183 \n\nPain in the womb 183 \n\nWatch for signs of progress 185 \n\nSafe ways to encourage labor 191 \n\n\n194 \n\n\nHelp the mother give birth 206 \n\nBaby is breech 215 \n\nDelivering twins 219 \n\nBaby is very small or more than \n5 weeks early 221 \n\n\nwww. nesperian.org \n\n\nA Book for Midwives (201 0) \n\n\nChapter 1 3: The birth of the placenta: stage 3 of labor \n\n.. 222 \n\nCheck the mothers physical signs . . \n\n. 223 \n\nHelp her push out the placenta . . . . \n\n. 227 \n\nBleeding after birth \n\n. 224 \n\nWatch for bleeding after the \n\nWatch for signs the placenta \n\nplacenta is born \n\n. 236 \n\nhas separated \n\n. 226 \n\nWhat to do for the baby \n\n. 240 \n\nChapter 1 4: The first few hours after the \n\nbirth \n\n.. 246 \n\nWhat to do for the mother \n\n. 247 \n\nBreathing, heartbeat, temperature . . \n\n. 254 \n\nWhat to do for the baby \n\n. 252 \n\nThe baby's body \n\n. 256 \n\nGeneral appearance \n\n. 253 \n\nClean up and answer questions . . . . \n\n. 267 \n\nChapter 1 5: The first weeks after the birth \n\n.. 268 \n\nWhat to do for the mother \n\n. 269 \n\nEncourage the baby to breastfeed \n\nWatch her womb and bleeding .... \n\n. 270 \n\nand watch how she grows \n\n. 274 \n\nWatch for signs of womb infection . \n\n. 271 \n\nCare for the cord \n\n. 277 \n\nWatch for signs of vaginal infection \n\n. 272 \n\nLook for signs of infection \n\n. 277 \n\nWhat to do for the baby \n\n. 274 \n\nWatch the color of the baby's skin \n\nand eyes \n\n. 279 \n\nChapter 16: Breastfeeding \n\nBreast is best \n\n. 281 \n\nCommon difficulties while \n\n.. 280 \n\nHow to breastfeed \n\n. 282 \n\nbreastfeeding \n\n. 286 \n\nWhen the mother works \n\nSituations that affect breastfeeding . \n\n. 291 \n\noutside the home \n\n. 284 \n\nAlternatives to breastfeeding \n\n. 294 \n\nHEALTH SKILLS \n\nIntroduction 296 \n\nChapter 17: Family planning 298 \n\nChoosing a family planning method . 300 Making family planning work for \n\nChart: family planning methods .... 301 the communitY 318 \n\nChapter 1 8: Sexually transmitted infections (STIs) 320 \n\n\nWhat are STIs? \n\n. . 321 \n\nTeaching women how to \n\nDischarge from the vagina \n\n. . 323 \n\nprevent STIs \n\n. 336 \n\nSores on the genitals \n\nSTIs that affect the whole body . . . \n\n. . 329 \n. . 334 \n\nHow to help stop STIs in your \ncommunity \n\n. 337 \n\nChapter 1 9: Advanced skills for pregnancy and birth \n\n.. 338 \n\nVaginal exams during labor \n\n. . 339 \n\nEpisiotomy \n\n. 354 \n\nHome methods for starting labor . \n\n. . 341 \n\nSewing a tear or an episiotomy . . . . \n\n. 356 \n\nInjections \n\n. . 345 \n\nCaring for a woman after female \n\nHow to give fluid through a vein . \n\n. . 350 \n\ngenital cutting (circumcision) .... \n\n. 367 \n\nCatheters \n\n. . 352 \n\nTurning a breech or sideways baby . \n\n. 369 \n\nA Book for Midwives (201 0) \n\n\nwww.hespenan.org \n\n\nChapter 20: The pelvic exam: How to examine a woman's vagina and womb., \n\nWhen to do a pelvic exam 374 The speculum exam \n\nBefore the exam 375 Tests for infections and cancer \n\nThe visual exam 376 The bimanual exam (2-hand exam) . \n\nChapter 21: Howto insert an IUD \n\nHelp a woman decide if the IUD Inserting the IUD \n\nis right for her 390 Afteryou insert tiiem|) \n\nBefore you insert the IUD 391 Removing the IUD \n\nChapter 22: Helping a woman after a pregnancy ends early \n\nProblems from a pregnancy Bleeding \n\nthat ends early 401 shock \n\nEmergency care for problems after \nmiscarriage or abortion 406 \n\nInfection 409 \n\n\nWork with the community to \nprevent unsafe abortions . . . \n\n\nProblems with the MVA , \nAfter the MVA \n\n\nWorking with medical centers \nand doctors \n\n\nChapter 23: Manual vacuum aspiration . \n\nDeciding when to do MVA 418 \n\nGetting ready for the MVA 419 \n\nDoing the MVA 422 \n\nChapter 24: Getting medical help \n\nWhat medical centers and hospitals \ncan provide 433 \n\nGetting to a medical center 438 \n\nChapter 25: Homemade tools and teaching materials \n\nLow-cost equipment 443 Teaching materials \n\nMedicines (green pages): uses, dosage, and precautions \n\nWhen to use medicines 463 \n\nHow to take medicines safely 464 \n\nHow to take medicines 467 \n\nKinds of medicine 470 \n\nProblem index 472 \n\n\nAlphabetical list of medicines \n\nOral contraceptives \n\nMedicines for HIV and AIDS . \n\n\nTo learn more. \n\n\nTechnical and medical words. \n\n\nIndex (yellow pages). \nDue date calculator... \n\n\nwww. nespenan.org \n\n\n372 \n\n377 \n\n379 \n\n385 \n\n388 \n\n392 \n\n398 \n\n399 \n\n400 \n\n412 \n\n414 \n\n415 \n\n416 \n\n428 \n\n430 \n\n432 \n\n438 \n\n442 \n\n447 \n\n463 \n\n473 \n\n490 \n\n492 \n\n\n499 \n\n503 \n\n505 \n\n527 \n\n\nA Book for Midwives (201 0) \n\n\nMidwives and \ncommunity health \n\n\nFor thousands of years, since long before \nthere were doctors or hospitals, midwives \nhave been helping women stay healthy, \nhelping babies into the world, and helping \nfamilies grow. Ask a woman why she prefers \nthe care of a midwife and she will tell you \nthat midwives are knowledgeable, patient, \nand respectful of her traditions. \n\nWhy are midwives such important and \nvalued health workers? \n\n• Midwives trust in the safety of pregnancy and birth, and have \nconfidence that women can work together to protect their \nown health. \n\n• Midwives often live in the communities they serve, so the \nfamilies they help know and trust them. \n\n• Many midwives spend more time with the women they care \nfor than a doctor or clinic worker would. This helps midwives \nto better understand women's needs, and to see danger signs. \n\n• Most midwives are women. Many women feel more \ncomfortable talking to a woman health worker. \n\n• Midwives charge lower fees than most doctors or hospitals — \nvaluing service to the community over the pursuit of money \nor power. \n\n• In poor communities where there are few health services, \nmidwives are often the only health workers. \n\nFor all these reasons, in most of the world midwives are the first \nand sometimes the only health workers women go to for help in \nbirth or for any health problem. But midwives face a number of \nchallenges in this important work. \n\n\nwww. nesperian. or \n\n\nr \n\n\nChallenges \n\nPerhaps the biggest struggle for midwives (and for all health \nworkers) is fighting sickness and death in women and their babies. \nEvery year, hundreds of thousands of women die in pregnancy and \nduring labor. Millions more are injured or disabled. Most of these \ndeaths and injuries happen to women who are poor — who do not \nhave enough food, or safe homes, or adequate medical care. \n\nMost of the midwives of the world live in poor communities, \nand many are themselves not paid a livable wage. The people of \neach community must \n\n\nI work in a restaurant 6 days \na week , and then go home to care \nfor my family. I’m tired all the \ntime and my husband asks me to \nstop attending births. \n\n\nBut I continue because \nit is what I am good at, \nwhat I love, what I am \ncalled to do. \n\n\nshow midwives how \nimportant their work is \nby supporting them in \nthe ways that they can. \n\nLocal governments would \nalso be wise to invest in \nmidwives. These governments \nrarely provide midwives with \nadequate education or \nsupplies, yet they rely on \nmidwives to care for the many \nwomen who have no access to \nother medical care. \n\nAlong with being \nunderpaid, midwives may \nstruggle to receive the respect \nthey deserve for their work. \n\nDoctors and others too often \ndismiss the contributions of \nmidwives. When midwives \nare not treated as valued \nhealth workers — part of a \ncommunity of health care \nproviders who all share the \nsame goals — their ability to \ncare for women is hindered. \n\nMidwives may actually be locked out \n\nof the health system when a woman who has a health emergency is \nnot allowed to bring her midwife with her to the hospital. \n\n\nwww. nesperian.org \n\n\nj \n\n\nr \n\n\n\"N \n\n\nTraditional midwives (sometimes called TBAs) face particular \nproblems. Many professional health workers, including \nprofessional midwives, see traditional midwives as incompetent or \nold-fashioned. These traditional midwives may be very \nknowledgeable about birth and skilled with plant medicines, \ngentle massage techniques, or other safe, effective practices. As \nmore people leave their villages for cities, these midwives may be \nsome of the only people preserving the knowledge and customs of \ntheir communities. Traditional midwives often work for little or no \npay, but instead because of a belief in the importance of their \nwork. Like other midwives, they do their work because they love \nwomen and babies, because they want to contribute to their \ncommunities, or because they are spiritually called to. \n\nHow A Book for Midwives can help \n\nMidwives need accurate information to help them protect the \nhealth and well-being of women, babies, and families. They need \nstrategies to fight poverty and the unequal treatment of women, \nand for working together and with other health workers towards \nhealth for all. We revised A Book for Midwives with these needs in \nmind. In this edition of A Book for Midwives, you will find: \n\n• information needed to care for women and their babies \nduring pregnancy, labor, birth, and in the weeks following \nbirth, because this is the primary work of most midwives. \n\n• skills for protecting a woman's reproductive health \nthroughout her life, because a woman's health needs are \nimportant whether or not she is having a baby, and because \n\n\na woman's health when she is \nnot pregnant affects how healthy \nand safe her pregnancies \nand births will be. \n\n\nv. \n\n\nJ \n\n\nWWW. \n\n\nA Book for Midwives (201 0) \n\n\nsafe, effective methods from both traditional midwifery and \nmodern, Western-based medicine, because good health care \n\nin labor and birth uses \n\nthe best from both \n\n\nMy grandmother is a \nmidwife. She uses plant \nmedicines and massage \nto help pregnant women. \n\n\nWestern medicine and \nthe traditions of midwifery \n\n• discussion of the ways that \npoverty and the denial of \nwomen's needs affect \nwomen's health, and \nhow midwives can \nwork to improve these \nconditions, because \nchanging these \nconditions can make \na lasting improvement \nin health. \n\n• suggestions for how \nmidwives can and must \nwork with each other, \nwith other health \nworkers, and with the \nlarger community, \nbecause working \ntogether strengthens \neveryone's knowledge \nand makes action to \nimprove women's health \nmore effective. \n\nThe basics of midwifery care \nwill never change. Women \n\nand families will always need compassionate and respectful care \nbefore, during, and after birth. And because midwives always \nbenefit from learning more, we hope that the expanded and \nupdated information in this book will help midwives everywhere \nlearn new and lifesaving skills, and apply those skills for the \ngood of the women, babies, and families they serve. \n\n\nI went to school in the city \nto become a midwife myself } \nand I’ve been able to teach \nmy grandmother some new \nways to sterilize tools , \nwatch for danger signs , \nand make birth safer. \n\n\n7 C \n\n\nBut I’m still learning \nthe old ways from her. \n\nSo many of them still work \nbetter than the new ways. \n\n\n1 l it rfii $±kt\\*r \n\nwww. nespenan.org \n\n\nA Book for Midwives (201 0) \n\n\nChapter 1 \n\nWords to midwives \n\n\nn this chapter: \n\n\nLearning is lifelong \n\n\nShare what you know \n\nShare what you know with other \nhealth workers and midwives 3 \n\nRespectful and compassionate care \n\nDo not judge 6 \n\nFollow your own advice 6 \n\nHelp people help themselves 7 \n\nWork to improve women's health \n\nPeople who affect a woman's health ... 8 \nMen can care for women's health 9 \n\n\nWork for the joy of it \n\n\n1 \n\n3 \n\nShare what you know with the \ncommunity 4 \n\n6 \n\nListen more than you talk 7 \n\nTalk openly about difficult subjects .... 7 \n\nKeep things private (confidential) 7 \n\n8 \n\nWorking together to save lives 10 \n\n\n11 \n\n\ni 1* 4li i if 4 «r \n\nwww. nesperian.org \n\n\nWords to \nmidwives \n\n\nTo work for the health and well-being of women and babies — that is, to be \na midwife — you must be willing to learn, to treat people with respect and \ncompassion, and to work together with others to meet the health needs of \nthe community. \n\n\nLearning is lifelong \n\nThe first step on the path to becoming a midwife — or any kind of health worker \n— is learning from others. And even the most experienced midwives continue to \nlearn and gain new skills throughout their whole lives. \n\nMidwives learn from experience and from books and classes. Each way of \nlearning is important. All midwives should find a balance between study and \npractice. \n\n\nBooks and study help midwives \nunderstand a broad range of \ninformation. \n\n\nBut practice is the only way to learn \nthe skills needed to care for women \nand babies. \n\n\nwww.iicspcrian.org \n\n\n1 \n\n\nChapter 1: Words to midwives \n\n\nExperienced midwives continue to learn \n\nThere is always more to know about birth and about health. Every birth is \ndifferent, medical information changes, and there are new skills to be learned. \nAs long as you are a midwife you can: \n\n\n• watch how other midwives, \nhealth workers, and doctors do \nthings. \n\n• ask the women and families you \nwork with what they like and do \nnot like about the care that you \ngive. \n\n• read books or other written \nmaterials. Keep helpful books \nwith you so you can look up \ninformation you do not use \nregularly or remember. \n\n• learn new skills. If you can get \nthe training and tools to do new \nprocedures safely, do not be \nafraid to learn a new skill. This \nwill allow you to help more \nwomen in your community and \nto become a better midwife. \n\nMidwives learn from teachers, books, and other midwives and health workers. \nMostly they learn safe ways to practice. But as any midwife gains more experience, \nshe will discover that some of what she learned is not the safest or most effective \nway to care for women. \n\nMidwives must be willing to change their ideas when they learn new ways of \npracticing so they are always practicing in the best ways they can. Midwives must \nlook honestly at the ways they practice to be sure they are working well — \nwhether they learned these practices from doctors, traditional healers, or \nanyone else. \n\nAsking \"why?\" \n\nAsking \"why\" is important because it helps you do more than just remember what \nyou have been told or what you have read. When you know why, you can make \ndecisions even when there is no person or book to tell you exactly what to do. You \ncan also adapt a treatment or tool to be of use in a way that others may not use it. \nFinally, asking \"why\" is important for understanding the causes of problems — \nto treat problems effectively, and to prevent them from happening again. \n\n\nA Book for Midwives (201 0) \n\n\nwww. Hesperian. ore \n\n\nShare what you know \n\n\nShare what you know \n\nAlong with learning from books and teachers, midwives learn much of what they \nknow from each other and from the families they care for. And midwives can \nimprove health by sharing what they know with the community. \n\nShare what you know with other health workers \nand midwives \n\nMidwives can work together to help each other. If one midwife becomes sick or \ncannot work, another midwife can help the women she was caring for. Midwives \ncan also learn from and teach each other. In some communities, midwives and \nother health workers share information with each other, talking honestly about \ntheir work. Some midwives come together to meet every few months, compare \ninformation, and share resources. At midwife meetings you can: \n\n• take turns telling stories about births you have attended. \n\nBe sure to share the difficult \nbirths and mistakes. \n\nAdmitting mistakes is \ndifficult, but it is a great gift \nwhen there is an opportunity \nto learn from them. Other \nmidwives can explain what \nthey would have done the \nsame or differently. To protect \nthe mother's privacy, do not \nshare her name. \n\n\nNext time I’ll check a \nwoman’s temperature during \nlabor. Then I can find an \ninfection earlier. \n\n\n• ask other health workers to come meet with your group. For example, an \nherbalist could come talk about local plants that can fight infections. Or a \nmidwives group could talk with nurses from a local maternity center about \nhow midwives and nurses can work together. \n\n\n• share educational books (including this one!) \nwith other midwives. If no one has much money, \nperhaps a group of midwives can put their money \ntogether to buy a book to share. \n\n\nwww. nespenan.org \n\n\nA Book for Midwives (201 0) \n\n\n3 \n\n\nChapter 1: Words to midwives \n\n\n• practice helping women with different problems by acting them out \n(role play). For example, one \nperson can pretend to be a \npregnant woman who is not \neating enough healthy food. \n\nAnother person can pretend to be \nher midwife — listening and \ngiving advice. Afterwards, each \nactor can explain how she felt, \nand the others in the group can \noffer suggestions for what they \nwould do differently. Make sure everyone has a chance to play one of the roles. \n\n• make use of different midwives' skills. If one midwife knows how to read, \nshe can read aloud from books to the other midwives. A midwife who knows \nhow to sterilize tools can teach the others in the group. \n\nShare what you know with the community \n\nAs a midwife, you give advice, treat problems, even save lives. But the overall health \nof those around you is not in your hands alone. In part, this is because people \ndecide for themselves how to eat, how to do their work, and what choices they \nmake. By teaching and sharing information, midwives can help people to make \ntheir own choices more wisely. This is why your first job as a midwife is to teach. \n\nTeaching can happen anywhere and anytime. During a checkup, when you \nexplain to a woman why you are asking each question, you are teaching her. When \nyou show a woman's husband why family planning is his responsibility too, you \nare teaching him. Even at the market, at a community gathering, or anytime you \nmeet with others, you have the chance to teach. \n\n\nTeaching classes \n\nThere are probably topics that many people in the community could benefit from \nlearning about. If possible, call meetings for pregnant women, families, or other \ncommunity members to teach about health and birth. You can teach about: \n\n• how the body works. \n\n• how to choose and use family planning. \n\n• how to eat and care for yourself in pregnancy. \n\n• how to have a safer birth. \n\n\n• how to care for yourself after a birth and how to breastfeed. \n\nTeaching is a skill, and it takes practice. A good place to start \nis by listening. When you find out what people already know, \nyou can help them build on that knowledge. And when you \nlisten, you will learn from those you are teaching. \n\n\nYour ears are \n2 of your most \nimportant \ntools. \n\n\nWWW. \n\n\nnespenan. \n\n\nrg \n\n\n4 \n\n\nA Book for Midwives (201 0) \n\n\nShare what you know \n\n\nFor example, if a group of women wants to learn about sexually transmitted \ninfections (STIs), you can first ask each person to share what she knows about STIs. \nWomen may know about STIs from books or classes, from talking to other \nwomen, or from having had infections themselves. \n\nAfter people have shared their knowledge, find out what questions they have. \nPeople in the group may be able to answer each others questions. You can \nprobably add some important medical information and point out when people \nhave incorrect beliefs too. By encouraging the group to talk, you find out what \nthey really need to know — and help them understand how much knowledge they \nalready have. A person who feels confident that she understands a problem is more \nable to work to solve it. \n\nShow respect for the people you teach, and be sure that what you say is \nmeaningful to their lives. \n\n• Sit in a circle with everyone on the same level. This puts you in the same \nplace as everyone else, and shows that you are not the only one with \nknowledge. \n\n• Be prepared. Think about what you want to share before you start teaching. \n\n• Use many methods to teach. People learn differently, and everyone learns \nbetter when they learn the same thing in different ways. After you talk with \nthe group about STIs, the group could act out a play about them. Or make \nposters about STIs to share with the community. \n\n\nYou all said you want to \nlearn about what to eat \nduring pregnancy and \nafter the baby comes. \nWhat do you know about \nhealthy eating now? \n\n\nI’ve heard you \nshould not eat \nmeat when you are \nbreastfeeding. It \nwill harm the baby. \n\n\nThat’s not true! \nYou need to eat \nmeat to make the \nblood strong! \n\n\nAsking questions will help you understand what people already \nknow, what they want to learn, and what obstacles they face. \n\n\nRemember, some people are used to speaking up in groups. Others may be \nafraid. Encourage women, those who have little schooling, or anyone who usually \nkeeps quiet to share his or her thoughts. For more ideas on how to teach so people \ncan truly learn, see Helping Health Workers Learn. \n\n\nWWW. \n\n\nnesperian.org \n\n\nA Book for Midwives (201 0) \n\n\n5 \n\n\nChapter 1: Words to midwives \n\n\nShare your knowledge with the people you care for \n\nWith accurate information, each woman has the ability to understand her body \nand to make wise decisions about her health. Each time you meet with a woman \nduring pregnancy or for other care, explain what you are doing and why. Answer \nany questions the woman has about her body or her health. \n\nAdmit what you do not know \n\nNo one knows every answer. Some problems have no easy answer! Admit what \nyou do not know, and people will trust the knowledge you do have. \n\n\nI worried about you \nwhen you did not \ncome last month. \nWas something \nwrong? \n\n\nRespectful and compassionate care \n\nEveryone deserves to be treated with respect. As a \nhealth worker, the way you treat a woman is \nparticularly important. \n\nMidwives are often trusted \nauthorities. A kind or \nencouraging word from you \ncan go a long way in giving a \nwoman confidence in her \nability to care for herself. An \nunthinking or cruel remark can cause \nhurt that lasts many years in a woman. \n\nDo not judge \n\nSome women are used to being treated \ndisrespectfully. When you begin to work with \na woman who is often treated with disrespect \nbecause of her age, the work she does, her \nethnicity or religion, how much money she \n\nhas, having a disability, or for other reasons, she may expect you to treat her badly \nas well. You can only overcome this fear by showing her that you are there to listen \nand help her — not to judge or criticize. \n\n\nFollow your own advice \n\nPeople are more influenced by what you do than what you say. And because \nmidwives are respected by their communities, the things you do may encourage \nothers to care for themselves. If you breastfeed your children, other women in the \ncommunity may be more likely to breastfeed. If you do not smoke, other women \nmay follow your example and not smoke, or may stop smoking. Live your own life \nas you would advise others to do. \n\n\nA Book for Midwives (201 0) \n\n\nwww. nesperian.org \n\n\nRespectful and compassionate care \n\n\nHelp people help themselves \n\nEveryone has the right to decide \nwhat happens to her own body. \n\nAnd people can and should \ntake the lead in their \nown care. In this way, \nthey can become — \n\nactively responsible ~~ / / — \n\nr i • iii WA' \n\ntor their own health \nand the health of \ntheir communities. \n\nListen more than you talk \n\nA woman often needs someone who will listen to her without judgment. And as \nshe talks, she may find that she has some of the answers to her problems. \n\nTalk openly about difficult subjects \n\nSome women feel shy, ashamed, confused, or private about their problems. This is \nespecially common with family problems and sex. A midwife who talks honestly \nand openly about these subjects will discover that many women share the same \nproblems. By speaking directly and comfortably to women about their families, \nsexuality, and sexual health, you will help women feel less alone, and you may \nhelp them solve problems that have a large effect on their health. \n\nKeep things private (confidential) \n\nNever tell anyone about someone else's health or care — unless the person says it \nis OK. And when you talk to women about their health, do it in a private place \nwhere others cannot hear. \n\nIn particular, respect a woman's privacy about subjects that may be sensitive to \nher, such as sexually transmitted infections, miscarriages and abortions, and \n\nfamily problems. You should never share \nthis type of information without a \nwoman's permission. \n\nThere is only one time when it is OK \nto share information about someone's \nhealth: if another health worker is caring \nfor the woman during an emergency, \nthe health worker will need to know the \nwoman's health history in order to \nprovide safe and effective care. \n\nA midwife must keep what she \nknows about a woman private. \n\n\nI will never tell ^ \nanyone what \nyouve shared \nwith me. \n\n\nThank you. It's \na relief to be \nable to speak \nfreely. \n\n\nwww. nesperian.org \n\n\nA Book for Midwives (201 0) \n\n\n7 \n\n\nChapter 1: Words to midwives \n\n\nWork to improve women's health \n\nMidwifery is not just about treating health problems as they arise. Health problems \nhave many causes. Some are physical, some are social, economic, or political. \n\nBy treating social, economic, and political causes, you can prevent many health \nproblems — and protect more women in the community. \n\nWorking to treat social causes and to improve women's health is not something \none midwife can do alone. She must work with the whole community. \nUnderstanding causes and finding solutions is more possible when people work \ntogether. See page 23 for ideas about working with others to make change. \n\n\nPeople who affect a woman's health \n\nA woman's health is affected by many people. To care for a woman, you must work \nwith those people too. \n\n\nSome of the people that affect a woman's health are: \n\n\n• her husband, children, \nparents, and other family \nmembers. \n\n• the people she works with, \nor works for. \n\n• her neighbors and friends. \n\n• community leaders — \nincluding spiritual leaders, \ngovernment officials, and \nvillage heads. \n\n\n• other health workers — \n\nlike traditional healers, doctors, \nand community health workers. \n\n\nA woman's health can be \nprotected — or hurt — \nby the whole community. \n\n\nAnyone who influences the way a woman works, eats, has sex (or does not \nhave it), or cares for her daily needs has an effect on a woman's health. Sometimes \nthe effect is good — it protects or improves the woman's health. Sometimes it is \nbad — the woman's health and well-being are endangered. \n\nFor example, it may not help to tell a pregnant woman to eat more if her \nhusband always eats first and there is not enough left for her. She herself may \nbelieve her husband's and children's hunger is more important than her own. \n\nWho else could you involve to try to improve a woman's nutrition, when she \ndoes not have enough to eat? \n\n• the woman's husband, who is eating first. Perhaps you could talk to him \nabout how much food a pregnant woman needs. \n\n\nWWW. \n\n\nnespenan. \n\n\nrg \n\n\n8 \n\n\nA Book for Midwives (201 0) \n\n\nWork to improve women's health \n\n\n• the men of the community, who all expect to eat first. The woman's husband \nmay be more likely to change if other men do too. You could have a meeting \nof men and women and discuss why pregnant women must eat more to be \nhealthy. If one man in the community agrees that women must have as much \nor more healthy food as men, this opens the door for others. \n\n• children, who will soon grow up to be mothers and fathers. Each time a man \neats first and most, and a woman eats last and least, their children see and \nlearn that a man's hunger is more important than a woman's. By talking to \ngroups of schoolchildren or by changing the way your own family eats, the \nnext generation may grow up to value men and women more equally. \n\nWho could you involve to make sure there is enough food for everyone? \n\n\nMen can care for women's health \n\nWhenever you can, encourage men to be partners in improving women's \nhealth. Husbands, fathers, sons, community leaders, spiritual leaders, \nbosses, and other men all play a role in how healthy women will be. If \nthe men of the community feel responsible for the health of women, the \nwhole community will benefit. Midwives can help men be involved. \n\nBuild on the roles and skills that men already have. For example, in \nmany communities men are seen as protectors. Help \nmen learn how to protect the health of women. \n\nEncourage men to share the responsibilities of \npregnancy and parenting. Men can care for children in \nthe same ways that women do: comforting, bathing, \nfeeding, teaching, and playing with them. \n\nInvite women and men to community meetings, \nand encourage women to speak up. \n\nWork with men who are sympathetic to women's needs. They can talk \nto other men who listen more closely to a man than to a woman. \n\nGive practical suggestions. Men who care very much about the health \nof women in their lives may not know where to start. For example: \n\n• Tell men how they can get tested and treated for sexually \ntransmitted infections. If only a woman is treated, she will quickly \nbe infected again by her partner. \n\n• Explain to a man that his pregnant wife needs help with her \ndaily work. \n\n• During labor, show a man how and where to rub a woman's back \nto relieve her pain. \n\n\nwww. nespenan.org \n\n\nA Book for Midwives (201 0) \n\n\n9 \n\n\nChapter 1: Words to midwives \n\n\nWorking together to save lives \n\nWhen midwives work with the whole community, they can find solutions to \nhelp the women they care for — or to help everyone in the community. Here is \na true story: \n\n\nA creative solution \n\nIn the small villages of West Africa, when a woman has a problem in labor, \nit is very hard for her to get to a hospital. Few villagers have cars, and most \ntaxi drivers refuse to take women in labor. When a woman is in danger, \nthere is little her midwife can do. \n\nSome midwives and \nvillagers talked about this \nproblem, and discovered a \ncreative solution. Even \nthough no villagers had \ncars, they were near a large \nroad. All day and night, \ntrucks drove down the \nroad bringing products to \nthe city. Someone \nsuggested that if a woman \nneeded help in labor, she \ncould ride with a truck \ndriver to the hospital. \n\nFor this plan to work, the villagers needed to be sure that truck drivers \nwould agree to stop if they were needed. They talked to someone from the \nunion of truck drivers. The union members were happy to help, and now \nthey have a system that is simple and effective. \n\nWhen a woman needs to go to the \nhospital, the midwife puts a yellow flag \nout near the road. When a passing truck \ndriver sees the flag, he stops and picks \nup the woman and the midwife, and \ntakes them to the city hospital. \n\nBy working together with each other, \nother villagers, the truck drivers, and \ntheir union, these midwives helped \nsave lives. \n\n\nWWW. \n\n\nnespenan.org \n\n\n10 \n\n\nA Book for Midwives (201 0) \n\n\nWork for the joy of it \n\n\nWork for the joy of it \n\n\nIf you want other people to take part in improving their lives and caring for their \nhealth, you must enjoy such activities yourself. If not, who will want to follow \nyour example? \n\nMost midwives do their \nwork out of love and as a \nservice to the community. \n\nAlthough their work has \ngreat value, midwives are rarely \npaid much (a sad truth for many \nhealth workers and women workers in \ngeneral). Even so, a midwife who works \nhard and puts the needs of her \ncommunity first will usually be \nrespected and appreciated by the \n\npeople she serves. ^ ^ \n\nYou may or may not be paid for your work, but never refuse to care for \nsomeone who is poor or cannot pay. Everyone deserves your full care and \nattention. \n\n\nThe work of a midwife is often difficult. Midwives work long hours, lose sleep, \nstrain their bodies, and challenge their minds. Midwives feel an intense \nresponsibility that can cause stress or deep emotional pain. For most midwives, \nthese challenges are all worth facing, because the work of a midwife is also so \nrewarding. Teaching women and families about their bodies and health, treating \nserious health problems, and helping welcome new lives into the world are some \nof the most important and rewarding tasks anyone can do in their lives. Our world \nneeds the valuable work of midwives because midwives make this world stronger, \nhealthier, and safer. \n\n\nwww. nesperian.org \n\n\n11 \n\nA Book for Midwives (201 0) \n\n\nChapter 2 \n\nTreating health problems \n\n\nIn this chapter: \n\nFinding the causes of health problems \n\nFinding the best treatment \n\nBenefits and risks 16 Know your limits, \n\nTypes of medicine 17 \n\nFinding root causes of health problems \n\nMake change in your community to \nprevent health problems 23 \n\nMidwives can make change \n\n\n13 \n\n16 \n\n20 \n\n21 \n\n\n25 \n\n\nwww.nespenan.org \n\n\n12 \n\n\nTreating health \nproblems \n\n\nMost of the daily work of a midwife is treating health problems. When a woman \nyou are caring for has a problem, like exhaustion, pain in the belly, or even \nheavy bleeding, you will need to take these steps to solve it: \n\n1. Find the immediate cause of the problem. \n\n2. Choose the best treatment. \n\n3. Look for the root (underlying) causes of the \nproblem — to fully address the problem or prevent \nproblems from happening again. \n\n\nFinding the causes of health problems \n\nIn this section, we tell how Celeste, a midwife, solves a health problem. The details \nof this story apply only to Celeste, but the way she thinks about the problem and \nworks to solve it can be used by any midwife for any health problem. We list \neach step that Celeste uses so that you can use these steps too. \n\n1. Start with a doubt. This means start by admitting what \nyou do not know. \n\n2. Think of all the possible causes. Most ways of feeling \nsick can be caused by many different problems. \n\n3. Look for signs to find the likely cause. Health problems \nhave signs. You can see these signs in how someone \nfeels, how their body looks and acts, and by taking \nmedical tests. \n\n4. Decide the most likely cause. \n\n5. Make a plan for what to do. This could be a plan to change a person's \nhabits, change something in their home or environment, or give a medicine. \n\n6. Look for results. Find out if your treatment is working. If it is not, start these \nsteps again. \n\n\nWWW. \n\n\nnespenan.org \n\n\n13 \n\n\nChapter 2: Treating health problems \n\n\nCeleste's steps for finding causes \n\n1. Start with a doubt. \n\nA young pregnant woman named Elena came to her midwife, Celeste, \nfor care. During the checkup, Elena said that she felt tired all the time. \n\nFirst, Celeste acknowledged that she did not know what was making \nElena tired. \n\n\n3. Look for signs to find the likely cause. \n\nCeleste asked Elena questions to find out more about the tired feeling. \n\n\nAre you \nworking more \nthan usual? \n\n\nAre you \nsleeping less? \nDo you feel ill? \n\n\nI work hard [ \nbut no harder \nthan usual. \n\n\nVm sleeping \nenough , and do \nnot feel ill. \n\n\nCeleste also asked Elena what she usually ate. Elena said that she \nmostly ate maize and beans every day. Actually, mostly just maize. \nElena complained of the high cost of buying meat. \n\nCeleste checked Elena's physical signs. Elena had pale eyelids and \ngums and a fast, weak pulse — all signs of anemia. \n\n\nWWW. \n\n\nnespenan.org \n\n\n14 \n\n\nA Book for Midwives (201 0) \n\n\nFinding the causes of health problems \n\n\n4. Decide the most likely cause. \n\nCeleste could not do a blood test to be sure, because there was no \nlaboratory nearby, but all the other signs showed that Elena probably \nhad anemia. \n\n5. Make a plan for what to do. \n\nCeleste explained to Elena that anemia can cause tiredness and make it \nhard for a woman to recover after a birth — especially if the woman \nbleeds heavily. She told Elena that anemia means not enough iron in the \nblood and that it can usually be cured by eating foods rich in iron and \nprotein or by taking iron pills. \n\n\n6. Look for results. \n\nWhen Elena came back for her next check up, Celeste checked for signs of \nanemia. After improving her diet, Elena seemed be getting better. If Elena \nhad not gotten better, Celeste would have recommended that Elena take \niron and folate pills. \n\n\nThese 6 steps will help you solve most health problems. \n\n\nNote: To \"start with a doubt\" is very difficult for most health workers. \nMany health workers are afraid to admit when they do not know an \nanswer. But to accurately assess a problem, and to treat it \nappropriately, we must admit what we do not know. \n\n\nWWW. \n\n\nrian • org \n\n\nA Book for Midwives (201 0) \n\n\n15 \n\n\nChapter 2: Treating health problems \n\n\nFinding the best treatment \n\n\nWhen you treat any health problem, from anemia to too-long labor \nto heavy bleeding, you must find the treatment that 1 \nmost benefits and the least risk of harm. \n\n\nBenefits and risks \n\n\nAny time you make a decision about a medical \ntreatment, you should consider the benefits and \nrisks. \n\n\nA benefit is the good that an action or \n\n\ntreatment might bring. A risk is the harm that it \nmight cause. Each time you make a decision, try \nto choose the action with the most benefit and \nthe least risk. \n\n\nWhen the benefits \"weigh' \nmore than the risks, an \naction is worth doing. \n\n\nThink again about Elena and Celeste: \n\nWhat if Elena's anemia did not go away after eating \n\n\nmore iron-rich foods and taking iron pills? She and \nCeleste would have to make a difficult decision. \n\nCeleste knows that a woman with severe anemia is probably safer giving birth \nin a well-equipped medical center than at home. This way, if severe bleeding \nhappens, a blood transfusion is immediately available. Without this care, Elena \nmight be very weak after the birth. This weakness will make her more likely to get \nan infection. It will make it very hard for her to care for her family and herself. And \nif a baby's mother is not able to care for him well, he may be in danger too. \n\nOn the other hand, most women in the village have anemia. And most of them \nwill not have serious problems after their births. The hospital is a day's journey \naway and very expensive. Elena's family would have to spend most or all of their \nmoney for her to give birth there. \n\nStaying home and going to the hospital each have benefits and risks. What \nwould you do? \n\nMedicines in particular have both benefits and risks. Even a medicine that is \nvery helpful for treating a health problem may have side effects or dangers. In this \nbook, there are procedures and medicines that have very serious risks. We include \nthem because when they are truly necessary, they can save lives. But before giving \nany medicine or doing any invasive (inside the body) procedure, including \nemergency procedures like removing the placenta by hand (page 230) or MVA \n(page 416), you must decide if you can do it safely — with more benefit than risk. \n\n\n16 \n\n\nA Book for Midwives (201 0) \n\n\nWWW. \n\n\nFinding the best treatment \n\n\nI am going to have to \nreach inside to get \nthe placenta out. \n\n\nYes , very! But the road is \nwashed out by the rain — and \nthere is no way to get help \nbefore she bleeds to death. \n\n\nTypes of medicine \n\nAround the world, people use many different ways of healing: \n\n• Traditional medicine (also called folk medicine): These \nways of healing have been passed down from older healers \nto younger ones for many generations. Traditional ways of healing use \nmassage, plant medicines, and communication with the spiritual world. \n\nTraditional medicines, particularly home remedies, can be very effective. \n\nThey are often the safest, easiest, and least costly treatments for most health \nproblems. And when money runs out, or outside aid groups leave, the plants, \nmassage techniques, and other traditional ways of healing will still be here. \n\nMany traditional medicines have been tested using science. Testing has shown \nthat some traditional medicines work well and others do not, or they only \nwork because people's belief in them is strong. Some traditional \nmedicines are harmful or dangerous. \n\n• Western medicine: This system of healing relies on scientific testing, Q © \nmanufactured medicines (drugs), and surgery to treat health problems. \n\n• Non-Western systems like acupuncture, ayurveda, or homeopathy: \n\nThese systems of healing may have been used for thousands of years, \n\nare taught in books and schools, and may have been tested using science. \nMany of these systems also use plant medicines. \n\nOne person may use several of these ways of healing. \n\nThere is not enough space in this book to fully describe every system of healing. \nWhat is important to remember is that each type of healing has benefits, and that \nany kind of medicine must be used with care. \n\nwww. nespenan.org \n\n\nA Book for Midwives (201 0) \n\n\nChapter 2: Treating health problems \n\n\nWestern medicine \n\nWestern medicine, when used correctly, can save lives. And Western medicine is \nusually the best treatment for emergencies. For example, when a woman is \nbleeding heavily after a birth, there may be plant medicines in your area that can \nslow her bleeding. But Western medicines often work better and more quickly — \nthey are more sure to save a bleeding woman's life. \n\n\nUse Western medicines correctly \n\nMost Western medicines have been carefully tested by science. Western medicine is \nusually very effective at treating problems. But Western remedies are often \nexpensive, some have side effects, and in many cases they are not necessary. Most \nbasic health problems could be treated just as well with traditional or home \nremedies, or just by waiting. \n\n\nDon't you \nthink he \n\nneeds an \n\ninjection? J \n\nyW( m \n\nM\\\\ \n\nUsing any medicine when it is not necessary, or using too much, can cause \nserious health problems. For example, some people believe that only an injection \nwill help them when \nthey are sick. These \npeople would usually \nget better if they did \nnothing, and in many \ncases, unnecessary \ninjections have caused \nabscesses or have passed \ndisease (like HIV) when \ngiven with unsterilized \nneedles. So although \nmedicines can save lives, \n\nthey must be used Take time to explain why \n\ncorrectly. medicines are not needed. \n\n\nNo. All he has is \na cold. Let him \nrest , give him \ngood food and \nlots to drink. \nStrong medicine \nwon't help and \nmight even \nharm him. \n\n\nThis book is mostly about Western medicine \n\nThis book mostly teaches how to use Western methods of healing. There is one \nmain reason for this: Western medicines are available in most parts of the world. \nWe do not know enough, nor do we have enough room to explain how to use the \nmillions of traditional plants and ways of healing that are used around the world. \nTherefore, please use the back of this book to write down the traditional methods \nthat you use. And if you translate or adapt this book, be sure to include your local \nways of healing. It is very important to share these traditional ways of healing so \nthat they are not forgotten! \n\n\nWWW. \n\n\nnespenan.org \n\n\n18 \n\n\nA Book for Midwives (201 0) \n\n\nFinding the best treatment \n\n\nI make a tea from this \nplant It always seems to \nhelp when labor is slow. \n\n\nChoosing a medicine that is safe and helpful \n\nBefore you give a medicine \n(traditional or Western), you \nshould be confident that it is safe \nand helpful. To know if this is true, \nthink about (and ask others) \nthese questions: \n\n• What is it used for? \n\n• What happens when you use it? \n\n• How often does it help make a problem better? \n\n• What side effects or other problems does it cause? \n\nWhen you are trying a treatment for the first time, \nuse it alone, not mixed with other treatments. That way \nyou will know if it works, and if it causes problems. \n\nSee page 463 to learn more about using medicines safely. \n\n\nThanks! \nBut does it \ncause any \nproblems? \n\n\nMedicine and greed \n\nSadly, some healers and health workers are motivated by greed. In order to make \nmoney, they may recommend a treatment that is not necessary, that does not work, \nor even one that is dangerous. Some healers rely on the respect others have for \nthem to sell potions or medicines that do not really work. \n\nSome companies that make and sell medicines use their reputations to mislead, \ntoo. When drug companies act in this way, whole communities can be put in \ndanger. For example, a US drug company named Eli Lilly used to make a medicine \n\ncalled diethylstilbestrol (DES). \nDES was supposed to help \nprevent miscarriages. In fact, \nDES did not prevent \nmiscarriages. It caused birth \ndefects and cancer. Eli Lilly \nknew that the drug might cause \nthese problems but kept selling \nit anyway. And even after the \ndrug was made illegal in the \nUS, it was still sold in other \ncountries. \n\n'f o \n\n\nwww. nesperian.org \n\n\nA Book for Midwives (201 0) \n\n\nChapter 2: Treating health problems \n\n\nKnow your limits \n\nKnow when to do nothing \n\nIn this book, we talk mostly about how to solve health problems. This is \nimportant. But in many cases, the best thing to do for a woman in labor is \nnothing! A woman who is healthy is likely to have a healthy and happy birth. \n\nMost births go well. \n\nDoing unnecessary procedures can cause serious problems. Respect the process \nof birth. When all is going well, simply watch and wait. \n\nKnow when to get help \n\nNo matter how skilled you are, there will be times when you need help. Knowing \nwhen to get medical advice, when to enlist the support of another midwife, or \nwhen to send a woman to a doctor or medical center, is a skill that every midwife \nmust try to master. \n\nIt can be hard to know when to get medical help. \n\nHospitals and medical centers are often expensive or far \naway. Many women are afraid to go to them. A woman with \na small problem may want to stay home. She may not want \nto go to a medical center unnecessarily. But if she stays at \nhome without help, the problem could get much worse. \n\nIf you know a woman is having a problem like \nhemorrhage, infection, or pre-eclampsia, do not delay — \nget medical help. The sooner you go, the better her chances \nof recovery. Sometimes you may have to rush, sometimes \nyou may not. If labor is long, for example, and you live and \nwork very far from a medical center, you must start your \njourney early, before the problem is serious. If the medical \ncenter is only across the road, you have more time. \n\nKnow when to take action at home \n\nMidwives who work very far from medical care must also sometimes give \ntreatments that are better done in a medical center or hospital — because the \nwoman needs the treatment right away. For example, if a woman in an isolated \nvillage has a seizure from eclampsia, her midwife should give her magnesium \n\nsulfate, a drug that is not usually \nsafe to give at home. Then the \nmidwife should take the woman \nto a medical center right away, \nbecause both the seizure and the \nmagnesium sulfate are very \ndangerous. \n\n\nDeciding when to get \nhelp can be difficult. \nWhen in doubt — \nget medical help. \n\n\n20 \n\n\nA Book for Midwives (201 0) \n\n\nwww. nesperian. ore \n\n\nFinding root causes of health problems \n\n\nWARNING ! In this book, we explain how to do some procedures \nthat can be dangerous if they are not done correctly, such as: how \nto do a pelvic exam, how to insert an IUD, or how to sew a tear. \n\nIt is not enough to read about these procedures. Before you do \nmany of the procedures in this book, first watch other \nexperienced health workers doing them. Then practice while \nsomeone with experience and training watches and helps you. \n\nOnly after you have practiced many times in this way is it safe for \nyou to do these procedures on your own. \n\n\nFinding root causes of health problems \n\nAs a midwife, you must find and treat the immediate causes of health problems. For \nexample, think again about the story of Celeste and Elena. The immediate cause of \nElena being tired was her anemia. If she eats more iron-rich foods or perhaps takes \niron pills, her anemia will probably get better. By looking at the immediate causes, \nwe can help people feel better or save their lives, especially in emergencies. \n\n\nTreating the immediate cause is very important. But if we only treat the \nimmediate cause, the problem may not truly be solved. It may come back, or it may \naffect others in the community. Sickness usually results from a combination of \ncauses — direct causes, like germs or lack of iron, and less direct root causes that \nmay be social, economic, or political. By finding these root causes, you can prevent \nproblems from happening again. \n\n\nIn the case of Elena, there are many root causes of her problem. Celeste could \nprobably figure out some of those causes herself. Better yet, she and Elena could \nmeet with a group of people from the community to help think about the problem, \nbecause anemia is not just Elena's problem, it is a community problem. \n\n\nWhy was Elena tired? \n\nBut why did she have anemia? \n\nBut why didn't she eat \nenough iron-rich foods? \n\nBut why else? \n\nBut why couldn't she afford \nmeat? \n\nBut why do farmers make \nso little money? \n\n\nBecause she had anemia. \n\nBecause she did not eat enough foods with iron. \nShe did not know which foods had iron. \n\nShe could not afford meat. \n\nBecause she is poor. She and her husband \nwork on a farm and make little money. \n\n\nwww. nesperian.org \n\n\nA Book for Midwives (201 0) \n\n\n21 \n\n\nChapter 2: Treating health problems \n\n\nAfter you have asked everyone \"why\" in this way for some time, you will find \nthat there are many reasons why Elena had anemia. This exercise also shows why \nanemia is not just a problem for Elena but for most of the women in the village. \nIndeed, it is a problem for most women in most villages and poor communities \naround the world. \n\n\nLook deeply to prevent more problems \n\nFinding the many root causes of health problems means \nlooking hard at the different parts of people's lives that \ncontribute to the problem. \n\nFor example: A fistula is a terrible complication of \nsome births. When a labor goes on much too long, the \ntissue inside a woman's vagina can become crushed and \nbreak open, leaving a hole to her bladder. This cai \nserious health problems and constant leaking of \nurine. To prevent a fistula, simply prevent a long \nlabor. If a woman is in labor for more than a day, \nbring her to a medical center or hospital. \n\nBut by looking more deeply at the many \ncauses of a long labor, we can do more to \nprevent fistula and other related problems. \n\n• Young girls who do not eat well often grow up to have small bones \n(including small pelvises). An abnormally small pelvis can cause a \nlong labor. Some young girls do not eat enough because their \nfamilies cannot afford food. Some are not fed enough because they \nare not considered as important as boys. \n\n• Some girls have children too young. Young girls have long, \ncomplicated labors because their bodies have not fully grown. Girls \nmight marry and have children early because it is the custom of their \ncommunities or because their parents are poor and cannot care for \nthem. Or both. \n\n• Women in bad health are more likely to have long, complicated \nlabors. Anyone can have health problems, but those who do not \nhave access to basic health care are in the greatest danger. \n\n• Rural and poor women cannot easily get medical help in an \nemergency. \n\nTo prevent fistulas, must we simply get women to hospitals faster, \nor can we also work to change the conditions that cause long labors, \nlike poor nutrition of young girls and too-early marriage and childbirth? \nHow can we work to stop the root causes of these problems — poverty \nand unfair treatment of women and girls? \n\n\n22 \n\n\nA Book for Midwives (201 0) \n\n\nwww. nesperian.org \n\n\nFinding root causes of health problems \n\n\nMake change in your community to \nprevent health problems \n\n\nMost deaths and injuries from pregnancy and childbirth can be prevented by \nlooking at and treating root causes. But to do so, a community must look beyond \nthe experiences of individual women. Look at the common dangers that affect all \nwomen in pregnancy and birth. And use the skills of every community member to \nprotect women's health. \n\nMidwives, who are most experienced with birth, can tell others in the \ncommunity why women are dying and being injured during birth. Families, \nmidwives, and other health workers and community members can work together \nto make changes, small and large, to improve health for all. When everyone in the \ncommunity becomes involved with health, we can do much more than one \nmidwife alone. \n\nHow to start \n\nLack of healthy food, dirty drinking water, lack of transportation in emergencies, \nand alcohol abuse are a few of the problems that contribute to serious health \nproblems for women. These can all be addressed when they are not considered \nindividual problems and when the whole community works together for change. \nBut it can be difficult to know where to start. A good first step is to meet with \ncommunity members to talk. If you teach birth classes to pregnant women, meet \nwith other midwives, or are a member of a social or church group, you can use that \ngroup to solve problems. \n\n\nWWW. \n\n\nA Book for Midwives (201 0) \n\n\n23 \n\n\nChapter 2: Treating health problems \n\n\nFirst, name the problems you are facing. \n\n\nYou have all read how to stay \nhealthy in pregnancy. But not \neveryone can do these things. Why? \n\n\nHow can we \neat well when \nthere is no \nmoney for \nfood? \n\n\nWe always have \nto wait hours to \nbe seen at the \nclinic. \n\n\nAfter you have named some of the problems in the community, choose what \nto work on first. It might be the problem that is the most common, the problem \nthat causes the most serious harm, or the problem that can be most easily solved. \nList every idea the group can think of to work on this problem. Then focus on \nsolutions that someone in the group can make happen. \n\n\nWe agree that the whole \\ \ncommunity can help \\ \npregnant women eat \\ \n\nbetter. But how? J \n\n\nI could plant' \nsome green \nvegetables in \nthe coffee field. \n\n\nWe should talk to t/re\\ \nstorekeeper. He should \\ \nsell more beans and \\ \n\nrice and less liquor! J \n\n\n24 \n\nA Book for Midwives (201 0) \n\n\n1*Ahn*ly?L \n\nwww. nesperian.org \n\n\nFinding root causes of health problems \n\n\nMake a plan. You will need \nto decide who will do each task, \nwhat they will need to do it, and \nwhen they will do it. \n\n\nI can pay for the seeds , \nbut we all must work \ntogether to plant and \ncare for them. \n\n\nBe sure to meet again to talk about how the plan is going. \n\n\n^ The seedlings are coming\\ \nup well. And everyone 1 \nhas been taking turns 1 \nwatering them J \n\n\nI I talked to the storekeeper , \n/ and he said he will not sell \nI beans — they don’t make \ny^^enough money for him. \n\n\ngoi \n\nstorekeeper together. \nIf we tell him we’ll stop \nbuying anything from \nhim , he may listen to \nour demands! \n\n\nMidwives can make change \n\nMidwives and the women they serve may face any kind of health problem, from \nsimple ones like nausea to serious ones like a bad hemorrhage. But when \nmidwives work carefully to discover causes, and use wise judgment and support \nfrom the community, they can solve nearly any problem, even many of the most \ndifficult ones. \n\n\nwww. nesperian.org \n\n\nA Book for Midwives (201 0) \n\n\n25 \n\n\nChapter 3 \n\nA woman's body in pregnancy \n\n\nIn this chapter: \n\nA woman's sexual and reproductive parts \n\nHow women become pregnant \n\nHow the baby grows 30 Menopause \n\nInfertility 30 \n\n\nWWW. \n\n\nnespefia.ri.org \n\n\nA woman's body \nin pregnancy \n\n\nIn this chapter, we describe the parts of a woman's body that are most affected by sex, \npregnancy, and birth. We call these parts sexual or reproductive parts. We also explain \nhow pregnancy happens, and how a woman's body changes during pregnancy. \n\n\nA woman's sexual and reproductive parts \n\nA woman's genitals (vulva) \n\n\nouter lips \n\ninner lips \n\nopening of \nthe vagina \n\n\noy clitoris \n\na very sensitive spot \nthat can give sexual \npleasure when touched \n\nurethra \n\n~ the opening that \nurine comes out of \n\n\nanus \n\nthe opening of \nthe rectum and \nintestine, where \nstool comes out \n\n\nThe pelvis \n\nThe bones below the belly \nare called the pelvis. \n\n\npelvis \n\n\n$ | , . \n\nI t pubic \n\n\nbone \n\n\nThe pelvis is shaped like a bowl \nwith a hole in the bottom. \n\n\nthrough the hole to get out. \n\n\n27 \n\n\nChapter 3: A woman's body in pregnancy \n\n\nThe womb, tubes, and ovaries \n\nThe womb (uterus) is a hollow muscle. It sits \ninside the pelvis. Monthly bleeding comes \nfrom the womb, and the womb is where the \nbaby grows during pregnancy. \n\n\nintestines \n\n\nkidney \n\n\nThe womb is \nin the woman's \nbelly along with \nher other organs. \n\n\nbladder \n\n\nIf you could see the womb inside a woman's belly, it would look like this: \n\nwomb \n\n\ntube \n\nThe tubes connect \nthe womb to the \n\n\ncervix \n\n\nThe cervix is the opening \nof the womb into the \nvagina. It is usually closed \nand plugged with mucus. \n\n\novary \n\nThe ovaries hold tiny \neggs. Some people \ncall eggs, \"the seeds \nof the woman.\" \n\n\nvagina \n\nThe vagina is the opening in \nthe outside of the woman's \nbody that leads to the cervix \nand womb. \n\n\nwww. nesperian.org \n\n\n28 \n\n\nA Book for Midwives (201 0) \n\n\nHow women become pregnant \n\n\nHow women become pregnant \n\nAbout once a month, a woman's Men make tiny cells called sperm inside \n\novary releases a tiny egg. The of their testicles. When a man ejaculates \n\negg moves down the tube and (comes), a fluid called semen comes \n\ninto the womb. out of his penis. Millions of sperm cells \n\ncome out in that fluid. \n\n\nThe semen and \nsperm travel through \nthis tube and out of \nthe penis. \n\ntesticle \n\nThe sperm is made \nin the testicles. \n\n\nIf a man ejaculates inside a woman's vagina during sexual intercourse, his \nsperm cells can travel through her vagina, through her womb, and into her tubes. \n\nIf the woman and man have sexual intercourse near the time of the month that \nthe woman's egg is moving down her tube, one of the man's sperm cells may meet \nher egg. The egg may then plant itself in the lining of the womb. If this happens, \nthe woman becomes pregnant. \n\n\nEvery month that the woman does not become pregnant, the bloody lining of \nher womb comes out about 2 weeks after she releases the egg. We call this \nmonthly bleeding, or menstruation. \n\n\nwww. nesperian.org \n\n\n29 \n\nA Book for Midwives (201 0) \n\n\nstaying well \n\n\nChapter 3: A woman's body in pregnancy \n\n\nHow the baby grows \n\n\nAfter a sperm and egg join inside a woman's womb, they combine to become one \ngroup of cells that multiply and grow into a baby. \n\nThe mother's blood contains oxygen from the air she breathes and nutrition \nfrom the food she eats. Her blood then passes air and food to the baby through the \ncord and placenta. \n\nDuring the first 3 months of pregnancy, it is hard to see much happening from \nthe outside. But inside the womb, the baby is forming organs, bones, and other \nbody parts. During these early months, it is especially important that a pregnant \nwoman avoid noisonous \n\n\nWhen a person has difficulty having a child, he or she \nis infertile. For a couple that wants to have children, \ninfertility can bring sadness, anger, or shame. \n\nOften the woman is blamed when she does not \nbecome pregnant. Even if the couple gets medical help, \nmany doctors will check only the woman for fertility problems. \n\nBut often the man is the one who is infertile. Neither men nor women should be \nblamed for infertility. And both need support during this difficult time. \n\n\nThis is what \n\n\nyou would \nsee if you \ncould look \ninside a \npregnant \nwoman's \nwomb. \n\n\nThe baby is connected to the \nplacenta (afterbirth) by a cord, \n\n\nInside the womb, the baby \nfloats in a bag of fluid called \n\n\ninside of the mother's womb. \n\n\namniotic fluid (the bag of waters). \n\n\nand the placenta is attached to the \n\n\nInfertility \n\n\n30 \n\n\n•I Iu \n\nnespenan.org \n\n\n4lhl«jUA!lL \n\n\nA Book for Midwives (201 0) \n\n\nWWW. \n\n\nHow women become pregnant \n\n\nInfertility has many causes. Some cannot be prevented. But \nmany causes of infertility are preventable. \n\n• Sexually transmitted infections can leave scars \ninside a man's or woman's reproductive parts \nthat prevent pregnancy. \n\n• Illnesses such as diabetes, tuberculosis, \nmalaria, and mumps can cause infertility. \n\n• Dangerous chemicals from \npesticides, cleaning products, or \nfactories can get into the air, water, \n\nor food. These chemicals can make it Even washing clothes that have dangerous \ndifficult for a woman to get pregnant, chemicals on them can harm fertility, \nor can harm the growing baby. \n\n• Smoking, chewing tobacco, drinking a lot of alcohol or using drugs can all \nharm fertility. \n\nThere are other causes of infertility that are not preventable. To learn more, look \nat a general health book like Where Women Have No Doctor. \n\n\nMenopause \n\n\nWhen women grow older, they stop bleeding each month (menopause). They also \nstop producing eggs and lose the ability to become pregnant. \nThis may happen suddenly, or slowly over 1 or 2 years. For \nmost women, menopause happens when they are between \n45 and 55 years old. \n\n\nDuring menopause, many women have some of these signs: \n\n• changes in monthly bleeding before it stops completely \n\n• suddenly feeling very hot and sweaty (hot flashes) \n\n• vagina becomes smaller and more dry \n\n• sudden changes in feelings \n\nMany women are relieved when they do not have to worry \nabout pregnancy anymore. As elders, women can share the \nwisdom of their years of life experience. \n\nMen make sperm through most of their lives, even when \nthey are very old. \n\n\nwww. nesperian.org \n\n\n31 \n\nA Book for Midwives (201 0) \n\n\nstaying well \n\n\nChapter 4 \n\nHelping women stay healthy \n\n\nn this chapter: \n\n\nEating well \n\nTalking to women about food 34 \n\nEat more food 34 \n\nEat a variety of foods 34 \n\nEat these 5 important vitamins \nand minerals every day 36 \n\n\nIdeas about food affect \nwomen's health \n\nEating well with little money \n\n\n33 \n\n39 \n\n41 \n\n\nCaring for the body for good health \n\n\nKeep clean 42 \n\nCare for the teeth and mouth 43 \n\nExercise 43 \n\n\n,42 \n\n\nSleep, rest, and relax 44 \n\nEnjoy the pregnancy 44 \n\n\nThings to avoid during pregnancy and breastfeeding 45 \n\nStay away from people with rubella Stay away from chemicals \n\n\nand other sicknesses \n\n45 \n\nand fumes \n\n47 \n\nAvoid taking medicines \n\n45 \n\nAvoid smoking, alcohol, \n\nand other drugs \n\n46 \n\nwww. nespenan.org \n\n\n32 \n\n\nHelping women \nstay healthy \n\n\nA woman who eats well and takes good care of her body is much more likely to \nhave a healthy pregnancy and healthy baby. In fact, the ways to stay healthy listed \nin this chapter can be used by women and their families to stay well throughout \ntheir whole lives. \n\n\nEating well \n\nEating well means eating enough food and eating \na variety of healthy foods. \n\nEating well: \n\n• helps a woman resist illness and stay healthy. \n\n• keeps a woman's teeth and bones strong. \n\n• gives a woman strength to work. \n\n• helps the baby grow well in the mother's womb. \n\n• helps prevent heavy bleeding after birth. \n\n• helps a mother recover her strength quickly \nafter birth. \n\n\nEating well helps a \nwoman and her baby stay \nhealthy and strong. \n\n\nProblems from poor nutrition (not eating well) \n\n\nPoor nutrition can cause tiredness, weakness, difficulty \nfighting infections, and other serious health problems. \n\nPoor nutrition during pregnancy is especially \ndangerous. It can cause miscarriage or cause a baby to be \nborn very small or with birth defects. It also increases the \nchances of a baby or a mother dying during or after birth. \n\n\n1 Or \n\nwww. nesperian.org \n\n\n33 \n\n\nChapter 4: Helping women stay healthy \n\n\nTalking to women about food \n\n\nTalk to women about the food they eat. The earlier women start eating healthier \nfoods, the better chance they have to stay healthy, to have normal births, and to \nhave healthy babies. ^ \n\n\nTo find out whether a woman is \neating well, ask her what she \nusually eats, and how much. For \nexample: \"What did you eat \nyesterday?\" Be sure to tell her what \nis healthy about what she eats. \nThen make a suggestion for how \nshe could eat better. \n\n\nI eat cassava \nevery day, and I \nusually have \nsome fish — or \nbeans cooked \nwith onions and \ntomatoes, and I \ndrink soda pop. \n\n\nThat sounds good. \nCassava gives energy. \n\nBeans and fish give \nstrength. If you drink \nfruit juice instead of \nsoda pop, and you also \neat some green \nvegetables, you will \nget more vitamins. \n\n\nEven if a woman knows the best \nfoods for health, she may not eat them. Many \nfamilies cannot afford to buy enough food or a \nwide variety of foods. Other women simply may \nnot like the taste of some foods. To help a \nwoman eat better, suggest healthy foods that she can and will choose to eat. \n\nEat more food \n\nPregnant women and women who are breastfeeding need to eat more than usual. \nThe extra food gives them enough energy and strength, and helps their babies grow. \n\nSome pregnant women feel nauseated and do not want to eat. But pregnant \nwomen need to eat enough — even when they do not feel well. Simple foods like \nchapatis, tortillas, or rice can be easier for these women to eat. \n\nEat a variety of foods \n\nIt is important for pregnant \nwomen (like everyone else) \nto eat different kinds of \nfood: main foods \n(carbohydrates), \ngrow foods (proteins), \nglow foods (vitamins \nand minerals), and \ngo foods (fats, oils, \nand sugar), along with \nplenty of fluids. \n\n\nFor a healthier body, \neat many kinds of foods. \n\n\n34 \n\n\nA Book for Midwives (201 0) \n\n\nwww. Hesperian. ore \n\n\nEating well \n\n\nMain foods (carbohydrates) \n\nIn most parts of the world, people eat one main food at each meal. This main food \nmay be rice, maize, wheat, millet, cassava, taro, plantain, breadfruit, or another \nlow-cost starchy food. These foods give the body energy. But to grow and stay \nhealthy, the body needs other types of food too. \n\nGrow foods (proteins) \n\nGrow foods contain protein, which is needed for the growth of muscles, bones, \nand strong blood. Everyone needs protein to be healthy and to grow. \n\nSome grow foods high in proteins: \n\n\n• meat, fish, and insects \n\nNote: Meat, fish, and cheese are nutritious foods but they can carry \nparasites or disease when they are eaten raw. Pregnant women should \nonly eat fish, meat, or cheese that is well cooked or pasteurized. \n\nFish, especially fatty fish, can also contain mercury and other poisons \nbecause water is often contaminated. Pregnant women \nshould avoid fatty fish, to be safe. \n\n\nFruits and vegetables are high in vitamins and minerals. It is \nimportant for women to eat as many different fruits and vegetables as they can. \n\nGo foods (sugars and fats) \n\nGo foods contain sugars and fats, which give the body energy. Everyone needs \nthese foods to be healthy. \n\nThese days, many people eat more sugars and fats than they need. That is \nbecause more people drink sugary soda pop, or eat foods that come from packages \ninstead of foods made at home. These packaged, sugary foods are expensive and \nnot as healthy. They also damage the teeth. It is better to eat go foods that are \nnatural, not packaged. \n\n\nand lentils) \n\n• nuts and seeds \n\n\n• legumes (beans, peas, \n\n\n• eggs \n\n• cheese, milk, \n\n\nand yogurt \n\n\nGlow foods (vitamins and minerals) \n\nGlow foods contain vitamins and minerals, which help \nthe body fight infection and keep the eyes, skin, and \nbones healthy and strong. \n\n\nSome healthy go foods \nhigh in sugars: \n\n• fruit \n\n• honey \n\n• molasses \n\n\nSome go foods \nhigh in fats: \n\n\nnuts and seeds \navocados \n\nvegetable oil, \nbutter, ghee, and lard \n\nfatty meat \n\n\nWWW. \n\n\nTian.org \n\n\n35 \n\n\nA Book for Midwives (201 0) \n\n\nChapter 4: Helping women stay healthy \n\n\nEat these 5 important vitamins and minerals every day \n\nPregnant and breastfeeding women need more of five vitamins and minerals — \niron, folic acid, calcium, iodine, and vitamin A — than other people do. Pregnant \nwomen should try to get these vitamins and minerals every day because the baby \nneeds them to grow and be healthy. Every pregnant woman needs enough for the \nbaby and for herself. \n\nIron \n\nIron helps make blood healthy and prevents anemia (weak blood, see page 116). \n\nA pregnant woman needs a lot of iron to have enough energy, to prevent too \nmuch bleeding at the birth, and to make sure that the growing baby can form \nhealthy blood and store iron for the first few months after birth. \n\nThese foods contain a lot of iron: \n\n• beans, peas, and lentils \n\n• sunflower, pumpkin, and squash seeds \n\n• dark green leafy vegetables \n\n• breadfruit \n\n• yams \n\n• hard squash \nmolasses \n\n\nmeat (especially liver, kidney, and \nother organ meats) \n\npoultry (birds) \n\ngrasshoppers, crickets, and termites \nfish, clams, and oysters \n\n\nOther ways to get more iron: \n\n• Eat iron foods with citrus fruits or tomatoes. The vitamin C in these foods \nhelps a woman absorb iron into her system. \n\n• Cook food in iron pots or add a clean piece of iron — like an iron nail — \nto the cooking pot. Only use a nail that you know is made of pure iron, \nnot a mix of metals. \n\n• Put a clean piece of pure iron, like an iron nail, in a \nlittle lemon juice for a few hours. Drink the juice \nmixed with clean water. \n\nIt can be difficult for a pregnant woman to get enough \niron, even if she eats iron-rich foods every day. If possible, \nshe should also take iron pills or iron syrup. These \nmedicines may be called ferrous sulfate, ferrous gluconate, \nferrous fumerate, or other names. \n\n\nIn many places health centers will give iron pills to \npregnant women. Sometimes iron pills are combined with folic acid. The iron pills \nmay make it hard for the woman to pass stool (constipation), and her stool may \nturn black. These problems should get better in a few days. (See page 76.) \n\n\nWWW \n\n\n.nespenan.org \n\n\n36 \n\n\nA Book for Midwives (201 0) \n\n\nEating well \n\n\nHookworm and malaria can cause anemia \n\nWomen with hookworm are likely to have anemia. Hookworm can \neasily be treated with mebendazole or albendazole, though these drugs \nshould not be taken in the first 3 months of pregnancy. These drugs \nhave not been tested enough to be sure that they are safe for women who \nare in the later months of pregnancy or who are breastfeeding. However, \nmost doctors believe that the benefit of treating hookworm is greater \nthan the possible harm of these medicines. \n\nIf hookworm is common in your community, ask your local health \nauthority what treatment is recommended for pregnant women. \n\nMalaria can also cause anemia and other serious problems in \npregnancy. See page 98 for how to prevent or treat malaria. \n\n\nFolic acid (folate) \n\nLack of folic acid can cause anemia in the mother and severe birth defects in the \nbaby. To prevent these problems, it is most important for a woman to get enough \nfolic acid before she gets pregnant and in the first few months of pregnancy. \n\n\nThese foods contain a lot of folic acid: \n\n\ndark green leafy vegetables \n\nmeat (especially liver, kidney, \nand other organ meats) \n\npeas and beans \n\nsunflower, pumpkin, and \nsquash seeds \n\n\nwhole grains (brown rice, \nwhole wheat) \n\nfish \neggs \n\nmushrooms \n\n\nSome women also take folic acid pills. \n\n\nFolic acid pills \n\n• take 0.5 to 0.8 mg (500 to 800 meg) folic acid \n\n\nby mouth, 1 time each day \n\n\nwww. JlCSpCri3Tl.org \n\n\nCalcium \n\nA growing baby needs a lot of calcium to \nmake new bones, especially in the last few \nmonths of pregnancy. Women need \ncalcium for strong bones and teeth. \n\n\n37 \n\n\nA Book for Midwives (201 0) \n\n\nChapter 4: Helping women stay healthy \n\n\nThese foods contain a lot of calcium: \n\n• milk, curd, yogurt, and cheese \n\n• ground sesame (tahini) \n\n• almonds \n\n• green leafy vegetables \n\n\n• yellow vegetables (hard squash, yams) \n\n• shellfish \n\n• lime (carbon ash) \n\n• bone meal and eggshells \n\n\nWomen can also get more calcium in these ways: \n\n• Soak bones or eggshells in vinegar or lemon juice for a few \nhours. Then use the liquid to make soup or eat with other foods. \n\n• Add lemon juice, vinegar, or tomatoes when cooking bones. \n\n• Grind eggshells into a fine powder and mix into food. \n\n• Soak maize in lime (carbon ash) before cooking it. \n\n\nIodine \n\nIodine prevents goiter (swelling of the throat) and other problems in adults. Lack \nof iodine in a pregnant woman can cause her child to have hypothyroidism \n(cretinism), a disability that affects thinking and brain development. \n\nThe easiest way to get enough iodine is to use \niodized salt instead of regular salt. \n\nThese foods contain a lot of iodine: \n\n• shellfish (like shrimp) \n\n• fish \n\n• seaweed \n\n• egg yolks \n\n• liver \n\nIf hypothyroidism or goiter are common in your \narea, find out if the local health ministry will give \niodized oil by mouth or iodine by injection. If not, \nwomen can make iodine solution at home with polyvidone iodine. \n\n\nTo make an iodine solution to drink \n\nAdd 1 drop of Lugol's iodine to 1 glass of clean drinking water or milk. \n\np In places where goiter or cretinism are common, everyone except \nbreastfeeding babies should drink 1 glass of this iodine solution \n\n0 every month of his or her life. This is especially important for children \n\nand pregnant women. Do not take more iodine than this. Too much \n. ■ \n\nis dangerous. \n\nStore iodine at room temperature, and in dark containers to protect \nit from light. \n\n\n38 \n\n\nA Book for Midwives (201 0) \n\n\nwww. Hesperian, or \n\n\nEating well \n\n\nVitamin A \n\nVitamin A prevents night blindness and helps fight \ninfections. Lack of vitamin A also causes blindness in \nchildren. A woman needs to eat plenty of vitamin A \nduring pregnancy and while breastfeeding. \n\nDark yellow and green leafy vegetables and yellow fruits have vitamin A. \n\n\nAlong with eating healthy foods, women should drink plenty \nof clean water and other fluids every day. Fruit juices, coconut \nwater, animal milks, and many herbal teas are all healthy fluids \nto drink. \n\n\nIdeas about food affect women's health \n\nSome beliefs about foods are harmful — especially when people believe that \nwomen should not eat as much as men do, or should not eat a variety of foods. \n\nIt is not safe for girls to be fed less than boys \n\nGirls need as much food as boys — to grow and learn and work. If a girl does not \nget enough food, her bones may not grow well. This can cause serious problems \nduring labor when the girl becomes a woman and has babies of her own. \n\nWhen a woman must feed her family first, \nshe may not get enough to eat \n\nA woman may be taught to feed her family before \nherself. She eats only what is left and often does \nnot get as much as others in the family. This is \nnever healthy. And when a woman is pregnant, \nor has just had a baby, it can be very dangerous. \n\nIf the family will not help the woman eat \nenough, she may need to hide food, eat while \nshe is cooking, or eat while her husband is \nout of the house. \n\nPackaged and processed foods are rarely as good as homemade \n\nPeople are eating more and more packaged and processed foods. Some people like \nthe taste, and some people think that packaged foods are healthier. \n\nPackaged foods may be advertised as the healthiest choice, but this is rarely the \ntruth! Advertisers will say anything just to sell products. Some packaged foods are \nfortified with vitamins and minerals, but our bodies cannot use these added-on \nvitamins as well as our bodies use the vitamins that we get from eating whole, \nfresh foods. Most packaged foods contain more sugar, salt, and fat than we need. \n\nMany are full of chemicals to keep the food looking and tasting fresh, and some of \nthese chemicals have not been carefully tested to be sure of their safety. \n\n39 \n\nA Book for Midwives (201 0) \n\n\nChapter 4: Helping women stay healthy \n\n\nAvoiding foods can be dangerous \n\nIn many places, pregnant women are told not to eat certain foods. In these \ncommunities, people believe that these foods will harm the baby. At the same \ntime, a doctor or a midwife may tell a woman it is important to eat those same \nfoods. This can be confusing for the woman. \n\nAvoiding foods can be \ndangerous. For a woman to \nbe healthy during and after \npregnancy, she must eat a \nwide variety of foods — main \nfoods, grow foods, glow \nfoods, and go foods. Eating \nonly one kind of food is not \nenough. \n\nIf a woman does choose to \navoid certain foods, make sure \nshe is getting enough of each \nkind of food, and enough \nvitamins and minerals from her food. \n\n\nEveryone needs to eat a wide variety of foods. \n\n\nFinding creative answers \n\nBeliefs about food can be hard to change. But you may find ways to help \nwomen eat better without working against their beliefs. This example is \nbased on a true story: \n\nMaria is a midwife in Guatemala. She and her \npeople believe that some foods are \"hot\" foods, and \nsome foods are \"cold\" foods. They believe that \npregnant women should not eat cold foods. \n\nTo Maria and her people, beans and eggs are cold \nfoods (even when they are cooked). But Maria knows \nthat beans and eggs are good, low-cost ways for \npregnant women to get the protein and iron they need. \n\nMaria wants pregnant women to eat well, but they \nwill not eat cold foods. And Maria too thinks that cold \nfoods may not be good for pregnant women to eat. Her solution is simple \nand smart. She tells pregnant women to eat beans and eggs with a little hot \npepper or another hot food. This way, the foods will not be cold anymore. \n\nMaria has found a creative answer to a problem. She has found a way for \npregnant women to eat better and has shown respect for the beliefs of her \ncommunity. \n\n\n40 \n\n\nA Book for Midwives (201 0) \n\n\nwww. nesperiaii.org \n\n\nEating well \n\n\nEating well with little money \n\nThe biggest cause of poor nutrition \nis poverty. Rich people in wealthy \ncountries can buy any foods they \nwant, while those in poor \ncommunities cannot. And \nwithin each community, some \ncan afford to eat better than \nothers. A few people own most \nof the land or businesses, and \nmake money off of the work of \nothers. Even within each \nfamily, a father may eat better \nthan his wife or children. \n\nTo learn more about the \nroot causes of poverty and \nways to work for change, \nsee the books Where There Is \nNo Doctor and Helping \nHealth Workers Learn. \n\n\nThe problems of hunger and poor nutrition will not be \nsolved until we all share with each other fairly. \n\n\nEven a very poor family can eat better by \nspending money wisely. A father who buys alcohol \nand tobacco could instead buy nutritious food or \nhe could buy a hen to lay eggs. A mother who buys \nher children sweets or soda pop could instead buy \neggs, beans, or other low-cost healthful foods. \n\nHere are some ideas that families can use to eat \nbetter with little money: \n\n\nBreast milk \n\nBreast milk costs nothing, and has all the nutrition a baby needs. Young children \ndo not need fortified milks — especially if they are still breastfeeding and eating \nother foods. \n\n\nBeans , peas , and lentils \n\nBeans and other legumes have a lot of \nprotein and vitamins, and they usually \ndo not cost much. They have even \nmore vitamins if they are sprouted \nbefore being eaten. \n\nGrow beans this year. Next year, maize. \n\nPlanting legumes makes soil richer. \n\nOther crops will grow better in a field where legumes once grew. \n\n\nwww. nespenan.org \n\n\nA Book for Midwives (201 0) \n\n\n41 \n\n\nChapter 4: Helping women stay healthy \n\n\nLess expensive meats and animal products A. \n\nBlood and organ meats like liver, heart, and kidney have a \nlot of iron and may cost less than other meats. Fish and \n\nchicken are as healthy as other meats, and usually cost less — JjL _ \n\nespecially for a family that fishes or raises their own chickens. ^ C 5o \n\nEggs have a lot of protein, iron, and vitamin A. Eggs give more protein for less \nmoney than almost any other food. \n\nWhole grains \n\nGrains, like wheat, rice, and corn, are more nutritious when they have not been \nrefined (processed to take out the color). Taking out the color takes out healthy \nthings too. White bread and white rice have less vitamins, minerals, and proteins \nthan brown bread or brown rice. \n\n\nVegetables and fruits \n\nWhen vegetables are boiled or steamed, some \nof the vitamins from the foods go into the \ncooking water. Use this water to make soups. \n\n\nUse only a little water \nto cook vegetables. \n\n\nThe outside leaves of plants are usually thrown away, \nbut sometimes they can be eaten. The leaves of the cassava \nplant have more vitamins and protein than the root. \n\nMany wild fruits and berries are rich in vitamins and \nnatural sugars that give energy. \n\n\nAvoid buying vitamins \n\nMost of the time people can get enough vitamins and minerals by eating a variety \nof foods. Buying vitamins is usually a waste of money. \n\nBut pregnancy and breastfeeding are times that women may need to take extra \nvitamins — more than what they can get from food. Vitamin pills work as well as \nvitamin injections, and cost less. \n\n\nCaring for the body for good health \n\nFor a woman to stay healthy in pregnancy — or anytime — it is wise for her to \nkeep clean, exercise, and get plenty of rest. \n\nKeep clean \n\nKeeping the body clean helps prevent infections. If possible, the mother should \nregularly wash her body, including her genitals, with clean water. \n\n\n42 \n\nA Book for Midwives (201 0) \n\n\n1*Ahn*ly?L \n\nwww. nesperian.org \n\n\nCaring for the body for good health \n\n\nCare for the teeth and mouth \n\n\nHealthy teeth help a person's whole body be healthy, and care for the teeth \nis especially important in pregnancy because unhealthy teeth can lead to \ngum infections. This can cause a baby to be born too early. \n\nIn some places there is a saying, \"Have a baby, lose a tooth.\" But this does not \nhave to be true! A woman can protect her teeth in these ways: \n\n\n• Eat calcium-rich foods. \n\n• Avoid sweets, candy, and soda pop. \n\n• Clean the teeth after every meal with a soft brush, \ntooth stick, or rough cloth. Toothpaste, salt, \n\nor plain water on the brush are helpful but \nnot necessary. \n\nTo make a tooth-cleaning stick: \n\n\nClean the surfaces of all the \nteeth, between the teeth, \nand the gums every day. \n\n\nSharpen this end to clean Chew on this end and Or tie a piece of rough cloth \n\nbetween the teeth. use the fibers as a brush. on the end of a stick. \n\n\nIf possible, everyone should see a dentist or dental worker regularly. \n\n\nExercise \n\n\nExercise makes a woman's body \nstronger. During pregnancy, exercise \nhelps her body get ready for labor \nand birth. Exercise can also help a \nwoman have energy and feel happy. \n\nMany women get all the exercise \nthey need by hauling water, working \nin the fields, milling grain, chasing \nafter children, and walking up and \ndown hills. \n\nWomen who work sitting or \nstanding (in offices, stores, or \nfactories, for example) or who do not \nmove around much during the day \nusually need more exercise. They can \ntake long walks, dance, do physical \nwork, or find another way to move. \n\n\n1 l IT rfif \n\nwww. nesperian.org \n\n\n43 \n\nA Book for Midwives (201 0) \n\n\nChapter 4: Helping women stay healthy \n\n\nSqueezing exercise (Kegels) \n\nThe squeezing exercise strengthens \nmuscles in the pelvis and vagina. \n\nDoing the squeezing exercise can help \nto: \n\n• prevent leaking urine. \n\n• prevent the vagina from tearing \nduring birth. \n\n• speed healing after birth. \n\n• increase sexual pleasure. \n\nA woman can learn this exercise \nwhile she is urinating. As the urine \ncomes out, she should squeeze the muscles in her vagina until the urine stops. \nOnce she learns how to squeeze these muscles, she should only do it when she is \nnot urinating. \n\nThe squeezing exercise is helpful at all times, not just during pregnancy. \n\nIf possible, women should practice at least 4 times a day, doing at least \n10 squeezes each time. \n\n\nSleep, rest, and relax \n\nSleep and rest help women stay strong and resist sickness. Getting enough rest also \nhelps prevent high blood pressure, sick babies, and other problems. \n\n\nMany women must work all day in fields, factories, \nor stores. Then they must also haul water, find fuel, \nmill grain, cook, clean, and care for their families. \n\nThis can be very hard at any time. It can be especially \nhard for pregnant women who need more rest than \nusual. \n\nExplain to pregnant women that it is important for \nthem to rest for a few minutes every 1 or 2 hours. \n\nHelp the woman's family understand why it is \nimportant for her to rest and sleep. \n\n\nEnjoy the pregnancy \n\nIf women have enough food, rest, and care, pregnancy \ncan be a wonderful time. \n\nMany communities have rituals and practices that honor \npregnant woman. People help her with her work, bring her \nspecial foods, or give her massages or gifts. Customs like \nthese help a woman get the food and rest she needs, and \nhelp her feel good about herself and her pregnancy. \n\n\n44 \n\n\nA Book for Midwives (201 0) \n\n\nwww. nesperian.org \n\n\nThings to avoid during pregnancy and breastfeeding \n\n\nThings to avoid during pregnancy \nand breastfeeding \n\nSicknesses, drugs, and poisonous chemicals are not healthy for anyone. They are \nparticularly dangerous in pregnancy and while breastfeeding. The following things \nare the most dangerous in the first 3 months of pregnancy, but they can be \ndangerous at all times. \n\n\nStay away from people with rubella and other sicknesses \n\n\nPregnant women \nshould stay away \nfrom people with \nsicknesses or rashes. \n\n\nIt is best for pregnant women to stay away from people who \nare sick. This will help protect them from becoming sick \nthemselves. \n\nSome sicknesses are particularly dangerous to pregnant \nwomen or their babies. Rubella (German measles) is one \nsickness that can cause serious birth defects or disabilities in \nthe baby, including deafness and heart problems, and can \neven cause death. \n\n\nAvoid taking medicines \n\nWhen a woman takes medicines, they pass through her \nblood to her baby. Medicines that are safe for a grown \nwoman or even a child can be dangerous to the tiny \nbaby inside the womb. \n\nCough syrups, pain relievers, some modern \nmedicines, and some plant medicines can all be \ndangerous. Some of them can cause birth defects or \ndisabilities in the baby, including disabilities that \naffect thinking or the brain. \n\nIf possible, pregnant women and women who are \nbreastfeeding should not take medicines. If a woman is \nsick and needs medicine, find out if this medicine is \nsafe in pregnancy or while breastfeeding. Look in the green medicine pages at the \nend of this book (see page 463) or ask a doctor if the medicine is safe. If plant \nmedicines are used in your community, try to learn which ones are safe during \npregnancy and breastfeeding. \n\nMost of the medicines we recommend in this book are safe to take during \npregnancy or breastfeeding. (If they are not safe, we will include a warning about \nwhen they can be dangerous.) But even drugs that are safe should only be taken \nwhen they are truly needed. Rest, water, and healthful foods are often enough to \ncure sicknesses and other problems. \n\n\nPregnant women should \nonly take medicines that \nare safe in pregnancy and \nthat are truly needed. \n\n\nwww. nesperian.org \n\n\n45 \n\nA Book for Midwives (201 0) \n\n\nChapter 4: Helping women stay healthy \n\n\nAvoid smoking, alcohol, and other drugs \n\nCigarette smoke, alcohol, and other drugs are all harmful to \nthe mother. When a woman smokes, drinks, or takes drugs, \nthey also pass through her blood to her baby. \n\nSmoking is dangerous for anyone. It can lead to serious \nproblems including cancer. When a pregnant woman \nsmokes, or even when she breathes the smoke from someone \nnear her, her blood vessels get smaller and do not carry as \nmuch air or food to her baby. Because of this, babies of \nwomen who smoke are more likely to be small or sick. \n\nDrinking a lot of alcohol can be dangerous for anyone. \n\nHeavy drinking can lead to many illnesses including serious \nproblems of the liver. When a pregnant woman drinks, even \njust 1 or 2 drinks a day, her baby can have birth defects or \ndisabilities that affect the brain. \n\nSome drugs, particularly opium, heroin, cocaine, and \nbarbiturates, are very addictive and dangerous. When a \npregnant woman takes these drugs, her baby can be born \nwith a drug addiction or with other serious health problems. \n\nIf you work with a woman who may be addicted to \nalcohol or other drugs, try to find help for her. She may be \nable to stop if she understands the risks to her and her baby. \n\nAdvise her to stay away from people who are smoking, drinking, or taking drugs. \n\nYou may be able to help her find others in your community who have \nstopped using alcohol or drugs and who meet to support each other. The book \nWhere Women Have No Doctor has more ideas about how to help someone stop \nabusing alcohol and drugs. \n\n\n46 \n\nA Book for Midwives (201 0) \n\n\nWhatever a mother \nputs into her body \npasses to her baby. \n\n\nThings to avoid during pregnancy and breastfeeding \n\n\nStay away from chemicals and fumes \n\nStrong chemicals used for cleaning, and poisons used to kill pests in the fields or \nat home, are dangerous for everyone. They are especially dangerous to women \nwho are pregnant or breastfeeding. These chemicals can cause miscarriage, \ninfertility, birth defects, cancer, and other \nillnesses. \n\nAny chemical with a strong smell is \nprobably not safe. Many dangerous \nchemicals have no smell at all. \n\nIf possible, everyone should avoid \nthese dangerous chemicals. But a \npregnant woman should have no contact \nwith them. She should not use them \nherself or breathe chemical fumes or dust. \n\nHer family should not store food in \ncontainers that once had chemicals inside. \n\nTiny amounts of the chemicals may be left \nin the container even after it is washed — \nenough to harm a person's health! \n\nFamilies should try not to use \nchemicals at all. But many people who \nwork with chemicals have no choice. It is \npart of their job at a factory, on a farm, \ncleaning, or somewhere else. People who use chemicals at work may be able to \ntalk to the other workers about the problem. Maybe all the workers together can \ntalk to the owner about using fewer chemicals or using safer ones. \n\n\nPoisonous chemicals include: \n\n• pesticides (chemicals that \nkill bugs or weeds) used in \nfarming. \n\n• pesticides used at home to \nkill bugs or rodents. \n\n• strong cleaners and solvents. \n\n• some kinds of glue and paint. \n\n• gasoline, oil, and other fuels. \n\n\nIf someone in the family must work with chemicals, he or she should: \n\n• use as few chemicals, and as little of each one, as possible. \n\n• keep chemicals away from places where food is stored. \n\n• keep chemicals away from children. \n\n• avoid breathing chemicals. Wear a mask or at least cover the mouth \nand nose, and try to work where there is a good air flow. \n\n• avoid getting chemicals on the skin. Wear gloves, long sleeves, and \nclosed shoes. \n\n• after working with chemicals, change clothes before coming in \nthe house. Pregnant women should not wash these clothes. \n\n\n1 l ft li t \n\nwww. nesperian.org \n\n\n47 \n\nA Book for Midwives (201 0) \n\n\nChapter 5 \n\nPreventing infection \n\n\nIn this chapter: \n\nPreventing infection saves lives 49 \n\nInfection is caused by germs 49 How germs get into the body 50 \n\nPrevent infection by keeping germs away 52 \n\nClean your hands and wear protective clothing 53 \n\nWash your hands often 53 Protect yourself from infection 56 \n\nWear gloves 54 \n\n\nClean the space and bedding 57 \n\nClean the space 57 Clean or sterilize the bedding 58 \n\n\nClean and sterilize tools \n\n\nSoak your tools 59 \n\nClean your tools 59 \n\nSterilize your tools 59 \n\nBaking 61 \n\nPressure steaming 61 \n\n\nGet rid of wastes safely \n\nBurying wastes 68 \n\n\n59 \n\nBoiling 62 \n\nSteaming 62 \n\nUsing chemicals 63 \n\nSome equipment needs special care . . 65 \n\n\n,67 \n\n\nwww.ilCSpcrian.org \n\n\n48 \n\n\nPreventing \n\ninfection \n\n\nPreventing infection saves lives \n\nInfection makes people sick and can even kill them. It is one of the most common \ncauses of death after childbirth. Procedures that involve putting medical tools \ninside a woman's womb, like inserting an intrauterine device (IUD) or doing \nmanual vacuum aspiration (MVA), can also cause infection. Much of the work of a \nmidwife, and any procedure inside the womb (invasive procedure), can only be \nsafe if you are able to follow the steps we outline in this chapter to prevent \ninfection. \n\nThis chapter explains how to avoid infection by killing or \ncontrolling harmful germs. Germs are organisms that carry \nsickness. Germs are everywhere, but \nthey are so small that they can only be \nseen with a microscope. The dangerous \ngerms in blood, stool, body fluids \n(like semen and amniotic waters), and dirt \ncan cause serious sickness when they get Germs live in \n\ninto someone's body. body fluids, \n\nlike blood. \n\n\nInfection is caused by germs \n\nSome sicknesses, like arthritis, diabetes, asthma, and epilepsy, are not caused by \ngerms. They cannot be passed from one person to another. \n\nOther sicknesses, like measles, hepatitis, tetanus, womb infection, HIV, and the \nflu, are called infections and are caused by germs. People get sick when the germs \nthat cause these infections get inside their bodies. \n\n\nGerms can live on \ntools, even tools \nthat look clean. \n\n\nwww. nesperian.org \n\n\nChapter 5: Preventing infection \n\n\nHow germs get into the body \n\nGerms can get inside the body in different ways. \n\n\nSome germs pass through semen or vaginal mucus \n\n(body fluids) when people have sex. HIV and other \nsexually transmitted infections like chlamydia and \ngonorrhea can spread this way. \n\n\nSome germs pass through blood when the blood or body \nfluid of an infected person get into a cut or through the \nskin — like with a needle that has been used for piercing \nor injections. HIV, hepatitis B, and hepatitis C can spread \nthis way. \n\n\nSome germs live in dirty water and pass when people \ndrink it. Cholera and diarrheal diseases spread this way. \n\n\nSome germs live in dirt, on skin, or in the air, and are not \n\ndangerous unless they get into a person's blood. These germs \ncan get into the blood when an instrument that has germs \non it is used inside a woman's womb, or to cut the skin or a \nbaby's cord. Tetanus and womb infection can spread this way. \n\n\nSome germs pass through the air when a sick person \ncoughs or sneezes. Colds, flu, and tuberculosis can \nspread this way. \n\n\nKeep sick people away from births \n\nOne simple thing midwives can do to prevent \ninfection is to keep sick people away from women \nwho are pregnant or giving birth. Keep \nanyone who has a sore throat, cough, fever, or \nother illness that passes through germs away \nfrom births. And do not let anyone with a sore \non his or her hands or face touch a new baby. \n\n\n50 \n\n\nA Book for Midwives (201 0) \n\n\nwww. Hesperian. ore \n\n\nPreventing infection saves lives \n\n\nIf you are sick but you must go \nto a birth, you can cover your mouth \nand nose with a scarf, a folded cloth \nor a mask. Wash your hands often \nand cover your mouth when you \nsneeze or cough. Be sure to wash \nyour hands after each time you \nsneeze or cough. Try not to touch \nthe new baby too much. \n\n\nAnyone may carry germs that cause sickness \n\nPeople do not always know that they have an infection. And there is no way to tell \nfor sure what germs a person has just by looking at her. Some people have germs \nin their blood or other body fluids but do not seem sick. \n\nTo be safe, and to stop the spread of dangerous \ninfections like hepatitis and HIV, health workers \nmust treat everyone as if they might have dangerous \ngerms in their body fluids. Health workers can \nprevent germs from spreading: \n\n• by wearing gloves and \nother protective clothing, \nto prevent blood and \nother body fluids that \ncontain germs from \ngetting on themselves or \nothers. \n\n• by cleaning and sterilizing the \ntools they use during births and \nother procedures. \n\nNote: Good general health can help avoid infection. Healthy eating, \nenough rest, and emotional and spiritual well-being are all important \nfor staying healthy. Sometimes they are enough to help people fight \ngerms that get inside the body so the person does not get sick. \n\nBut during birth and invasive medical procedures, a woman's body is \nmore open and vulnerable to infection, and good general health is \nusually not enough. Germs that are usually kept out of the body can \nget into the womb. Any cut in the skin also makes a person more \nvulnerable to infection because the skin usually helps keep germs out \nof the body. Even an injection can cause an infection if the syringe has \nharmful germs on it. \n\n51 \n\nA Book for Midwives (201 0) \n\n\nwww. nesperian.org \n\n\npreventing \n\ninfection \n\n\nChapter 5: Preventing infection \n\n\nPrevent infection by keeping germs away \n\nHere are the basic rules to prevent infection. \n\nClean your hands and wear protective clothing. \n\nWash your hands often and wear protective clothing to \nprevent spreading germs from one person to another and \nto keep germs away from yourself (see page 53). \n\nClean the space and bedding. \n\nClean the area where births and exams happen, to \nkeep germs away (see page 57). \n\n\nClean and sterilize tools. \n\nWash and sterilize tools to kill any germs on them \n(see page 59). \n\n\nGet rid of wastes safely. \n\nThrow away waste products carefully to prevent people in \nthe community from getting sick from the germs left on \nthem (see page 67). \n\n\nRemember: Infection can spread most easily when a health worker is \ncaring for many people. For example, if her hands are not clean or her \ntools are not sterile, she will pass germs from one woman to another \nto another. For this reason, a woman giving birth at a hospital or \nmaternity center with many other women has more risk of infection \nthan a woman giving birth at home. \n\n\nAdapt this book to work for you \n\nThis chapter contains many detailed instructions for \npreventing infection. They are all important, but they \nmay not all be possible. You will have to decide \nwhich you are able to do, or if there are ways you \ncan adapt the instructions to work for you. \n\n\n52 \n\n\nA Book for Midwives (201 0) \n\n\n1 «r \n\nwww. Hesperian. ore \n\n\nPrevent infection by keeping germs away \n\n\nClean your hands and \nwear protective clothing \n\nWash your hands often \n\nWashing your hands is one of the most important things you \ncan do to prevent infection. It prevents you from spreading \ngerms to another person, and it helps protect you from germs, \ntoo. If you can do nothing else to prevent infection, you must wash your hands. \n\nWash your hands with soap and clean water. If you do not have soap, you can \nuse ash (but not dirt!). Be sure to rinse all the soap or ash off. When you wash your \nhands, and especially when you rinse them, use clean water that is flowing, not \nwater sitting in a bowl. When you wash your hands in a bowl, the germs that come \noff into the water will get back onto your hands again. \n\nWash your hands each time before you touch a woman's body. Wash after you \ntouch her body, or after you touch anything that has her blood or fluid on it (like \nthe placenta). Wash before you put on gloves and after you take gloves off. If you \nare helping more than one woman at once, like at a hospital, it is very important to \nwash between helping each person. \n\nNormal hand washing removes most germs. But sometimes to remove more germs, \nyou should wash your hands for a full 3 minutes, and scrub under your fingernails. \n\n\nHow to do a 3-minute hand wash \n\nBefore you start, take off rings, bracelets, and other jewelry. \n\n1 \n\n\nWash your hands and \narms with soap and \nclean water — all the \nway up to your elbows. \n\n\nMake sure to scrub in \nbetween your fingers. \n\n\nKeep scrubbing, brushing, \nand washing your hands \nand arms for 3 minutes! \nSpend most of this time \non your hands. \n\n\nRinse \nwith clean, \nrunning water. \n\n\nIf you have a clean brush, \nscrub your fingernails. \n\n\nDry your hands in the air \ninstead of using a towel. \nDo not touch anything \nuntil your hands are dry. \n\n\nwww. nesperian.org \n\n\nA Book for Midwives (201 0) \n\n\n53 \n\n\npreventing \n\ninfection \n\n\nChapter 5: Preventing infection \n\n\nAlways do a 3-minute hand wr^u \n\n\nbefore you: \n\n• touch the mothers vagina \n\n• do a pelvic exam i \n\n• deliver the baby \n\n• sew up a tear \n\n\nafter you: \n\n• clean up after the birth \n\n• touch any blood or \n\n\nother body fluids \n• urinate or pass stool \n\n\n• insert an IUD (see Chapter 21) \n\n• do an MVA (see Chapter 23) \n\nAlcohol and glycerine hand cleaner \n\nYou can make a simple hand cleaner to use if you do not have water to wash your \nhands. When used correctly, this cleaner will kill most of the germs on your hands. \n\nMix 2 milliliters glycerine with 100 milliliters of ethyl or isopropyl alcohol \n60% to 90%. \n\nTo clean your hands, rub about 5 milliliters (1 teaspoon) of the hand cleaner \ninto your skin. Be sure to clean between your fingers and under your nails. Keep \nrubbing until your hands are dry. Do not rinse your hands or wipe them with a \ncloth. \n\n\nClean water \n\nThroughout this book we talk about how important it is to wash \nyour hands and wash your tools. But the water you use must be \nclean to be of any use. If the water in your community may \ncarry germs, be sure that water is boiled before using it to ^ \nwash your hands or to wash tools before a birth. \n\n\nWear gloves \n\n\nLatex and other plastic gloves protect \n\n\nB women from any germs that \nmay be hiding under your \nfingernails or on your skin. \nThey also protect you from \n\n\nPlastic bag gloves \n\nIf you do not have a a \n\n\ngetting infections. Wear clean gloves \nwhenever you touch the mothers \ngenitals, or any blood or body fluid. \n\n\nor if you are touching any tools that \nhave been sterilized, you must wear \nsterile gloves. \n\n\nIf you are doing invasive procedures, \n\n\ngloves, use plastic bags Li/JLIa \nthat have been washed \nin disinfectant soap instead. Bags \nare harder to use than gloves, but \nthey are better than nothing. \n\nIn the rest of this book, we will \nonly mention gloves. But be sure \nto use plastic bags if you do not \nhave gloves. \n\n\n54 \n\n\nA Book for Midwives (201 0) \n\n\nWWW. \n\n\nPrevent infection by keeping germs away \n\n\nHow to put on sterile gloves \n\n\n1 \n\n\n2 \n\n\nOpen the package without Carefully wash your \n\ntouching the gloves. Do hands. Let them dry \n\nnot touch the outside of a in the air. \n\nsterile glove with your \n\nhand or it will not be \n\nsterile anymore. \n\n\nThe gloves should be \nfolded out at the cuff. \n\nPick up one glove under \nthe cuff on the inside of \nthe glove and slip your \nhand into it. Do not touch \nthe outside of the glove. \n\n\nWiggle your hand in \nwhile you pull with \nyour finger tucked \ninside the glove. \n\n\nPick up the second glove \nby slipping your gloved \nfingers into the fold of \nthe cuff. Slide your hand \ninto the glove. \n\n\nOnce the gloves are on, \ndo not touch anything \nthat is not sterile — or \nthe gloves will not be \nsterile anymore either! \n\n\nPractice with the same pair of gloves over and over again until it feels easy. \n\n\nRemember: \n\n\nIf you carefully wash and put on and then scratch your glove is not \n\nyour hands... sterile gloves .. . your head... sterile anymore! \n\nOf course, when you touch a woman you will get germs on your gloves, but do \nnot move germs from one part of her body to another. For example, if you touch a \nwoman's anus where there are many germs, do not put your fingers inside the \nvagina with the same gloves. Germs from the anus can make a woman sick if they \nget into the vagina or womb. \n\nAfter you use a pair of gloves one time, throw them away, or sterilize them \nbefore you use them again (see page 66). \n\nwww. nespenan.org \n\n\nA Book for Midwives (201 0) \n\n\nChapter 5: Preventing infection \n\n\nProtect yourself from infection \n\nMidwives must protect themselves from germs and infection. You will not be able to \nhelp women if you are sick. And if you are infected with dangerous germs, you can \neasily spread them to the women you are trying to help. \n\nSome germs that cause serious illnesses, like AIDS and hepatitis B, only live in \nblood, urine, stool, the bag of waters, and other body fluids. That means you do not \nget these illnesses just by touching someone's skin. But the germs that cause AIDS \nand hepatitis B can infect you if an infected person's blood gets into a cut or opening \nin your skin — even a cut so small that you cannot see it (see page 99 for all the ways \nHIV can spread). Keep blood and other body fluids off your clothing and skin, and \nif they do get onto you, wash them off right away with soap and water. \n\n\nWear protective clothing \n\nYou do not need expensive equipment to keep body \nfluids off your skin, out of cuts, and out of your \nmouth and eyes. You can wear an apron or an extra \nshirt to keep fluid off your body. Protect your eyes \nwith eyeglasses or plastic goggles. Cover your feet \nso that you do not step into blood or other fluids. \n\n\nWash all your clothing after any blood, waters, or other \nbody fluids gets on it. If you get body fluids in your eyes \nor mouth, rinse them for several minutes with clean water \nor saline (water with a little salt added). \n\n\nIf you do not have \nclothing made to protect \nyou from blood and fluids, \nyou can make it from \nwhat you already have. \n\n\n56 \n\n\nBe careful with needles \n\nIf a syringe is used to give an injection, or a needle was used for sewing a vaginal tear, \nthe needle has blood on it. If you accidentally stick yourself with that used needle, you \nwill be exposed to germs. Carry needles carefully with the point away from your body. \nDo not leave needles lying around. \n\nUse each needle only once and then throw it away in a box like the one on page 68. \nYou may be able to get needles that can only be used once and do not need a cap. If you \nmust reuse a needle, put the cap on very carefully and then put the needle in a bucket \nfilled with bleach solution (see page 57) until you are ready to clean and sterilize it. \n\n\nHow to avoid puncturing \n\nDo not use your hand to \nput the cap on the needle. \n\n\nyour skin with a needle \n\nInstead, use the needle \nto pick up the cap. \n\n\nNote: If you do get stuck by a needle, immediately wash the area with \nsoap and water or alcohol and dispose of the needle properly (see \npages 67 and 68). Do not use it on another person. \n\n\nA Book for Midwives (201 0) \n\n\n1 *r \n\nwww. nesperian.org \n\n\nClean the space and bedding \n\n\nClean the space and bedding \nClean the space \n\nAt home \n\nOne reason that birth or medical procedures \ncan happen as safely in a woman's home as \nin a medical center is that there are not as \nmany germs in a clean house as in a hospital. \n\nBut the home should still be cleaned carefully — \nespecially the area where the baby will be born or where procedures such as a pelvic \nexam or IUD insertion will be done. \n\n\nSweep these areas free of dust and dirt, and wash surfaces with soap and water. \nPut your tools or birth kit on a clean surface. \n\nMove animals out of the house and do not do any medical procedures in places \nwhere animals sleep or pass stool, or where people urinate or pass stool. If the floor \nin the house is made of animal waste (dung), do not let the woman's body or any \nof your tools touch the floor. Dung has many germs in it that can easily spread to \npregnant women. You can cover the floor with clean straw, cloth, or plastic. \n\n\nIn a hospital , maternity center ; or clinic \n\nBe extra careful. Germs can easily be passed from one person to another. \n\nAfter each birth, wash floors and surfaces. If possible, use a bleach \n(sodium hypochlorite) solution to wash the floor. \n\n\nHow to make a disinfecting solution of 5% bleach \n\nIf your bleach says: \n\n5% available chlorine 10% available chlorine 15% available chlorine \n\n\nuse undiluted, \nstraight bleach \n\n\nuse 1 part and 1 part \nbleach water \n\n\nuse 1 part and 2 parts \nbleach water \n\n\nMix just enough solution for 1 day. Do not use it again the next day. \nIt will not be strong enough to kill germs anymore. \n\n\nIf you do not have bleach, you can wash the floor with: \n\n\n• ethanol (medical alcohol) 70% \n\n• isopropyl alcohol 70% \n\n• hydrogen peroxide 6% \n\n• soapy water \n\n\n• ammonia \n\n(But do not ever mix \nbleach with ammonia \n— when mixed they \nmake a poison.) \n\n\nwww. nesperian.org \n\n\nA Book for Midwives (201 0) \n\n\nChapter 5: Preventing infection \n\n\nClean or sterilize the bedding \n\nAt home \n\nWash cloth for covering the bed (bedding) in \nsoap and water, and dry it thoroughly by \nhanging it in the sun or ironing it. Do not dry \nbedding on the ground; it will pick up germs. \n\n\nIn a hospital , maternity center ; or clinic \n\nBedding must be sterilized after each birth. Use one of these methods to kill \nthe germs: \n\n\n• Wash the bedding with soap or \n\nand water. Then boil for 30 \nminutes. Dry thoroughly in a \n\n\n• Wash bedding with soap \nand water. Then use a hot \niron to dry it. \n\n\nIf neither of these methods is possible, wash the bedding in soap and water and \nhang it in the sun until it is fully dried. Turn the bedding so the sun shines on \nboth sides, and take care to keep it clean. \n\n\nStore bedding to keep germs away \n\nIf you are not going to use the bedding right away, keep it clean and dry until you \nare ready to use it. Put it in a clean bag or wrap it in clean paper and store it in a \nclean, dry place. \n\nNote: Do not store bedding that is damp or wet. Germs will come back! \n\n\nOther kinds of underpadding \n\nSometimes there is no bed or bedding. The birth or procedure happens on the \nfloor. In these cases, it is useful to have some kind of underpadding. This protects \nthe baby and the mother from the germs and dirt that \nare on the floor. Find a way to clean the \nunderpadding before it is used. For example, \nbanana leaves can be washed with a \ndisinfectant solution, and then smoked or \ndried in the sun. Cloth rags or sacks can be \nboiled and then dried. \n\n\n58 \n\n\nA Book for Midwives (201 0) \n\n\n•a llfilii «r \n\nwww. nesperian. ore \n\n\nClean and disinfect tools \n\n\nClean and sterilize tools \n\nAll the tools used at a birth, exam, or procedure must be cleaned and sterilized. \nCleaning and sterilizing the tools gets rid of germs. This protects women from \ngetting sick. \n\n1. Soak your tools \n\nTools that have been used must be soaked for at least 20 minutes in bleach \nsolution (see page 57). \n\n\n2. Clean your tools \n\nAll tools and equipment you use at a birth or a procedure \nmust be clean. Wash them well after each birth, using a \nbrush to remove any blood or dirt in the hinges or rough \nedges of your tools. Clean off any rust, and get rid of tools \nthat are dull or damaged. To protect yourself, wear heavy \ngloves when you clean your tools. \n\nAfter everything is washed, any tools that you use inside \na woman's body must also be sterilized to kill germs. \n\n3. Sterilize your tools \n\nTo sterilize means to kill all the germs on something. If your tools are sterilized, \nthey will not spread germs to women when you use them. This will protect women \nfrom getting infections. \n\n\nCarefully wash \nall the dirt off \n\n\nWhat do we mean when we say \"sterile\"? \n\nSterilize means kill all the germs that cause infections. To sterilize a tool \nyou must use baking or pressure steaming. \n\nDisinfect means to kill most of the germs that cause infections. Some soaps \nand cleaning products are called \"disinfectant.\" But to disinfect medical tools \nor instruments you cannot simply clean something with a disinfectant soap \n— you must boil, steam, or soak the tool in disinfectant chemicals. This kind \nof disinfection is called High Level Disinfection (HLD). \n\nAll the procedures in this book can be done safely with tools that are \neither sterile or HLD. To be simple, we only use the word \"sterilize\" or \n\"sterile\" throughout the book. But any time we say that a tool should be \nsterile, we really mean it can be sterile or HLD. \n\n\n1 i \n\nwww. nesperian.org \n\n\nA Book for Midwives (201 0) \n\n\n59 \n\n\npreventing \n\ninfection \n\n\nChapter 5: Preventing infection \n\n\nSterilize everything that will go inside a woman's body, will cut her skin, or will \nbe used to cut the cord at birth. \n\n\nSterilize these items: \n\n• syringes and needles \n\n• scissors or razor blade for cutting the cord \n\n• materials for sewing tears \n\n• clamps or hemostats \n\n• gloves \n\n• gauze \n\n• compress cloths \n\n\n• bulb syringe or mucus trap \n\n• MVA cannula \n(see page 420) \n\n• speculums, in some cases \n\n\nNote: You do not need to sterilize tools that are used only on the \noutside of the body. Stethoscopes, measuring tape, and blood pressure \ncuffs must be clean but do not need to be sterile. \n\n\nWhen you sterilize a tool, the germs on it are killed \nand it is safe to use. But if that tool touches anything \n(including the bed, a table, or you!) it is no longer sterile. \nGerms from whatever it touched are on it, and those \ngerms can cause an infection when the tool is used. \n\n\nThe next few pages explain 5 different ways to sterilize your tools: \nbaking, pressure steaming, boiling, steaming, and soaking in chemicals. \n\nBaking and pressure steaming are best — they kill the most germs. If you cannot \nuse either of those methods, boiling, steaming, or using disinfectant chemicals \nis fine. Use the ways that work best for you. \n\n\nWARNING! If you cannot sterilize your tools, then do not \nuse them. Unsterilized tools will do more harm than good. \n\n\nWWW. \n\n\n1 lit S+k. *r \n\nnespenan.org \n\n\n60 \n\n\nA Book for Midwives (201 0) \n\n\nClean and disinfect tools \n\n\nBaking \n\nUse baking to sterilize metal tools, and \nstring for tying the cord. Do not bake \nrubber or plastic. It will melt. \n\n\nWash and rinse all the tools well, then put them into 4 layers of \nclean cloth or heavy paper. Wrap the cloth up around the \ninstruments and tie it shut. \n\nPut the packet of tools or string into a container or on a pan. \n\nBake on a medium-high heat (1 70°C or 340°F) for 1 hour. \n\nThis is a little longer than it takes to bake a big potato or yam. If you cannot \nmake your oven hot enough, bake items longer. \n\n\nLet the packet cool, then store it in a clean, dry place. \n\n\nPressure steaming \n\nUse pressure steaming to sterilize metal tools or rubber \nor plastic equipment. \n\nSome clinics and hospitals have a machine for \nsterilizing called an autoclave. Autoclaves sterilize \ninstruments using pressure and steam. If you have a \npressure cooking pot, you can sterilize your tools in the \nsame way that an autoclave does. \n\n\nPut a steamer basket and water in the pressure cooking pot. Put your tools \ninto the steamer, close the lid on the pot, and put the pot on a flame to boil \n\nAfter it comes to a boil, cook at 1 5 or 20 pounds of pressure for 20 minutes. \n\n\nAfter sterilizing tools, let them dry. Do not touch them, or they will not be \nsterile anymore! \n\n\nwww. nesperian.org \n\n\n61 \n\nA Book for Midwives (201 0) \n\n\npreventing \n\ninfection \n\n\nChapter 5: Preventing infection \n\n\nUse sterilized tongs, chopsticks, or spoons to pick the tools out of the pot. Move \nthem directly to a sterilized container. Remember, if the tool touches anything, \nincluding your hands, it is no longer sterile. \n\nLet the tools dry in the sterilized container. Cover the container \n/l; m with a sterilized cloth or paper to keep dust out. \n\nWhen the tools are all dry, put the lid on the container \nand seal it with tape or some other material to keep the \ngerms out. \n\nBoiling \n\nUse boiling to sterilize metal tools, rubber or \nplastic equipment (like mucus bulbs), and cloth \n\nAfter you wash and rinse your tools, cover with \nwater and boil for 20 minutes. \n\nStart counting the 20 minutes when the water \nstarts boiling. \n\n\nUse sterilized tongs, chopsticks, or spoons to pick the tools out of the pot. Move \nthem directly to a sterilized container. Remember, anything you touch is no longer \nsterile. \n\n\nSteaming \n\nUse steaming to sterilize metal tools, \ngloves, plastic equipment, and other tools. \n\nA steaming pot has 3 parts that \nfit together tightly: one pot on the bottom \nto boil water in, one pot in the middle that \nhas holes in its bottom, and a lid. \n\n\nBoil a little water in the bottom pot. Put the tools into \nthe steamer pot with the holes. Cover with the lid. \n\n\nSteam over boiling water for at least 20 minutes. \n\n\nStart counting the 20 minutes when the water \nstarts boiling. \n\n\nmm>) \n\nsteaming pot method \n\n\na lid \n\n\none pot \nwith holes \nin the \nbottom \n\n\none pot on \nthe bottom \nto boil water \nin \n\n\n62 \n\n\nA Book for Midwives (201 0) \n\n\nwww. Hesperian. ore \n\n\nClean and disinfect tools \n\n\nWait for the tools to dry, and then use sterilized tongs to \nmove the tools from the steamer into a sterilized container, \nand seal the container. \n\nSteaming uses less water than boiling, and tools that are \nsteamed do not get dull or broken as quickly as tools that \nare boiled. \n\n\nA method from the Philippines \n\nThe Medical Mission Sisters in the Philippines have \ndeveloped a method to sterilize tools with steam: \n\n1. Put your clean tools into a metal tray. \n\n\nPlace the tray in a cooking pan. \n\n\nFill the pan with \nwater until it \nreaches halfway up the tray. \n\n\nwater level \n\n\nCover the pan with 8 layers of clean \ngreen banana leaves. Bind the leaves tightly \nin place with strips of banana leaf or bark. \nBe careful not to spill water into the tray \nwhen you do this. \n\n\nPut the pan on a low fire and boil for \nabout 1 hour. \n\n\n6. Throw away the top layer of the leaves. \nYou can use one of the inner layers to \nput your instruments on. \n\n\nUsing chemicals \n\nSome people use chemicals to sterilize metal, \nrubber, or plastic tools and equipment. We do \nnot recommend using chemicals to sterilize. \n\nMost chemicals used to sterilize are poisonous. \n\nThey poison the ground and the water when they \nare thrown away. They are poisonous to the \npeople who work in factories making them, and \nthey are poisonous to the people who use them to clean tools. \n\nBut some tools can only be sterilized with chemicals. \n\nThermometers and some kinds of gloves cannot be baked, boiled, or steamed. \n\n\nwww. nesperian.org \n\n\nA Book for Midwives (201 0) \n\n\n63 \n\n\npreventing \n\ninfection \n\n\nChapter 5: Preventing infection \n\n\nIf you do need to use chemicals: \n\n• mix up the bleach solution on page 57. \n\nor If you do not have bleach, use one of the following chemicals: \n\n• ethanol (medical alcohol) 70% \n\n• isopropyl alcohol 70% \n\n• hydrogen peroxide 6% \n\nor If you cannot get any of these chemicals, you can use: \n\n• strong drinking alcohol like gin, or a strong local brew. \n\nBe sure that all of your tools are very clean before sterilizing them with chemicals. \nEven a little blood or body fluid left on the tool can stop the chemicals from \nworking. Do not use chemicals to sterilize tools that will go inside the womb. \n\n\nSoak in bleach or disinfecting chemicals for at least 20 minutes. \n\nor \n\nSoak in strong drinking alcohol for a whole day. \n\nAfter soaking, pour the chemicals off and let the tools dry. \n\n\nWARNING! Glutaraldehydes and formaldehyde are chemicals \nthat we think are too dangerous to ever use. Many clinics and \nhospitals use these to sterilize, but they are very toxic. \nFormaldehyde, for example, causes cancer. Try to find a \ndifferent way to sterilize. \n\n\nIf you use chemicals, keep them off your skin, and wear gloves when you use \nthem. Get rid of chemicals carefully. You may have to dump bleach or other \nchemicals into a latrine to be sure animals and children do not drink it. \n\n\nStoring tools and supplies \n\nAt some births there will be plenty of time to sterilize \nyour tools and equipment at the mother's house. But at \nother births, you may not have time. For this reason, try \nto sterilize your tools and equipment at home and keep \nthem in a sterilized container in your kit. A metal \nbox or pot with a tight-fitting lid is best. \n\nUse any of the above methods to sterilize a \ncontainer and tools to move equipment. \n\nDo not touch the inside of the container. \n\n\n64 \n\n\nA Book for Midwives (201 0) \n\n\nwww. Hesperian. ore \n\n\nClean and disinfect tools \n\n\nIf you cannot get such a container, wrap the tools and equipment in 4 layers of \ncloth or heavy paper before sterilizing them. Then keep the sterilized tools \nwrapped up until you are ready to use them. (You can only use cloth or heavy \npaper to wrap your tools if you are sterilizing by baking.) \n\nRemember that germs grow in moisture, and they will come back if the \ninstruments are put away while they are wet. But if you are going to use the tools \nright away, it is OK to use them when they are wet. Germs need time to grow. \n\n\nSome equipment needs special care \n\n\nSterile packets \n\nGauze, compresses, gloves, and other \nequipment sometimes come in sterile \npackets. Because the inside of the \npacket is sterile too, you can use this \nequipment directly out of the packet. \n\nBut remember: once you take \nsomething out of its sterile packet Thls glove IS stenle- \nand use it, or if the packet gets wet or \ngets holes in it, the equipment is not sterile anymore. \n\n\ntear in package \n\n\nThings in sterile packets are often meant to be used only once and then thrown \naway (disposable). But some of these things can be used again if they are carefully \ncleaned and sterilized before each use. Gloves can be boiled or steamed. Gauze and \ncompresses can be washed and then boiled or baked. \n\n\nThermometers \n\nWash the thermometer in soap and rinse with cool, ^ r~ ,, tL ^ \n\nclean water before and after you use it. Do not use \nhot water because the thermometer may break. \n\nAfter washing, it is best to soak the thermometer in alcohol for 20 minutes. You \ncan use ethyl, isopropyl, or medical alcohol (ethanol). Do not reuse the alcohol. \nRinse the thermometer in clean water before you use it again. \n\n\nRazor blades \n\nRazor blades for cutting cords often come inside of a sterile packet. To keep the \npacket sterile, wrap it in clean paper or cloth, or keep it in a clean dry box. If the \npacket gets wet or dirty, it is not safe to use the razor blade \nunless you sterilize it again. \n\nTry not to reuse razor blades — but if you do, they must be \nsterilized first. Razor blades can be sterilized by any method. \n\n\nlitEVES V \n\n\n1 l ft li t \n\nwww. nesperian.org \n\n\n65 \n\nA Book for Midwives (201 0) \n\n\npreventing \n\ninfection \n\n\nChapter 5: Preventing infection \n\n\nGloves \n\nMost plastic gloves can be boiled or steamed, but some will fall apart in the water. \nGet strong gloves that can be boiled and reused a few times. \n\nBefore boiling or steaming gloves, turn the cuff inside \nout. After sterilizing a glove, touch only the inside part of \nit. If you touch the outside, it will not be sterile anymore. \n\nIf the gloves you have cannot be boiled, wash them \ncarefully and soak them in bleach or medical alcohol. Then \nOnly touch the rinse them in clean water before using them again. \n\ninside of the glove. \n\n\nMucus bulb (bulb syringe) \\ \n\nWhen you wash out a mucus bulb, make sure to fill it with soapy water \nand then squeeze the water out. Do this several times. Then rinse it out well. \n\nIf you sterilize the mucus bulb by boiling, make sure to let water into the \ninside of the bulb before boiling and then squeeze out all the water afterward. \n\n\nNeedles \n\nMany people get sick with serious illnesses like hepatitis or HIV from using \nunsterilized needles. \n\nReusable syringes and disposable syringes \n\nReusable syringes can be used again and again. Reusable syringes make less waste \nand can save money, but they must be washed very carefully and sterilized after \nevery use. \n\nDisposable syringes are \nmade to be thrown out \nafter one use. Some \ndisposable syringes can be \ntaken apart, boiled or \nsteamed, and reused several \ntimes. But we do not \nrecommend this, because \nneedles that are not \ncompletely sterilized can \nspread disease. \n\nNever reuse a needle \nor syringe without \ncleaning and \nsterilizing it first! \n\n\nHow to wash and sterilize a syringe \n\nand needle for reuse: \n\n1. Put on a pair of \nheavy gloves to \nprotect your hands \nfrom germs. \n\n2. Draw 5% bleach solution \n(see page 57) up through the \nneedle into the syringe barrel. \n\n3. Squirt out the bleach solution. \n\n4. Repeat several times. Rinse \neverything several times with clean water. \n\n5. Take the syringe and needle apart and \nboil or steam them. (See page 62.) \n\n\n66 \n\n\nA Book for Midwives (201 0) \n\n\nwww. nesperia.ri.org \n\n\nGet rid of wastes safely \n\n\nRemember: \n\n\nIf you take a sterile syringe and put it in it is not sterile anymore, \n\nout of boiling water . . . your pocket . . . Instead, it is dangerous! \n\n\nGet rid of wastes safely \n\n\nThere are three different kinds of waste after a birth or procedure: \n\nbody wastes sharp wastes other wastes \n\n\n\"A \n\nlike blood, \n\nlike needles for \n\nlike used \n\nstool, or placenta \n\nsewing or syringes \n\nplastic gloves \n\nThese wastes carry germs and can spread infections to you and to people in the \nfamily and community. Wear gloves when you touch wastes, and get rid of them \ncarefully. \n\nBody wastes \n\nThe simplest way to dispose of body wastes is to put them in a latrine or to \nbury them deep in the ground. \n\nIn many communities, families bury the placenta, sometimes with other special \nobjects. Burying the placenta is an important ritual for many people, and is also a \nway to protect the community from germs that may grow in the placenta. \n\nSharp wastes \n\nSharp wastes must be put into a container so they will not \ninjure anyone who finds them. A container made of metal or \nheavy plastic, with a lid or tape to close it, works well. \n\nWhen the container is half full, add bleach if possible, then \nseal it closed and bury it deep in the ground (see page 68). \n\n\n1 »*4ll l if it & \n\nwww. nesperian.org \n\n\nA Book for Midwives (201 0) \n\n\n67 \n\n\npreventing \n\ninfection \n\n\nChapter 5: Preventing infection \n\n\nMake a box to dispose of needles safely \n\nFind a metal or hard plastic box. Make a long \nhole in the lid of the box that is wide on one \nside and gets narrower on the other side. \n\n\nWhen you have finished using a \ndisposable syringe, put the needle \ninto the box and slide it down to \nthe narrowest point. \n\n\nThen pull up on the syringe \nand the needle will fall off into \nthe box. The plastic syringe can \n\n\nWhen the box is half full, pour 5% bleach solution into the box, seal it \nclosed, and then bury it deep in the ground. \n\n\nOther wastes \n\nOther wastes, like plastic gloves, syringe barrels, or cloth soaked in blood, should \nbe sterilized and then buried deep in the ground. You can sterilize them by \nsoaking them in bleach for 20 minutes. \n\n\nWARNING! Do not burn plastic gloves, syringes, or any \nother plastics. Burning plastic wastes is dangerous — when \nplastic burns, it makes smoke and ash that is very poisonous. \n\n\nBurying wastes \n\nFind a place away from where people get their \ndrinking water and away from where children \nplay. Dig a safe waste pit to bury wastes. \n\n\n68 \n\n\nA Book for Midwives (201 0) \n\n\nwww. nesperian.org \n\n\nGet rid of wastes safely \n\n\nA safe waste pit \n\n1. Dig a pit 1 to 2 meters wide and 2 to 5 meters deep. The bottom of the pit \nshould be at least 1 meters above the water table. \n\n2. Line the inside of the pit with a layer of \nclay or rocks at least 10 centimeters thick. \n\n3. Build up a ridge of earth around the \ntop of the pit to prevent surface water \nfrom running in. \n\n4. Build a fence around the area where the \npit is located to keep animals out. \n\nEach time waste is put in the pit, cover the waste with 10 centimeters of soil, or \na mix of soil and lime. Lime helps \n\ndisinfect the waste, and will also keep animals away while the pit is in use. \n\nWhen the waste rises to V2 meter from the surface, cover it with V2 meter of soil \nand seal it with a layer of concrete at least 90 centimeters thick. If the pit is used \nonly for medical waste and not for regular garbage, it will not fill up too quickly. \n\n\nGarbage dumps \n\nWhen wastes are sent to a garbage dump, they can spread infections there. \n\nIn many places, people pick through garbage to find things to sell, like used \nsyringes. This is dangerous for the people picking through the garbage, and \nfor the people who buy the syringes to use them again. \n\nWhen a syringe is not usable anymore, dispose of it safely. If you must \nsend needles to the garbage dump, sterilize them first, and seal them in a \nbox or tin. \n\n\nwww. nesperian.org \n\n\nA Book for Midwives (201 0) \n\n\n69 \n\n\npreventing \n\ninfection \n\n\nPregnancy \n\nINTRODUCTION \n\n\nAll women need care and attention during \npregnancy. This care is usually called \nprenatal or antenatal care. Prenatal care \nhelps pregnant women be healthier \nand have fewer problems in birth. \n\nPrenatal care should come from the \nwoman herself, from her family and \nthe community, and from a midwife \nor someone else who is experienced \nin helping pregnant women. \n\nIn some places, midwives only care for women when they are in \nlabor or giving birth, not during pregnancy. This may be because \nmost of the time, people only go to a healer or doctor when they are \nsick or if something is wrong. Pregnancy is usually normal and \nhealthy, so people may not think that prenatal care is important. But \nmost midwives know that women who have good care during \npregnancy are more likely to have safer births and healthier babies. \n\nCare in pregnancy has 2 purposes: \n\n1. Observing and listening to the pregnant woman \nby checking her body for healthy signs and warning \nsigns and by asking her about problems or listening \nto her questions. \n\n2. Teaching a woman how to have a healthier \npregnancy (for example, how to eat a healthy diet \nand how to avoid harmful things). \n\n\nwww. nesperian . o r g \n\n\n70 \n\n\nMidwives should start prenatal care as soon as a woman knows \nshe is pregnant, and should examine the woman regularly during \nthe pregnancy. We call these meetings \"checkups.\" If possible, \nevery woman should have at least 4 checkups. \n\nDoing more checkups will give you more chances to share \nimportant information and to prevent health problems. And any \nwoman who has warning signs should have checkups more often. \n\nThis section is divided into 3 different chapters: \n\n• Chapter 6 explains the changes a woman may go through \nin pregnancy. \n\n• Chapter 7 explains how to learn about a woman's health history \nduring the first checkup. \n\n• Chapter 8 explains how to check a woman for healthy signs \nand warning signs at each checkup. \n\n\nwww.nesperian.org \n\n\n71 \n\n\nChapter 6 \n\nCommon changes in pregnancy \n\n\nIn this chapter: \n\nChanges in eating and sleeping \n\nUpset stomach (nausea) and \ndislike of some foods \n\nFood cravings \n\nBurning or pain in the stomach or \nbetween the breasts (heartburn) . . . \n\nBody changes and discomforts \n\nSwollen breasts \n\nSwollen feet \n\nSwollen veins (varicose veins) \n\nConstipation \n\n(difficulty passing stool) \n\nHemorrhoids (piles) \n\nNeeding to urinate often \n\nDischarge \n\n(wetness from the vagina) \n\nDifficulty getting up and down \n\nShortness of breath \n\nFeeling hot or sweating a lot \n\n\nSleepiness \n\n73 \n\nDifficulty sleeping \n\n74 \n\n74 \n\n\n76 The mask of pregnancy \n\n76 Purple spots on the skin .... \n76 Aches and pains in the joints \n\nSudden pain in the side of \n\n76 the lower belly \n\n77 Cramps in early pregnancy. . \n\n77 Baby's kicks hurt the mother \n\nBack pain \n\n77 \n\n' / Leg cramps \n\nHeadaches \n\n70 \n\nOther pains \n\n78 \n\n\n73 \n\n75 \n\n75 \n\n\n76 \n\n79 \n\n79 \n\n79 \n\n79 \n\n79 \n\n80 \n80 \n80 \n81 \n81 \n\n\nChanging feelings and emotions \n\n\nSudden changes in feelings 82 \n\nWorry and fear 82 \n\nStrange dreams and nightmares 82 \n\n\n82 \n\n\nForgetfulness 83 \n\nFeelings about sex 83 \n\n\nwww.nespenan.org \n\n\n72 \n\n\nCommon changes \nin pregnancy \n\n\nDuring pregnancy a woman's body changes. These changes can sometimes be \nuncomfortable, but most of the time they are normal. In this chapter, we describe \nsome of these changes, and discuss ways to help women feel better. We also \nexplain how to tell when a woman's discomfort may be a sign that something \ndangerous is happening with her pregnancy. \n\nThere are many ideas about how to treat the discomforts of pregnancy. We \ncannot explain all of these ideas here. If you know remedies or treatments for these \nproblems which we do not explain, use the remedies that work for you. We do not \nhave all the answers. But use the ideas on page 19 to help you decide if remedies \nare helpful or if they may be harmful. Not all remedies work. \n\n\nChanges in eating and sleeping \n\n\nUpset stomach (nausea) and dislike of some foods \n\nMany women have nausea in the first months of pregnancy. Sometimes it is \ncalled morning sickness. No one knows for sure what causes morning sickness, but \nfor many women, the way they eat affects it. If the nausea is mild, encourage the \nwoman to try any of these remedies: \n\n• Eat a food that has protein before bed or \nin the night. Some good foods with \nprotein are beans, nuts, and cheese. \n\n• Eat a few crackers, dry bread, dry \ntortillas, dry chapatis, or other grain \nfood when she first wakes up in the \nmorning. \n\n• Eat many small meals instead of 2 or 3 larger ones, and take small sips \nof liquid often. \n\n• Take 50 milligrams vitamin B-6, 2 times each day. (Do not take more.) \n\n\nwww.nesperian.org \n\n\n73 \n\n\npregnancy \n\n\nChapter 6: Common body changes in pregnancy \n\n\n• Use acupressure to relieve nausea. Find the spot \n3 fingers above the wrist between the 2 tendons on \nthe inside of the woman's arm. Press on this spot, — \nmoving your finger in small circles. Press firmly but \nnot hard enough to hurt. If acupressure is going to \nhelp, the woman should start to feel better within 5 minutes. \n\n• Drink a cup of ginger, mint, or cinnamon tea \n2 or 3 times a day, before meals. To make mint or \ncinnamon tea, put a teaspoon of mint leaves or a stick of \ncinnamon in a cup of boiled water. Let the tea sit for a few \nminutes before drinking it. To make ginger tea, boil \ncrushed or sliced ginger root in water for at least 15 \nminutes. \n\nA pregnant woman may suddenly dislike a food that she usually likes. It is OK \nnot to eat that food, and she will probably begin to like it again after the birth. She \nshould be careful that the rest of her diet contains a lot of nutritious food. \n\n\nFood cravings \n\n\nA food craving is a strong desire to eat a \nnot food at all, like dirt, chalk, or clay. \n\nIf a woman gets a craving for \nnutritious foods (like beans, eggs, \nfruits, and vegetables), it is OK for her \nto eat as much as she wants. But if she \nwants a lot of \"junk food\" (like candy, \nsoda, or packaged snacks) she should \neat nutritious food first. \n\nA woman who craves things that are \nnot food, like dirt or clay, should not \neat them. They may poison her and her \nbaby. They may also give her parasites, \nlike worms, that can make her sick. \nEncourage her to eat iron-rich foods \n(see page 36) and calcium-rich foods \n(see page 38) instead. \n\n\ncertain food, or even something that is \n\n\nI just want \\ \nto eat clay. \n\n\nYou may need more calcium ' \nand iron. Try eating green \nvegetables , nuts , seeds , or \nbeans instead. Dirt and clay \ncan give you parasites ana \nmake you sick. , \n\n\nBurning or pain in the stomach or between the breasts \n(heartburn) \n\nA burning feeling or pain in the stomach or between the breasts is called \nindigestion or heartburn. Heartburn happens because the growing baby crowds \nthe mother's stomach and pushes it higher than usual. The acids in the mother's \nstomach that help digest food are pushed up into her chest, where they cause a \nburning feeling. This is not dangerous and usually goes away after the birth. \n\n\n74 \n\nA Book for Midwives (201 0) \n\n\nwww. nesperian.org \n\n\nChanges in eating and sleeping \n\n\nHere are some things a woman can try to make herself more comfortable: \n\n\nKeep her stomach less full by eating smaller \nmeals more often and by eating foods and \ndrinking liquids separately. \n\nAvoid eating spicy or greasy foods, drinking \ncoffee, or smoking cigarettes — all of which can \nirritate the stomach. \n\nRegularly eat papaya or pineapple, which have \nenzymes that help the stomach digest food. \n\nKeep her head higher than her stomach when \nlying down or sleeping. This will keep her \nstomach acids in her belly and out of her chest. \n\n\nAs the baby \ngrows, he \npushes the \nwoman's \nstomach up. \n\n\n• Calm the acids in the stomach by drinking milk or taking a low-salt antacid \nthat contains no aspirin. (Antacids are not dangerous but they cost money \nand they make it harder for the body to use nutrients from food. Try other \nmethods before using antacids.) \n\n\nSleepiness \n\nSome pregnant women feel sleepy much of the day. This is most \ncommon during the first 3 months. \n\nIt is normal for pregnant women to feel sleepy. Their bodies \nare telling them to slow down and rest. But if a woman also feels \nweak, she may have other problems, like a sickness, depression \n(see page 274), or anemia (see page 116). \n\n\nDifficulty sleeping \n\nIf a woman cannot sleep because she is uncomfortable or restless, it may help if: \n\n\n• she lies on her side with something \ncomfortable between her knees and at \nher lower back. She can use a pillow, a \nrolled-up blanket, banana leaves, or \nsome other padding. \n\n\n• someone gives her a massage. \n\n• she drinks herbal teas that help her sleep. \n\n\nFighting, worry, and unhappiness in a woman's house or family can make it \ndifficult for her to sleep. If possible, a family should avoid arguing before going \nto sleep. \n\n\nwww. nesperian.org \n\n\n75 \n\nA Book for Midwives (201 0) \n\n\npregnancy \n\n\nChapter 6: Common body changes in pregnancy \n\n\nBody changes and discomforts \n\n\nSwollen breasts \n\nA woman's breasts get bigger during \npregnancy because they are getting ready \nto make milk for the baby. Sometimes the \nbreasts are also itchy or sore. \n\nDuring the last months of pregnancy, a watery, yellowish \nfluid may leak out of the nipples. This is normal. The fluid is \ncolostrum — the first milk for the baby. \n\n\nSwollen feet \n\nSwelling of the feet is very common, especially in the afternoon or in hot weather. \nSwelling of the feet is usually not dangerous, but severe swelling when the mother \nwakes up in the morning, or swelling of the hands and face anytime, can be signs \nof pre-eclampsia (see page 125). \n\nSwelling in the feet may improve if the woman puts her feet up for a few \nminutes at least 2 or 3 times a day, eats fewer packaged foods that are \nvery salty, and drinks more water or fruit juices. \n\nSwollen veins (varicose veins) \n\nSwollen blue veins that appear in the legs or on the woman's \ngenitals are called varicose veins. Sometimes these veins \nhurt. If the swollen veins are in the legs, they may feel \nbetter if the mother puts her feet up often. Strong \nstockings or elastic bandages may also help. \n\nIf the swollen veins are around the genitals, \nthey can cause bleeding problems if they tear \nduring birth. Putting a cool cabbage leaf on the \ngenitals may help. \n\n\nConstipation (difficulty passing stool) \n\nSome pregnant women have difficulty passing stool. This is called constipation. \nTo prevent or treat constipation, a woman should: \n\n\n• eat more vegetables and fruits. \n\n• eat whole grains (brown rice and whole wheat \ninstead of white rice or white flour). \n\n• drink at least 8 cups of clean water a day. \n\n• walk, move, and exercise every day. \n\n\nHome or plant remedies that soften the stool or make it slippery (like remedies \nmade from psillium seed or certain fruits or fiber plants) may also help. \n\n\n76 \n\nA Book for Midwives (201 0) \n\n\nwww. nesperian. \n\n\nrg \n\n\nBody changes and discomforts \n\n\nWARNING ! Pregnant women should not take medicines called \nlaxatives or purgatives for constipation. These work by making \nthe bowels tighten or contract — and they may cause labor to \nstart too soon. Some can harm the baby. \n\nAlso, pregnant women should not wash out the bowels with \nwater (enema). This could also start labor too soon. \n\n\nHemorrhoids (piles) \n\nHemorrhoids are swollen veins around the anus. They may burn, hurt, or itch. \nSometimes they bleed when the woman passes stool, especially if she is constipated. \nThe woman should try to avoid getting constipated by eating a lot of fruit and \nvegetables and drinking plenty of fluids. \n\nSitting or standing a lot can make hemorrhoids worse. But \nsitting in a cool bath or lying down can help. Some women say \nit helps to soak a clove of garlic in vegetable oil and then \ninsert it into the anus. \n\nIf you have heard of other remedies, ask an experienced \nhealth worker whether they are safe. Some remedies are \ndangerous for pregnant women and may hurt the baby. \n\n\nPregnant women \nneed to urinate \nmuch more often. \n\n\nNeeding to urinate often \n\nNeeding to urinate (pee) often is normal, especially in the first \nand last months of pregnancy. This happens because the \ngrowing womb presses against the bladder (the place where the \nbody stores urine). It is so common that some midwives joke: \n\n\"A man who cannot find his pregnant wife should wait near the \nplace where she urinates. If she is not there, she will be soon! \" \n\nIf urinating hurts, itches, or burns, the woman may have \na bladder infection (see page 128) or a vaginal infection \n(see Chapter 18). Be sure to treat these infections right away — \nthey can cause early labor and other problems. \n\n\nDischarge (wetness from the vagina) \n\nDischarge is the wetness all women have from the vagina. A woman's body uses \nthis discharge to clean itself from the inside. For most women the discharge \nchanges during their monthly cycle. Pregnant women often have a lot of \ndischarge, especially near the end of pregnancy. It may be clear or yellowish. \n\nThis is normal. \n\nChanges in the discharge can be a sign of an infection if the discharge is gray, \ngreen, lumpy, or has a bad smell, or if the vagina itches or burns (see Chapter 18). \n\n\nwww. nesperian.org \n\n\n77 \n\nA Book for Midwives (201 0) \n\n\npregnancy \n\n\nChapter 6: Common body changes in pregnancy \n\n\nDifficulty getting up and down \n\nIt is better if a pregnant woman does not lie flat on her back. When a woman is on \nher back, the weight of the womb presses on the big blood vessels that bring food \nand oxygen to the baby. If the mother wants to be on her back, she should put \nsomething behind her so she is not lying completely flat. \n\n\nA pregnant woman should also be careful how she gets up. She should not \nsit up like this: \n\nGetting up like this can harm the \nmuscles of the belly. \n\n\nNO! \n\n\nShortness of breath \n\n\nMany women get short of breath (cannot breathe as deeply as usual) when they are \npregnant. This is because the growing baby crowds the mother's lungs and she has \nless room to breathe. Reassure her that this is normal. \n\n\nBut if a woman is also weak and tired, or if she is short of breath all of the time, \nshe should be checked for signs of sickness, heart problems, anemia (see page 116), \nor poor diet (see page 117). Get medical advice if you think she may have any of \nthese problems. \n\n\nFeeling hot or sweating a lot \n\nFeeling hot is very common, and as long as \nthere are no other warning signs (such as signs \nof bladder infection, see page 128), the woman \nshould not worry. She can dress in cool clothes, \nbathe frequently, and drink plenty of water \nand other fluids. \n\n\n78 \n\nA Book for Midwives (201 0) \n\n\n1*Ahn*ly?L \n\nwww. nesperian.org \n\n\nBody changes and discomforts \n\n\nThe mask of pregnancy \n\nThe mask of pregnancy is a name for dark-colored \nareas that may appear on the face, breasts, and belly \nof some pregnant women. This mask is not harmful. \n\nUsually most of the color goes away after the birth. \n\nA woman may be able to avoid dark areas on her \nface by wearing a hat when she goes out in the sun. \n\nPurple spots on the skin \n\nPurple spots come from small groups of veins under the \nskin. They sometimes happen when blood vessels swell. \nThey are not harmful and usually go away after the birth. \n\n\ndark- \n\ncolored \n\nareas \n\n\nAches and pains in the joints \n\nA pregnant woman's body gets soft and loose so the baby can get bigger, and so \nshe can give birth. Sometimes her joints also get loose and uncomfortable, \nespecially the hips. This is not dangerous, but she can more easily sprain her ankles \nor other joints. So she should move more carefully. Her joints will feel better after \nthe birth. \n\n\nSudden pain in the side of the lower belly \n\n\nThe womb is held in place by ligaments on each \nside. Ligaments are like ropes that attach the \nwomb to the mother's bones. \n\nA sudden movement will sometimes cause a \nsharp pain in these ligaments. This is not \ndangerous. The pain will stop in a few minutes. \nIt may help to stroke the belly gently, or to put \na warm cloth on it. \n\n\nthe womb \n\n\nCramps in early pregnancy \n\nIt is normal to have mild cramps (like mild monthly bleeding cramps) \nat times during the first 3 months of pregnancy. These cramps happen \nbecause the womb is growing. \n\nCramps that are regular (come and go in a pattern) or constant \n(always there), are very strong or painful, or come with spotting or \nbleeding are warning signs. The woman may have a tubal pregnancy \n(see page 113) or maybe having a miscarriage (see page 91). She \nshould get medical help immediately. \n\n\nwww. nesperian.org \n\n\n79 \n\nA Book for Midwives (201 0) \n\n\npregnancy \n\n\nChapter 6: Common body changes in pregnancy \n\n\nBaby's kicks hurt the mother \n\nMost of the baby's movements feel good. But sometimes babies kick very hard or \nalways in the same place. And sometimes the baby's head bounces against the \nmother's back or bladder during the last weeks of pregnancy. These movements \nmay make the mother sore or uncomfortable, but they are not harmful. \n\n\nWARNING! The mother usually feels regular kicks every day by \nthe 6th or 7th month. If the baby stops kicking for a few hours, \nit is OK. But if the mother feels no movement for more than \na day and a night, there may be a problem. The mother \nshould meet with her midwife or get medical help. \n\n\nBack pain \n\nMany women get back pain. The weight of the baby, the womb, and the waters \nputs a strain on the woman's bones and muscles. Too much standing in one place \nor leaning forward can cause back pain. Hard work can also cause back pain. \n\nMost kinds of back pain are normal. But it can be caused by a kidney infection \n(see page 128). \n\nEncourage husbands, children, other family members, or friends to massage the \nwoman's back. A warm cloth or hot water bottle on her back may also feel good. \nHer family can also help by doing some of the heavy work (carrying small \nchildren, washing clothes, farming, and milling grain) for her. \n\nA woman can also do an exercise — called the angry cat exercise — to reduce \nlower back pain. She should do this exercise several times in a row, 2 times a day, \nand whenever her back hurts her. \n\n\nStart on hands and knees Push the lower back up. \n\nwith the back flat. \n\n\nReturn to flat back. \nRepeat. \n\n\n80 \n\n\nPoint the \ntoe up, \n\n\nthen stroke Do \nthe leg. the \n\n\nLeg cramps \n\nMany women get foot or leg cramps — \nsharp sudden pain and tightening of a \nmuscle. These cramps especially come \nat night, or when women stretch and \npoint their toes. To stop the cramp: flex \nthe foot (point it upward) and then \ngently stroke the leg to help it relax (do not \n\nstroke hard). See page 273 to learn when leg pain can be dangerous. \n\n\nnot point \ntoe down. \n\n\nA Book for Midwives (201 0) \n\n\nwww. Hesperian. ore \n\n\nBody changes and discomforts \n\n\nTo prevent more cramps, a woman should not point \nher toes (even when stretching), and she should eat \nmore foods high in calcium and \npotassium. The woman can also try \ntaking calcium, magnesium, \nand potassium pills. \n\n\nFoods rich in calcium and potassium \ncan help prevent leg cramps. \n\n\nHeadaches \n\n\nHeadaches are common in pregnancy but are usually harmless. Headaches may \nstop if the mother rests and relaxes more, drinks more juice or water, or gently \nmassages her temples. It is OK for a pregnant woman to take 2 paracetamol tablets \nwith water once in a while. \n\nSome women have migraine headaches. These are strong \nheadaches, often on the side of the head. The woman may see spots \nand feel nauseated. Bright light or sunshine can make them worse. \nMigraines may get worse in pregnancy. \n\n\nUnfortunately, migraine medicine is very dangerous in pregnancy. It can cause \nlabor to start too soon, and it may also harm the baby. It is better for a pregnant \nwoman with migraines to take 500 to 1000 milligrams paracetamol, and rest in a \ndark room. Although coffee and black tea are usually not healthy in pregnancy, \nthey are OK occasionally and they may help cure a migraine. \n\nHeadaches late in pregnancy are a warning sign of pre-eclampsia, especially \nif there is also high blood pressure or swelling of the face or hands. See \n\npage 125. \n\n\nOther pains \n\n\nIt is common to have other small aches and pains during pregnancy. \nGet medical advice for pain that is not normal in pregnancy, such as: \n• red, swollen joints. \n\n\n• severe pain. \n\n• signs of anemia with joint pain (see page 1 16 on anemia). \n\n\nWARNING! If there is pain in one leg that will not go away, it \nmay be a blood clot. See page 273 and get medical help. \n\n\nwww. nesperian.org \n\n\n81 \n\nA Book for Midwives (201 0) \n\n\npregnancy \n\n\nChapter 6: Common body changes in pregnancy \n\n\nChanging feelings and emotions \n\nPregnancy is an important time in a woman's life. Her baby \nis growing inside her, her body is changing, and she needs \nmore food and more rest. As a woman's body changes, \nher relationships, her sexuality, and her work life \ncan change too. \n\n\nIt s normal, Alfredo, \nshe's pregnant! \nShe just needs you \nto listen and stay \nclose to her. \n\n\nMaria! \n\nWhat's wrong i \nCan I help? \n\n\n( No . (sob) I'm fine. \nI I don't even know \nI why I'm crying. \n\n\nSudden changes in feelings \n\nPregnancy can make women very emotional \nSome women laugh or cry for no \nclear reason. Some feel depressed, \nangry, or irritable. \n\nOdd laughing or crying and \nother sudden mood changes or strong \nfeelings are normal. They usually pass quickly. \n\nBut do not ignore a woman's feelings simply \nbecause she is pregnant. Her feelings are real. \n\nWorry and fear \n\nMany women worry when they are \npregnant, especially about the baby's health \n\nand about giving birth. A woman's worries about other problems in her life \nmay also become stronger when she is pregnant. \n\n\nSuch worries are normal. They do not mean that something bad will happen. \nWomen with these feelings need emotional support, like someone to listen to their \nworries and encourage them to feel hopeful. They may also need help to solve the \nproblems they are having in their lives, like problems with their partners, money, \ndrugs or alcohol, or other issues. \n\n\nStrange dreams and nightmares \n\nPregnant women may have strong, vivid dreams. \n\nThey can be beautiful, strange, or frightening. \n\nFor many people, dreams are an important way of \nunderstanding themselves and the world. Some people \nbelieve that dreams can tell us about the future or give \nus messages from spirits. \n\nBut usually, when something happens in a dream, \nthat does not mean that it will happen to us in life. The events in the dream may \nbe telling us what we are afraid of or what we desire. Or they may simply be stories \nour minds make up while we sleep. Women who are having frightening dreams \nmay need someone to talk to about their hopes, fears, and feelings. \n\n\n82 \n\n\nA Book for Midwives (201 0) \n\n\nwww. Hesperian. ore \n\n\nChanging feelings and emotions \n\n\nForgetfulness \n\nSome women forget things when they are pregnant. For most \nwomen, this is not a big problem. But some may worry if they \ndo not know it is normal. No one knows why women become \nmore forgetful when they are pregnant, but it is common. \n\n\nFeelings about sex \n\nSome women do not want much sex when \nthey are pregnant. Others want sex more \nthan usual. Both feelings are normal. \n\nHaving sex and not having sex are both OK \nfor the woman and her baby. Sex is not \ndangerous for the baby. \n\nSometimes sex is uncomfortable in \npregnancy. A woman and her partner can try different positions for making love. It \nmay feel better with the woman on top, or in a sitting or standing position, or \nwith the woman lying on her side. \n\nThere are other ways, besides sexual intercourse, for couples to be close and please \neach other. Some couples touch and massage each others bodies. Some talk about \nhopes and fears together. \n\n\nSafer sex \n\nWhen a pregnant woman has sex, it is important \nto avoid infection by making sure that anything \nput inside her body is clean. This includes the \npenis and hands. \n\nA man who is having sex with more than \none woman must always use condoms — \nincluding with his pregnant partner. \n\nCondoms are a good way to prevent infections, \nHIV, and other illnesses. See Chapter 18 to \nlearn more about HIV and other sexually \ntransmitted infections. \n\n\nSex and early labor \n\nA woman who has gone \ninto early labor in other \npregnancies might \nchoose to avoid sex after \nthe 6th month. This may \nhelp prevent going into \nlabor too early. \n\n\nwww. nesperian.org \n\n\n83 \n\nA Book for Midwives (201 0) \n\n\npregnancy \n\n\nChapter 7 \n\nLearning a pregnant woman's health history \n\n\nn this chapter: \n\n\nQuestions in a pregnancy health history \n\n\nDoes she have signs of pregnancy? ... 86 \n\nHow pregnant is she now? \n\nWhen is the baby due? 88 \n\nHow old is she? 90 \n\nHow many children has she had? .... 90 \n\nHas she had any miscarriages or \nabortions? 91 \n\nHas she had any problems with past \npregnancies or births? 93 \n\nIs she healthy? 97 \n\nMalaria 98 \n\nHIV and AIDS 99 \n\nHas she been vaccinated against \ntetanus? If yes, when? 101 \n\nIs she taking any medicines now? ... 103 \n\n\n86 \n\nHas any medicine ever given her \nproblems? 103 \n\nWhat else in her life might affect her \npregnancy and birth? 104 \n\nMoney 104 \n\nLiving conditions 104 \n\nDistance from care 104 \n\nWork 105 \n\nFamily 105 \n\nMaking a transport plan 106 \n\n\n84 \n\n\n1 ** l if f Skit or \n\nwww. nesperian.org \n\n\nLearning a pregnant \nwoman's health history \n\n\nTo give good care to a pregnant woman, you should find out about her general \nhealth, her past health, and her past pregnancies and births. You also need to know \nwhat this pregnancy has been like so far. This is called a health history. \n\nLearning a woman's health history will help you give advice to make this \npregnancy and birth as safe as possible. \n\nThe best way to learn about a woman's history is to ask her. At first, she may not \nbe comfortable talking with you. If she feels shy about her body or about sex, it may \nbe difficult for her to tell you things that you need to know about her health. Try to \nhelp her feel comfortable by listening carefully, answering her questions, keeping \nwhat she tells you private, and treating her with respect. \n\nThis chapter suggests questions to ask each woman so you can learn more \nabout her. You probably have some questions of your own that you want to ask \nbut that we do not include here. For example, if there is hepatitis B in your \ncommunity, you may want to ask the woman if she has hepatitis B or tell her how \nto prevent it. Think about the information \nyou need to know in order to give f \ngood care. What questions do you \nusually ask a pregnant woman? \n\nIf you can, write down what you \nlearn about each pregnant woman. \n\nThis information may be needed \nlater in the pregnancy, or during \nlabor or birth. \n\nAfter learning a woman's health \nhistory, and every time you meet \nwith a pregnant woman, you \nshould do a regular pregnancy \ncheckup. The next chapter of this \nbook, Chapter 8, explains how to \ndo the regular pregnancy checkup. \n\n\nwww. hesperian.org \n\n\n85 \n\n\nChapter 7: Learning a pregnant woman's health history \n\n\nQuestions in a pregnancy health history \nDoes she have signs of pregnancy? \n\nSome signs of pregnancy are sure signs — they mean the woman is definitely \npregnant. Some signs are probable signs, meaning the woman is probably \npregnant, but the sign could be caused by something else. \n\nProbable signs of pregnancy \n\nThe woman's monthly bleeding stops. This is often the first sign of pregnancy. \nOther possible causes of this sign are poor nutrition, emotional troubles, or \nmenopause (change of life). \n\nThe woman has nausea or wants to vomit. Many pregnant \nwomen have nausea in the morning (which is why this feeling \nis often called \"morning sickness\"), but some women may feel \nthis way all day. Nausea is common during the first 3 months \nof pregnancy. Other possible causes of this sign are illness or \nparasites. \n\nThe woman feels tired and sleepy \nduring the day. This is common in the \nfirst 3 or 4 months of pregnancy. Other \npossible causes of this sign are anemia \n(see page 116), poor nutrition, \nemotional troubles, or too much work. \n\nThe woman needs to urinate often. This is most common \nduring the first 3 months and the last 1 or 2 months of \npregnancy. Other possible causes of this sign are stress, \nbladder infection (see page 128), or diabetes \n(blood sugar disease — see page 115). \n\n\nThe woman's belly grows. After 3 or 4 months, \nthe pregnancy is usually big enough to be seen from \nthe outside. Other possible causes of this sign are that the \nwoman has a cancer or another growth in her belly \nor that she is just getting \n…[truncated]", "summary": "A Book for Midwives Care for pregnancy, birth, and women's health Susan Klein, Suellen Miller, and Fiona Thomson Hesperian Berkeley, California, USA The Hesperian Foundation and the contributors to A Book for Midwives do not assume liability for the use of information contained in this book. All health workers have a responsibility to be honest with themselves and the people they care for about the limits of their …", "source_url": "https://archive.org/details/ABookForMidwives", "pdf_url": "https://archive.org/details/ABookForMidwives", "case": "hesperian", "sub_case": "SUSAN KLIEN", "tags": ["hesperian", "RADICAL MEDICINE; PEOPLE'S HEALTH."], "page_count": 0} {"title": "Right and Wrong use of modern medicine. Lesson from Book \"Where there is no doctor\"", "content": "| COMMUNITY HEALTH CSL. al \n47/1, (First Floor) St. Marks Road, “aes — \nRangalore - 560 001, aes . | \n\n\nRIGHT AND WRONG USES \nOF MODERN MEDICINES — \n\n\nYS \n. \n\n\n53 \nons os \nwen es \n\n\" et \nas, | \n: ted) \n=. 3 \na's, \nLora \n\n\n_ This is a reprint from \n\n\n4 here if Ss No Doctor \n\n\n_ (Indian adaptation ) \n\n\nae \n> \nMe \n2 \n! Seat \n~e \naor \n= \n\n\npublished by the \n\n\nVoluntary Health Association of India \nC-14 Community Centre \nSafdarjung Development Area \nNew Delhi 110016 \n\n\n61 \nCOM Me ALT \n\n\n- \n\n\nCHAPTER \n\n\nRIGHT AND WRONG USES \nOF MODERN MEDICINES \n\n\nSome medicines sold in pharmacies or village stores can be very useful. Others \nare of no value. Also, people sometimes use the best medicines in the wrong way, \nso that they do more harm than good. To be helpful, medicine must be used \ncorrectly. \n\n\nMany people, including most doctors and health workers, prescribe far more \nmedicines than are needed—and by so doing cause much needless sickness and \ndeath. | \n\n\nThere is some danger in the use of any medicine. \n\n\nSome medicines are much more dangerous than others. Unfortunately, people \nsometimes use very dangerous medicines for mild sicknesses. (| have seen a baby \ndie because his mother gave him a dangerous medicine, chloramphenicol, for a \ncold.) Never use a dangerous medicine for a mild illness. \n\n\n~- — ~- \nae corel tD e — \non: — pant ie \n\n\nGuidelines for the use of medicine: \n\n\n1. Use medicines only when necessary. \n\n\n2. Know the correct use and precautions for any medicine you use (see the \n_ GREEN PAGES). os \n\n\n3. Be sure to use the right dose. \n4. |f the medicine does not help, or causes problems, Stop using it. \n\n\n5. When in doubt, seek the advice of a health worker. \n\n\n6. Always check the expiry date (\\ast date before which to use) of the medicine. If \nthe medicine is given after this date, it may do more harm than good. \n\n\nNote: Some health workers and many doctors give medicines when none is \nneeded, often because they think patients expect medicine and will not be \nsatisfied unless they get some. Tell your doctor or health worker you only want \n\n\n62 \n\n\nmedicine if it is definitely needed. This will save you money and be safer for your \nhealth. \n\n\nOnly use a medicine when you are sure it is needed \n\n\nand when you are sure how to use it. \n\n\nTHE MOST CANGEROUS MISUSE OF MEDICINE \n\n\nHere is a list of the most cornmon and dangerous errors people make in using \nmodern medicines. The improper use of the following medicines causes many \ndeaths each year. BE CAREFUL! \n\n\n1. Chloramphenicol (Ch/ioromycetin) (p. 401) \n\n\nThe popular use of this medicine for simple diarrhea and other \nmild sicknesses is extremely unfortunate, because it is so risky. \nUse chloramphenicol only. for very severe illnesses, like typhoid \n(see p. 229). Never give it to newborn infants. \n\n\n2. Oxytocin (Pitocin), Pituitrin, and Ergonovine (Ergotrate) (p. 424) \n\n\nUnfortunately, some midwives use these medicines to speed up \nchildbirth or ‘give strength’ to the mother in labor. This practice \nis very dangerous. It can kill the mother or the child. Use these \nmedicines only to control bleeding after the child is born (see \n0.312). \n\n\n3. Injections of any medicine \n\n\nThe common belief that injections are usually better than \nmedicine taken by mouth is not true. Many times \n\n\nmedicines taken by mouth work as well as or better than \ninjections. Also, most medicine is more dangerous \ninjected than when taken by mouth. Use of injections \n\n\nshould be very limited (read Chapter 9 care \n\n\n4. Penicillin \n\n\nPenicillin works against only certain types of infections. Frequent use of penicillin \n\n\nfor sprains, bruises, or any pain or fever is a great mistake. As a general rule, injuries \nthat do not break the skin, even if they make large bruises, have no danger of \ninfection; they do not need to be treated with penicillin or any other antibiotic. \n\n\nPenicillin ointment or powder used.on the skin can make the person sensitive to \npenicillin. \n\n\nPenicillin is dangerous for some people. Before using it, know its risks and \n\n\nprecautions you must take (see p. 70 } \n\n\n63 \n\n\n5.__Injections of penicillin with streptomycin (p. 400). \na Pen streptomycin \n\n\nhere are many familiar brands names. \nThese medicines are used too much and often for the wrong \nreason. They should not be used for colds for two reasons \n\n\nla. They do not work against colds and flu.. \n1b. They can cause serious problems, sometimes deafness \nor death. \n\n\n2. Give streptomycin for treatment of tuberculosis only. \nIf you give it for any other disease, the person may \nbecome resistant to streptomycin, and then will have \nto take more expensive medicines to cure tuberculosis. \nDo not give this medicine for any other disease. \n\n\n6. Vitamin B72 and liver extract (p. 425) \n\n\nThese medicines do not help anemia or ‘weakness’ except in \n\nrare cases. Also, they have certain risks when injected. They \n\nshould only be used when a health worker has prescribed them \n>.< after testing the blood. |n nearly every case of anemia, iron pills \nfo) will do more good (see p. 147)* \n\n\n7. Other vitamins (0.424) \n\n\nAs a general rule, DO NOT INJECT VITAMINS. Injections are more dangerous, \nmore expensive, and usually no more effective than pills. \n\n\nUnfortunately, many people waste their money on syrups, tonics, and ‘elixirs’ \nthat contain vitamins. Many lack the most important vitamins (see p.139'). But \neven when they contain them, it is wiser to buy more and better food. Body- \nbuilding and protective foods like beans, vegetables, fruits,e€99S, and meat. \nare rich in vitamins and other nutrients (see p.129 -131). Giving a thin, weak \nperson good food more often will usually help him far more than giving him \nvitamin and mineral supplements. \n\n\nA person who eats well does not need extra vitamins. \n\n\nTHE BEST WAY TO GET VITAMINS: \n\n\n2 2 \n\n\nCS) am These CAL) pein These b Aem™ This \nare Y are is \nDee ad G) better better better \nthan than than \nAm / these. a this. emer” this. mF \n\n\nex | \n\n\nbe) \n\n\n64 \n\n\nFor more information about vitamins, when they are necessary, and the foods | \nthat have them, read Chapter 11, especially pages 129 and 138 \n\n\n8. Calcium \nInjecting calcium into a vein can be extremely dangerous. It can — \n‘oe quickly kill someone if not injected very slowly. Injecting \n\n\nSS calcium into the buttocks sometimes causes very serious \nabscesses or infections. ; \n\n\nNever inject calcium without first seeking medical advice! \n\n\n| Note: !n countries where people eat a lot of corn or \nother foods prepared with lime, it is foolish to use calcium injections or tonics (as \nis often done to ‘give strength’ or ‘help children grow’). The body gets all the \ncalcium it needs from the lime. \n\n\n9. ‘Feeding’ through the veins (Intravenous or ‘I.V.’ solutions) \n\n\nIn some areas, persons who are anemic or very weak spend their last paise, to \nhave a liter of |.V. solution put into their veins. They believe that this will make \nthem stronger or their blood richer. But they are wrong! \n\n\nIntravenous solution is nothing more than pure water with some salt or sugar in \nit. It gives less energy than a large candy bar and makes the blood thinner, not \nricher. It does not help anemia or make the weak-stronger. | \n\n\nAlso when a person who is not well trained puts the |.V. solution into a vein, \nthere is danger of an infection entering the blood. This can kill the sick person. \n\n\nIntravenous solution should be used only when a person can take nothing by \nmouth, or when he is badly dehydrated (see p.183). \n\n\nOnly a trained health worker should give these solutions. \n\n\nIf the sick person can swallow, give him a liter of water with a little sugar and \nsalt (see Rehydration Drink, p.182). It will do as much for him as injecting a liter \nof |.V. solution. \n\n\nFor people who are able to eat, nutritious foods do more to \nstrengthen them than any type of I.V. fluid. \n\n\n65 \n\n\nIf a sick person is able to swallow and keep down liquids... \n\n\nme — This \nis ne is \nbetter = 4 better \nthan ES 4 than \nthis. ‘Cn this. \nTer bee: a \nxO d \nWw “ \ni. 4 ¢ \n\n\n10. Laxatives and Purges (p. 417) \n\n\nIt is always dangerous to give a laxative or purge to a baby or \nto anyone who Is very weak, dehydrated, or has severe pain \nin his belly. Unfortunately, people often believe that purges \nbring back health or clean the bad things out of the body. In \nChapter 1 it is explained that purges or strong laxatives \nnearly always do more harm than good. \n\n\nTo learn the correct uses of laxatives and enemas, see p. 21. \n\n\nWHAT TO EAT WHEN TAKING MEDICINES \n\n\nMany people believe that they should avoid eating certain foods like brinjal \ntomato, curds, oranges, guavas, eggs, meat and cooking oil when they take any \nmedicine. They think all medicines will do harm if they are taken with these foods. \nThis is not true ! No medicines causes harm juat because it is taken with these foods. \n\nBut in case of some illnesses, certain foods can make the illness more severe \nbecause the body cannot digest these foods: | 3 \n\n\nPM ici tcev nc «5.s00s0sdaccemceae see p 149 \n\nUEC OIOIIIG, 6.5. ..5:10cvsherkseectes see p. 371 \n\nhigh blood pressure..............00cc00., see p.148 \n\ngall bladder problems...........ccccccccccccs, see p.375 \nstomach ulcers and heart burn..............0....... see p.150 \nurinary tract infection in children........... see p. 357° \n\n\nCertain foods can cause serious damage in these illnesses, whether or not any \nmedicine is being taken. Certain medicines will cause bad reactions if a person \ntakes alcohol (see metronidazole, page 407 \n\n\n66 \n\n\nWHEN SHOULD MEDICINE NOT BE TAKEN? \n\n\nThere are situations when, without a doubt, it is best not to use certain \nmedicines: \n\n\n1. Pregnant women or women who are breast feeding should \navoid all medicines that are not absolutely necessary. \n(However, they can take vitamins or iron pills without \ndanger.) \n\n\n2. With newborn children, be very careful when using \nmedicines. Whenever possible look for medical help before \ngiving them any type of medicine. Be sure not to give too \nmuch. : \n\n\n3. A person who has ever had any sort of allergic reaction— \nhives, itching, etc.—after taking penicillin, ampicillin, a \nsulfonamide, or other medicines, should never use that \nmedicine again for the rest of his life because it would be \ndangerous (see Dangerous reactions from injections of \ncertain medicines, p. 83). \n\n\n4. Persons who have ulcers or heartburn should avoid \nmedicines that contain aspirin. \n\n\n5. There are specific medicines that are harmful or dangerous \nto take when you have certain illnesses. For example, persons \nwith hepatitis should not be treated with antibiotics or other \nstrong medicines, because their liver js damaged, and the \nmedicines are more likely to poison the body (see p.210). \n\n\n6. Persons who are dehydrated or have disease of the kidneys should be especially \ncareful with medicines they take. Do not give more than one dose of a medicine \nthat could poison the body unless (or until) the person is urinating normally. For \nexample, if a child has high fever and is dehydrated (see p.88), do not give him \nmore than one dose of aspirin until he begins to urinate, Néver give sulfa to a \nperson who is dehydrated. \n\n\nThe book Where There I $s No Doctor is available \nat Rs 29/- plus postage. Multiple copies of reprints \nof various chapters are also available, | \n\n\nPlease write to: \n\n\nPublications Officer \n\nVoluntary Health Association of India \nC-14 Community Centre : \nSafdarjung Development A rea \n\n\nlhi 110016 \nNew Delhi Re. 2.50 \n\n\n", "summary": "| COMMUNITY HEALTH CSL. al 47/1, (First Floor) St. Marks Road, “aes — Rangalore - 560 001, aes . | RIGHT AND WRONG USES OF MODERN MEDICINES — YS . 53 ons os wen es \" et as, | : ted) =. 3 a's, Lora _ This is a reprint from 4 here if Ss No Doctor _ (Indian adaptation ) ae > Me 2 ! Seat ~e aor = published by the Voluntary Health Association of India C-14 Community Centre Safdarjung Development Area New Delhi 110016 61 COM Me ALT - …", "source_url": "https://archive.org/details/sochara.rightwronguseofm0000wern", "pdf_url": "https://archive.org/details/sochara.rightwronguseofm0000wern", "doc_date": "1981", "case": "hesperian", "sub_case": "Werner, David", "tags": ["hesperian"], "page_count": 0} {"title": "Disabled Village Children. A Guide for Community Health Workers, Rehabilitation Workers, and Families. First Edition.", "content": "ED 288 319 \n\n\nAUTHOR \nTITLE \n\n\nINSTITUTION \nREPORT NO \n\nPUB DATE \n\nNOTE \n\nAVAILABLE FROM \n\n\nPUB TYPE \n\n\nEDRS PRICE \nDESCRIPTORS \n\n\nABSTRACT \n\n\nEC 200 797 \n\n\nWerner, David \n\nDisabled Village Children. A Guide for Community \nHealth Workers, Rehabilitation Workers, and Families. \nFirst Edition. \n\nHesperian Foundation. Palo Alto, CA. \nISBN-0-942364-06-6 \n\nMay 87 \n\n703p. \n\nHesperian Foundation, P.O. Box 1692, Palo Alto, CA \n94302 ($9.00, 12 or more, $7.00 each). \n\nGuides - Non-Classroom Use (055) -- Reference \nMaterials - General (130) \n\n\nMFO04/PC29 Plus Postage. \n\nAdaptive Behavior (of Disabled); Adolescents; \n*Assistive Devices (for Disabled); Attitude Change; \nCareer Development; Child Development; Children; \nClinical Diagnosis; *Community Health Services; \n*Developing Nations; *Disabilities; Educational \nDiagnosis; Family Programs; *Handicap Identification; \nIllustrations; Parent Child Relationship; *Parent \nEducation; Prostheses; Rehabilitation; Self Care \nSkills; Sex Education; Teacher Attitudes; Young \nAdults \n\n\nThis heavily illustrated volume is a reference book \n\n\nintended to bring together basic information to help community health \n\n\nworkers, \n\n\nrehabilitation workers, and families in rural areas of \n\n\ndeveloping countries meet the needs of village children with a wide \nrange of disabilities. Part 1, \"Working with the Child and Family,\" \nreviews the prevention of disabilities (examining and evaluating the \ndisabled child) and simple ways to measure and record a child's \nprogress. A guide for identifying disabilities includes detailed \ndescriptions and illustrations of the most common disabilities found \nin developing countries. Also included is information on early \nstimulation and developmental activities for delayed infants and for \nyoung children with mental or physical delays, guidance on how to \nhelp children become more self-reliant, and exercises and techniques \nfor managing physical disabilities. Part 2, \"Working with the \nCommunity,\" includes sections on starting village-based \nrehabilitation activities, building playgrounds for all children, \nhelping teachers and children understand disabled children, using \npopular theater to raise awareness and gain greater community \nparticipation, and establishing a children's workshop for making \ntoys. It also discusses how to organize, manage, and finance a \nvillage rehabilitation program; adaptation of the home and community \nto the needs of the disabled; concerns of the disabled about love, \nsex, and social adjustment; the role of education at home, school, \nand work; work possibilities and training; and descriptions of \nsuccessful community-directed programs. Part 3, \"Working in the \nShop,\" provides specific instructions and advice about setting up a \nworkshop to make rehabilitation aids and procedures to be followed in \nproviding aids such as braces and casts, developmental and walking \naids, wheelchairs, and artificial limbs. The volume also includes a \nnine-page list of references, a glossary, and an index. This \npublication is announced in the May 1987 issue of \"Newsletter from \nthe Sierra Madre,\" which is appended. The newsletter includes a \nstory, article, photographs, and illustrations which describe the \nwork of Project Projimo and Project Piaxtla, of western Mexico, where \n\n\nthis book had its start and was field tested. \n\n\n(JW) \n\n\n. eB aS \n. . eI = \n.. a ee \neee = = «& \n> be 3. os 3 Ms \nBREESE. © \n~~ ' * 2 - ’ \n\n\n: “PERMISSION TO REPRODUCE THIS \n. va oF soucarion ; MATERIAL HAS BEEN GRANTED BY \nfoe) TIONAL RESOURCES INFORMATION \n\n\nCENTER (ERIC) \n\n\nOC) This document has been reproduced es \nreceived from the person or organization : —_—_ \n« [= onginating it i \nCD Minor changes have been made to improve \n\n\nLil reproducticn quality \n\n\nLS ‘ \n\nTO THE EDUCATIONAL RESOURCES \nPointe of view mons stated i docu \n\n. e i won ne oat nine : INFORMATION CENTER (ERIC).” \n\n\nEST COPY AVAILABLE \n\n\nHOW TO USE THIS BOOK \n\n\nThis is a reference book to help you meet the needs of disabled children. You need \n)t read it from cover to cover. Use |t to look up particular information as you need it. \nTo learn how the book is n i \norganized, and why, we suggest ya ] a. ae YING \nyou read ABOUT THIS BOOK at the hide Ht \nt \"rn \n\n\nbeginning. Also, please read Ho Introduction to PART 1 \nthe introduction to each of the \n3 main parts of the book. These \nchapters have page edges with a | \nshort black line, to help you find | \nthe beginning of PARTS 1, 2, and 3 . | \n| \n\n\nHome |e x \n\n\n1 to PART 2 \n{=a to PART 3 \n\n\nTo work more effectively with disabled S| \nchildren, we strongly suggest that you read \nthe first 5 chapters of PART 1. These wil! help you to examine a ch \ndifferent disabilities, and to keep important records in an easy way \n\n\nTHERE ARE SEVERAL WAYS TO FIND INFORMATION THAT YOU ARE \nLOOKING FOR: \n\n\n@ Check the list of CONTENTS at the beginning of the book. This tells you what \neach chapter is about and gives the page numbers. \n\n\nLook in the INDEX at the end of the book. It lists topics in alphabetical order \n(The edges of these pages are al! black.) \n\n\nIf you do not know what disability a child has, use the GUIDE FOR \nIDENTIFYING DISABILITIES on p. 52 to 58. It lists the common signs of \ndifferent disabilities and gives the page numbers. (There are several black lines \non the edges of these pages. ) \n\n\nThroughout the book you will find this symbol Cr) in the margin of some pages. It \nappears where there is information for cerebral palsy. \n\n\nIf you want more information than is in this book, see the list of books and teaching \nmaterials entitled REFERENCES (Where to Get More Information), p. 637. \n\n\nIf you do not know what some words mean, !ook in the LIST OF SPECIAL OR \nDIFFICULT WORDS, p. 643. Words explained in this LIST are written in /ta/ics when \nfirst used in a chapter \n\n\nIMPORTANT: To find all the information you will need for one disabled child, you \nwill usually need to look in several different chapters. To know where to look, follow \nthe page references shown. These are explained inside the back cover. \n\n\n“Asterisk: This little star is called an asterisk. It is used to indicate that there is more \ninformation about a word or an idea at the bottom of the page \n\n\npanel x For more information on how to use this \nbook, see the inside of the back cover \n\n\nJ \n\n\nDisabled Village Children \n\n\nA guide for community health workers, rehabilitation \nworkers, and families \n\n\nBy David Werner \nwith the help of many friends \n\n\nLibrary of Congress Cataloging in Publication Data \nCatalog Card No.: 86-81738 \nWerner, David Bradford \nDisabled Village Children \nPalo Alto, CA: Hesperian Foundation \n672 p. \nISBN: 0-942364-06-6 \n\n\nPUBLISHED BY: \n\nThe Hesperian Foundation \n\nP.O. Box 1692 \n\nPalo Alto, CA 94302, U.S.A. \nCopyright © 1987 by the Hesperian Foundation \n\n\nFirst Edition, May, 1987 \n\n\nAny parts of this book, including the illustrations, may be copied or adapted to \nmeet local needs, without permission from the author or publisher, provided the parts \ncopied are distributed free or at cost—not for profit. For any reproduction done \ncommercially, permission must be obtained from the author or the Hesperian \nFoundation. The author would appreciate being sent a copy of any materials in which \ntext or illustrations have been used. To avoid duplication of efforts, before beginning \nany translation, we suggest you contact the Hesperian Foundation. \n\n\nin order to keep down the cost, we are not using a commercial publisher. This means \nwe need help with distribution. We are looking for ways to get this book to those it can \nserve best. |f you are able to help or have suggestions, please write to us. \n\n\nThis book is dedicated to disabled children everywhere, \nwith the hope that they and their families \n\nwill help lead the world \n\nto be more loving, understanding, \n\nand just for everyone. \n\n\nREQUEST FOR YOUR SUGGESTIONS, \nCRITICISMS, AND IDEAS \n\n\nThis book is an attempt to pull together basic \ninformation to help you meet the needs of \nvillage children with a wide range of disabilities \n\n\nWe have done the best we can, given our \nlimitations. We know the book is not perfect \nand that it has weaknesses and perhaps some \nmistakes \n\n\nWe urge anyone reviewing or using the book \nwhether a disabled person, parent, health \nworker, or professional, to send us all your \ncriticism and suggestions. Help us to make \nimprovements for a later edition. Thank you \n\n\nWE WOULD APPRECIATE ANY \nSUGGESTIONS YOU MAY HAVE \nFOR WAYS THAT THIS BOOK \nMIGHT BE IMPROVED TO SERVE \nYOUR RURAL AREA BETTER \n‘ . \n\n\na \\ \n\n\nCONTENTS \n\n\nChapter \n¢ \n\n\nABOUT THIS BOOK \n\n\nPART 1 WORKING WITH THE CHILD AND FAMILY: Information on Different Disabilities \n\n\n1. Introduction to PART 1: Making Therapy Functiona! and Fun \n\n\nA. Where Do We Start? \n2. Ideas for Sharing Information from This Book \n3. Prevention of Disabilities \n4. Examining and Evaluating the Disabled Child \n5. Simple Ways to Measure and Record a Child's Progress \n\n\n. Recognizing, Helping with, and Preventing Common Disabilities \n6. Guide For identifying Disabilities \n\nPolio \nContractures: Limbs That No Longer Straighten 7 to 86 \nCerebral Palsy (difficulty with movements because of brain damaas 87 to 108 \nMuscular Dystrophy: Gradual, Progressive Muscle Loss 109 to 112 \nClub Feet, Flat Feet, Bow Legs, and Knock-knees 113to 118 \nCommon Birth Defects (cleft lip, extra or joined fingers \nincomplete limbs, and arthrogryposis) 119 to 124 \nChildren Who Stay Small or Have Weak Bones (includes Ricket \nBrittle Bone Disease, and Dwarfism 125 to 126 \nErb's Palsy: Arm Paralysis from Birth Injury 127 to 128 \nPainful Joints (includes How to Use Aspirin 129 to 134 \nJuvenile Arthritis 135 to 152 \nRheumatic Fever 153 to 154 \nHip Problems 155 to 158 \nBone Infections 159 to 160 \nSpinal Curve and Other Back Deformities 161 to 164 \nTuberculosis of the Backbone: Pott's Disease 165 to 166 \nSpina Bifida (babies born with a defect over their backbone 167 to 174 \nSpinal Cord Injury 175 to 194 \nPressure Sores 195 to 202 \nUrine and Bowel Management: With Spinal Cord Injury and Spina Bifida \n(includes Urinary Infections 203 to 214 \nLeprosy 215 to 226 \nAmputations 227 to 230 \nBurns and Burn Deformities 231 to 232 \nFits: Epilepsy 233 to 242 \nBlindness and Difficulty Seeing 243 to 256 \n\n31. Deafness and Communication 257 to 276 \n\n32. Mental Retardation: Down Syndrome, Cretinism, and Other Causes 277 to 282 \n\n33. The Child With Several Severe Disabilities 283 to 286 \n\n\n. Helping the Child Whose Mind and/or Body are Slow to Develop \n34. Child Development and Developmental Delay 287 to 300 \n35. Early Stimulation and Development Activities 301 to 318 \n1) Head Control and Use of Senses \n2) Rolling and Twisting \n3) Gripping, Reaching, and Hand-eye Coordination \n4) Body Control, Sitting, and Balance \n\n\n6) Standing, Walking, and Balance \n7 \n8 \n\n\nCommunication and Speech \nEarly Play Activities and Toys \n\n\n) \n) \n) \n5) Creeping and Crawling \n) \n) \n) \n\n\nD. Helping Children Develop and Become More Self-reliant \n\n\n36 \n37 \n38 \n39 \n40 \n41 \n\n\nFeeding \n\nDressing \n\nToilet Training \n\nBathing (includes Care of the Teeth and Gums) \n\nWays to Improve Learning and Behavior \n\nLearning Disabilities in Children with Normal Intelligence \n\n\n. Exercises and Techniques \n\n\n42 \n43 \n\n\nRange-of-motion and Other Exercises \nCrutch Use, Cane Use, and Wheelchair Transfers \n\n\nPART 2 WORKING WITH THE COMMUNITY: Village Involvement in the \nRehabilitation, Social Integration, and Rights of Disabled Children \n\n\n44. \n45. \n46. \n47. \n\n\n48 \n49 \n\n\n50. \n\n\n51 \n\n\n52. \n53. \n54. \n\n\n55 \n\n\nIntroduction to PART 2: Disabled Children in the Community \nStarting Village-based Rehabilitation Activities \n\nPlaygrounds for All Children \n\nCHILD-to-child: Helping Teachers and Children Understand \nDisabled Children \n\nPopular Theater \n\nA Children's Workshop for Making Toys \n\nOrganization, Management, and Financing of a Village \nRehabilitation Program \n\nAdapting the Home and Community to the Needs of the Disabled \nLove, Sex, and Social Adjustment \n\nEducation: At Home, at School, at Work \n\nWork: Possibilities and Training \n\nExamples of Community-Directed Programs \n\n\nPART 3 WORKING IN THE SHOP: Rehabilitation Aids and Procedures \n\n\n56. \n\n\n57 \n58 \n\n\n59. \n\n\n60 \n\n\n61. \n62. \n\n\n63 \n\n\n64. \n65. \n66. \n67. \n\n\nIntroduction to PART 3: Making Sure Aids and Procedures Do \nMore Good than Harm \n\nA ‘Shop for Making Aids’ Run by Disabled Villagers \n\nBraces (Calipers) \n\nCorrecting Joint Contractures (with casts or braces) \nCorrecting Club Feet (with tape or plaster casts) \nHomemade Casting Materials \n\nDevelopmental Aids (for lying, sitting, standing, balance, and \ncommunication) .... \n\nWalking Aids (bars, crutches, walkers, canes) \n\nDecisions about Special Seats and Wheelchairs \n\nAdaptations for Wheelchairs and Other Sitting Aids \n\nDesigns for 6 Basic Wheelchairs \n\nArtificial Legs \n\n\nREFERENCE (Where To Get More Information) \n\n\nLIST OF SPECIAL OR DIFFICULT WORDS Used In This Book \n\n\nINDEX \n\n\nSHAS \n\n\n319 to 332 \n333 to 336 \n337 to 344 \n345 to 348 \n349 to 364 \n365 to 366 \n\n\n367 to 392 \n393 to 398 \n\n\n401 to 404 \n405 to 414 \n415 to 426 \n\n\n427 to 454 \n455 to 462 \n463 to 476 \n\n\n477 to 484 \n485 to 490 \n491 to 496 \n497 to 502 \n503 to 514 \n515 to 522 \n\n\n525 to 532 \n533 to 538 \n539 to 558 \n559 to 564 \n565 to 568 \n569 to 570 \n\n\n571 to 578 \n579 to 588 \n589 to 606 \n607 to 612 \n613 to 624 \n625 to 636 \n\n\n637 to 642 \n\n\n643 to 644 \n\n\n645 to 654 \n\n\nTHANKS \n\n\nThis book has been a cooperative effort. Many persons have contributed in different ways. Some \nhave helped to write or rewrite different sections. Some have criticized early drafts. Some have used it in \ntheir programs and sent us feedback. Some have sent original ideas or technologies that we have tested \nand then included. In all, persons or programs from 27 countries on 6 continents (North and South \nAmerica, Africa, Asia, Europe, Australia) have contributed \n\n\nThe entire book has been carefully reviewed by specialists in related fields: physical therapists (PTs) \noccupational therapists (OTs), orthotists, prosthetists, wheelchair designers, rehabilitation engineers \nand leaders from among the disabled. | cannot include the names of all those who have helped in so \nmany ways, but the help of the following has been outstanding \n\n\nSophie Levitt, PT: Ann Hallum, PT: Terry Nordstrom, PT \nAnne Affieck, OT; Mike Miles, rehab planner and critic \nChristine Miles, special educator, Farhat Rashid. PT. Bruce \nCurtis, peer disabled group counselor; Ralf Hotchkiss \nwheelchair rider/engineer: Alice Hadley, PT: Jan Postma \nPT, Jean-Baptiste Richardier, prosthetist; Claude Simonnot \nMD/prosthetist; Wayne Hampton, MD/prosthetist: Jim \nBreakey, prosthetist; Wally Motlock, orthotist: Valery Taylor \nPT. Dr P K. Sethi, orthopedic surgeon/prosthetist: Pam \nZinkin, pediatrician/CBR expert: Paul Silva. wheelchair \nbuilder, David Morley, pediatrician; Elia Landeros, PT: Teresa \nPaez. social worker, Rafiq Jaffer, rehab specialist: Kris \nBuckner. parent of many adopted disabled children: Barbara \nAnderson, PT: Don Caston, rehab engineer; Greg Dixon \nDirector, Partners Appropriate Technology In Health: Susan \nHammerman, Director, Rehabilitation International: Carole \nColeman, specialist in sign language; Suzanne Reier \nrecreation therapist; Sarah Grossman, PT; Donald Laub \nplastic surgeon; Jean Kohn, MD in rehabilitation: Bob \nFredricks, orthotist, Katherine Myers, spinal cord injury nurse \nGrace Warren, PT in leprosy, Jean M. Watson, PT in leprosy \nDavid Sanders, pediatrician; Jane Neville. leprosy expert \nStanley Browne, MD. leprosy; Alexandra Enders, OT: John \nMcGill, prosthetist, Victoria Sheffield, Rita Leavell, MD, Jeff \nWatson, J. Kirk Horton, Lawrence Campbell, Helen Keller \nInternational, Owen Wrigley, |IHAP; Roswitha and Kenneth \nKlee, Winfried Lichtemberger, Jeanne R. Kenmore \nChristoffel Bliindenmission, Judy Deutsch, PT: Jane Thiboutot \nPT. RL Huckstep, MD; Linda Goode, PT; Susan Johnson \nPT. David Hall, child health consultant: Ann Goerat, PT for \nWHO, Mira Shiva, MD, Nigel Shapcott, seating specialist \nAnn Yeadon, educator; Charles Reilly, sign language \nconsultant, Eli Savanack, Gallaudet College; John Gray, MD \nMolly Thorburn, MD; Lonny Shavelson, MD: Margaret \nMackenzie, medical anthropologist; Rainer Arnhold, MD \nGulbadan Habibi, Caroline Arnold, Philip Kgosana, Garren \nLumpkin, UNICEF \n\n\nAbove all, | would like to thank the team of disabled village \nrehabilitation workers in Project PROJIMO, Ajoya, Sinaloa \nMexico, along with the hundreds of disabled children and \ntheir families. Their involvement and interaction in exploring \ntesting, inventing, and discovering simplified alternatives \nhas led to the formation of this book. Key among the \nPROJIMO team are: Marcelo Acevedo, Miguel Alvarez \nAdelina Bastidas, Roberto Fajardo, Teresa Garate, Bruce \nHobson, Concepcidn Lara, Inés Leén, Ramon Leon, Polo \nLeyva, Armando Nevarez, Maria Picos, Adelina Pliego, \nElijio Reyes, Cecilia Rodriguez, Josefa Rodriguez, \nConcepcidn Rubio, Moisés Salas, Rosa Salcido, Asuncién \nSoto, Javier Valverde, Florentino Velazquez, Efrain Zamora, \nMiguel Zamora \n\n\nFor this book we have borrowed information, ideas \nillustrations, methods, and designs from many sources \n\n\npublished and unpublished Often credit has been given \nbut not always. If you notice we have borrowed from your \nmaterial and neglected to give you credit, please accept \nour unspoken thanks and apologies. Books in the Reference \nSection, p. 637 to 642, from which information or \nillustrations have been used are marked witha / \n\n\nFor their excellent and dedicated work in preparing the \nmanuscript for publication, special thanks go to: Carol \nThuman, coordination, typing, correspondence; Janet Elliott \ngraphics, artwork, and paste-up; Irene Yen, editing and \npaste-up; Jane Maxwell, editing, page design, and art \nproduction; Kathy Alberts, Elizabeth de Avila, Martin Bustos, \nMary Klein, Carlos Romero and Marjorie Wang, paste-up \nMartin Bustos and Anna Mufioz-Briggs, Spanish translation \nMyra Polinger, typing: Lynn Gordon, Bill Bower, Phil \nPasmanick and Dan Periman, general review; Alison Davis \nreference section research; Elizabeth de Avila, Don Baker \nAgnes Batteiger. Jane Bavelas. Leda Bosworth, Renée \nBurgard, Michael Lang, Betty Page, Pear! Snyder, Tinker \nSpar, Paula Tanous and Roger Wilson, proofreading; Lino \nMontebon, Joan Thompson and David Werner, drawings \nRichard Parker, Jonn Fago, Carolyn Watson, Tom Wells and \nDavid Werner, photography; Dyanne Ladine, art production \nMartin Bustos and Richard Parker, photo production; Hal \nLockwood and Helen Epperson of Bookman Productions \nand Tim Anderson and Linda Inman of Reprographex \ntypesetting and layout \n\n\nThe main costs of preparing this book were met by grants \nfrom the Public Welfare Foundation, whose continued \nfriendship and support of the Hesperian Foundation’s new \npublications is deeply appreciated. Additional funding \nwas generously provided by the Gary Wang Memorial \nFund, UNICEF, OXFAM UK, the Swedish International \nDevelopment Agency, and MISEREOR. We would also \nlike to thank the Thrasher Research Fund and Mulago \nFoundation for helping meet the costs of Project PROJ!MO \nfrom which this book evolved \n\n\n| would like to thank Trude Bock, who has given so \nwholeheartedly of herself and her home, not only for the \npreparation of this handbook, but also for the well-being \nof dozens of disabled children \n\nFinally, | want to give an extra word of thanks to Janet \nElliott and Carol Thuman, who shared responsibility for the \npreparation and quality of this book. Their care, concern \nand thoughtful hard work is reflected on every page \n\n\nPill. new. \n\n\nABOUT THIS BOOK \n\n\nA TRUE STORY: CRUTCHES FOR PEPE \n\n\nA teacher of village health workers was helping as a volunteer in the mountains of \nwestern Mexico. One day he arrived on muleback at a smal! village. A father came up \nto him and asked if he could cure his son. The health worker went with the father to \nhis hut. \n\n\nThe boy, whose name was Pepe, was sitting on the floor. His legs had been paralyzed \nby polio, from when he was a baby. Now he was 13 years old. Pepe smiled and reached \nup a friendly hand. \n\n\nThe health worker, who also had a physical disability, examined Pepe. ‘’Have you \never tried to walk with crutches?’’ he asked. Pepe shook his head \n\n\n“We live so far away from the city,”’ his father explained. \n“Let's try to make some crutches,”’ said the health worker. \nThe next morning the health worker got up at dawn. \n\nHe borrowed a long curved knife and went into the \n\n\nforest. He looked and looked until he found 2 forked \nbranches the right size. \n\n\nHe took the branches back to Pepe’s niga ee \nbegan to make them into crutches, like this. \n\n\nThe father came and seeing the crutches, he said, ‘They won't work!” \n\n\nThe health worker frowned. ‘Wait and see!’ he said \n\n\nWhen both crutches were finished, they showed them to Pepe, who was eager to try \nthem. His father lifted Pepe to a standing position and the health worker placed the \ncrutches under the boy’s arms. \n\n\nBut as soon as Pepe put his weight on the crutches, \nthey bent and broke. \n\n\n“| tried to tell you they wouldn't work,”’ said the \nfather. ‘’It's the wrong kind of tree. Wood's weak as \nwater! But now | see your idea. I'll go cut some branches \nof ‘jUtamo’. Wood's tough as iron, but iight! Don’t want \nthe crutches too heavy.” \n\n\nHe took the knife and went into the forest. Fifteen \nminutes later he was back with 2 forked branches of \n‘jdtamo’. He began making the crutches, his strong \nhands working rapidly. The health worker and Pepe \nhelped him. \n\n\nABOUT THIS BOOK \n\n\nWhen these crutches were finished, Pepe’s father tested \nthem by putting his own weight on them. They supported \nhim easily, yet were lightweight. Then Pepe tried them. At \nfirst, he had trouble balancing, but soon he could hold \nhimself up. By afternoon, he was walking with the \ncrutches! But they rubbed under his arms \n\n\n‘| have an idea,’’ said Pepe’s father. He ran to a wild \nkapok tree, and picked several of the large ripe fruits. He \ngathered the soft cotton from the pods and put a cushion \nkapok on the top crosspiece of each crutch. He wrapped \nthe kapok in place with strips of cloth. Pepe tried the \ncrutches again. They were comfortable \n\n\n‘Thanks, Papa, you fixed them great!’’ he said \n“Look how well | can walk now!\"’ He moved ab \n\n\n“I'm proud of you, son!’ said his father, smiling tor \n\n\nAs the health worker prepared to leave, the whole family came to say good-bye \n\n\n‘| can't thank you enough,”’ said Pepe’s father. ‘It’s so wonderful to see my son \nwalking. | don't know why | never thought of making crutches before. \n\n\n‘| should be thanking you,” said the health worker. ‘“You have taught me a lot.”’ \n\n\nAfter leaving, the health worker smiled to \nhimself. He thought, ‘‘How foolish of me not \nto have asked the father’s advice in the \nbeginning. He knows the trees better than | \ndo. And he is a better craftsperson. \n\n\n‘But it was good that the crutches | made \nbroke. Making them was my idea, and the \nfather felt bad for not thinking of it himself. \nBut when my crutches broke, he made much \nbetter ones. That made us equal again!”’ \n\n\nSo the health worker learned many things \nfrom Pepe's father—things that he had never \nlearned in school. He learned what kind of \nwood is best for making crutches. He also \nlearned how important it is to use the skills \nand knowledge of the local people—because a \nbetter job can be done, and because it helps \nmaintain people's dignity. People feel equal \nwhen they learn from each other. \n\n\nABOUT THIS BOOK ti \n\n\nHOW THIS BOOK WAS WRITTEN \n\n\nThe story of Pepe’s crutches is an example of the lessons we have learned that helped \nto create this book. We are a group of village health and rehabilitation workers who \nhave worked with people in farming communities of western Mexico to form a \n‘villager-run’ rehabilitation program. Most of us on the rehabilitation ‘team’ are \ndisabled ourselves. \n\n\nFrom our experience of trying to help disabled children and their families to meet \ntheir needs, we have developed many of the methods, aids, and ideas in this book. We \nhave also gathered ideas from books, persons, and other programs, and have adapted \nthem to fit the limitations and possibilities of our village area. We hope this book wil! \nbe useful to village people in many parts of the world. So we have asked for cooperation \nand included suggestions from community program leaders in more than 20 countries \n\n\nThis book was Unlike most handbooks for village \n\nnot written workers and families, this book was not \n\nby experts, written by ‘professionals’ and then ‘field \ntested’. Instead, it grew out of the practica \nexperience of a team of disabled village \nhealth workers as we looked for \ninformation to help meet the most common \nproblems we face \n\n\nHowever, a large number of professionals \nhave helped in important ways. Many are \nwell-known leaders in their fields. They \ninclude physical and occupational! \ntherapists, special educators, nurses \ndoctors, brace and l!imb makers, and \nrehabilitation engineers. They have \ncarefully reviewed and even helped to \nrewrite sections of this book. Some have \nalso helped to teach and advise our village \nand then team \n‘field tested’ \n\n\nwith community \n\n\nworkers \nInstead, it was and then reviewed \n\n\nwritten by and and corrected by \nwith community experts. \nworkers, \n\n\nABOUT THIS BOOK \n\n\nHOW THIS BOOK DIFFERS FROM OTHER \n‘REHABILITATION MANUALS’ \n\n\nThis book was written from the ‘bottom up’, working closely with disabled persons \nand their families. We believe that those with the most personal experience of disability \ncan and should become leaders in resolving the needs of the disabled. In fact, the main \nauthor of this book (David Werner) and many of its contributors happen to be disabled. \nWe are neither proud nor ashamed of this. But we do realize that in some ways our \ndisabilities contribute to our abilities and strengths. \n\n\nIn many rehabilitation manuals, disabled persons are treated as objects to be worked \nupon, to be ‘normalized’ or made as normal as possible. As disabled persons, we object \nto attempts by the experts to fit us into the mold of normal. Too often ‘normal’ \nbehavior in our society is selfish, greedy, narrow-minded, prejudiced—and cruel to \nthose who are weaker or different from others. We live in a world where too often it is \n‘normal’ and acceptable for the rich to live at the expense of the poor, and for health \nprofessionals to earn many times the wages of those who produce their food but cannot \nafford their services. We live on a wealthy planet where most children do not get \nenough to eat, where half the people have never seen a trained health worker, and \nwhere poverty is a major cause of disability and early death. And yet the world’s leaders \nspend 50 billion dollars every 3 weeks on the instruments of war—an amount that could \nprovide primary health care to everyone on earth for an entire year! \n\n\nInstead of being ‘normalized’ into such an unkind, unfair, and unreasonable social \nstructure, we disabled persons would do better to join together with all who are treated \nunfairly, in order to work for a new social order that is kinder, more just, and more \nsane. \n\n\nThis large book, then, is a smali tool in the struggle not only for the liberation of the \ndisabled, but for their solidarity in the larger effort to create a world where more value \nis placed on being human than on being ‘normal’—a world where war and poverty and \ndespair no longer disable the children of today, who are the leaders of tomorrow. \n\n\nTop-down rehabilitation manuals too often only give orders telling the ‘local trainer’, \nfamily member, and disabled person exactly what they ‘must do’. We feel that this is a \nlimiting rather than liberating approach. It encourages people to obediently fit the child \ninto a standard ‘rehabilitation plan’, instead of creating a plan that fits and frees the \nchild. Again and again we see exercises, lessons, braces, and aids incorrectly, painfully, \nand often harmfully applied. This is done both by community rehabilitation workers \nand by professionals, because they have been taught to follow standard instructions or \npre-packaged solutions rather than to respond in a flexible and creative way to the \nneeds of the whole child. \n\n\nIn this book we try not to tell anyone what they must do. Instead we provide \ninformation, explanations, suggestions, examples, and ideas. We encourage an \nimaginative, adventurous, thoughtful, and even playful approach. After all, each \ndisabled child is different and will be helped most by approaches and activities that are \nlovingly adapted to her specific abilities and needs. \n\n\nABOUT THIS BOOK \n\n\ni3 \n\n\nAs much as we can, we try to explain basic principles and give reasons for doing \nthings. After village rehabilitation workers and parents understand the basic principles \nbehind different rehabilitation activities, exercises, or aids, they can begin to make \nadaptations. They can make better use of local resources and of the unique \nopportunities that exist in their own rural area. In this way many rehabilitation aids, \nexercises, and activities can be made or done in ways that integrate rather than separate \nthe child from the day-to-day life in the community \n\n\nAb Chat: \n\n\nThis is not the first handbook of ‘simplified rehabilitation’. We have drawn on ideas \nfrom many other sources. We would like to give special credit to the World Health \nOrganization's manual, Training the Disabled In the Community, and to UNICEF and \nRehabilitation International's Childhood Disability: Prevention and Rehabilitation at \nthe Community Level, a shortened and improved version of the WHO manual. The \nWHO manual has recently been rewritten in a friendlier style that invites users to take \nmore of a problem-solving approach instead of simply following instructions. \n\n\nThis handbook is not intended to replace these earlier manuals. It provides additional \ninformation. It is for those families, village health workers, and community \nrehabilitation workers who want to do a more complete job of meeting the needs of \nphysically disabled children. \n\n\nHOW WE DECIDED WHICH DISABILITIES TO INCLUDE \n\n\nBecause this book is written for village use in many countries, it was not easy to \ndecide what to include. People in different parts of the world give importance to \ndifferent disabilities. This is partly because some disabilities are much more common in \none area than another. For example, \n\n\n@ polio in some countries is the most common disability. In others, it is rare because \nof effective vaccination programs. \n\n\ndeafness and mental retardation are much more common in certain mountain \nregions because of lack of iodine in the diet (or in salt) \n\n\nblindness due to lack of vitamin A is common in some poor crowded communities, \nand depends a lot on local food habits. \n\n\nrickets is still common in regions where children are wrapped up or kept in dark \nplaces so much that they do not get enough sunlight. \n\n\nburn deformities are frequent where people cook and sleep on the ground near \nopen fires. \n\n\namputations are a big problem in war zones, refugee camps, and ‘shanty towns’ \nalong railway tracks. \n\n\ndisability from tuberculosis, leprosy, measles, malnutrition, and poor sanitation \nare especially common where lack of social justice lets some people live in great \nwealth while most live in extreme poverty. \n\n\nLocal beliefs also affect how people see different disabilities. In an area where people \nbelieve that fits are the work of the devil, a child with fits may be feared, teased, or \nkept hidden. But in places where everyone accepts fits as ‘just something that happens \nto certain persons’ a child who sometimes has fits may participate fully in the day-to- \nday life of the community, without being seen as ‘handicapped’. Both of these children \nneed medicine. But probably only the mistreated one needs ‘rehabilitation’. \n\n\nABOUT THIS BOOK \n\n\nig \n\n\nIt is important to consider how local people see a child who is in some way \n‘different’. How do they accept or treat the child who learns slowly, limps a little, or \noccasionally has fits? \n\n\nMany reports say that in both rich and poor countries, 1 in 10 children are disabled. \nHowever, this number can be misleading. Although 1 child in 10 may show some defect \nif examined carefully, most of these defects are so minor that they do not affect the \nchild's ability to lead a full, active life. In rural areas, children who are physically strong \nbut are slow learners often fit into the life and work of the village without special \nnotice. In India, a study found that only 1 in 7 of those recorded as mentally retarded \nby screening tests were seen as retarded by the community. \n\n\nStudies in several countries show that, on the average, only 2 or 3 children in 100 are \nconsidered disabled by the community. These are the children most likely to benefit \nfrom ‘rehabilitation’. \n\n\nCAUTION: \\f the community does not consider a child ‘disabled’, and \nthe child manages well, it may be wiser not to bring attention to her \ncondition. To do so might actually ‘disable’ the child more in the \n\neyes of the community, and make life harder for her. Think carefully \nbefore deciding to do a ‘complete survey’ on disability. \n\n\nWhen we started to write this book, we planned to include only physical disabilities. \nThis is because concerned villagers and health workers in rural Mexico considered \nphysical handicaps to be the area of greatest need. \n\n\nThis is \n\nunderstandable. \nIn poor farming \ncommunities, where \nmany day-to-day \nactivities depend \non physical \nstrength, and where \nschooling for most ; ; \n\nA child who is in a village but in a city \n\n\nchildren 's brief, mentally slow may not be very or in school \nthe physically but physically handicapped, may be very \n\n\ndisabled child can Rancroappee. \nhave an especially \ndifficult time \n\nfitting in. By \ncontrast, ina \nmiddle-class city \nneighborhood, where \nchildren are judged \nmainly by their \nability in school, but in a city \nit is the mentally A child who in a village or in school \n\n\nslow child who is physically may be very may not be \noften has the disabled but handicapped, especially \n\n\na intelligent, handicapped. \nhardest time. \n\n\nABOUT THIS BOOK \n\n\nThe team of disabled village workers in Mexico was at first concerned mostly with \nphysical disabilities. But they soon realized that they also had to learn about other \ndisabilities. Even children whose main problem was physical, like polio, were often held \nback by other (secondary) emotional, social or behavioral disabilities. And many \nchildren with brain damage not only had difficulties with movement, but also were \nslow learners, had fits, or could not see or hear \n\n\nAs the PROJIMO team’s need for information on different disabilities has grown, so \nhas this book. The main focus is still on physical disabilities, which are covered in more \ndetail. However, the book now includes a fairly complete (but less detailed) coverage of \nmental retardation and developmental delay (slow learning). Fits (epilepsy) are also \ncovered. \n\n\nBlindness and deafness are included, but only in a very brief, beginner’s way. This is \npartly because we at PROJIMO still do not have much experience in these areas. And \npartly it is because seeing and hearing disabilities require so much special information \nthat they need to be covered in separate books. Some fairly good instructional material \nis available on these disabilities, especially on blindness. We list some of the best \nmaterials that we know on p. 639 and 640. \n\n\nNote: This book does not include disabilities which are mainly in the area of internal medicine, \nsuch as asthma, chronic lung problems, severe allergies, heart defects, diabetes, bleeding problems, \nor cancers. And except for brief mention, it does not include very local disabilities such as \nlathyrism (parts of India). In local areas where such disabilities are common, rehabilitation workers \nshould obtain information separately. \n\n\nTo decide which disabilities to put in this book and how much importance to give to \neach, we used information from several sources, including the records of Project \nPROJIMC in Mexico. We found that the numbers of children with different disabilities \nwho came to PROJIMO were fairly similar to those in studies done by WHO, UNICEF, \nand others in different areas of the world. \n\n\nOn the next page is a chart showing how many children with each disability might be \nseen in a typical village area. (Of course, there is no such thing as a ‘typical’ village. The \npatterns of disability in some areas will be quite different from those shown on the \nchart.) The chart is based mainly or our records from PROJIMO over a 3-year period. \n\n\nNotice that in the chart, the number of children with each disability corresponds \nmore or less to the relative importance that we give to each disability in this book. In \ncertain cases we have made exceptions. For example, few persons with leprosy have \ncome to PROJIMO. But we have included a long chapter on leprosy because we realize \nit is a big problem in some places. \n\n\nIMPORTANT: The disabilities discussed in this book are those that are most common in rural \nareas in many countries. But not all disabilities are included. Also, certain disabilities may be \ndifficult to identify, or require special tests or analyses. When in doubt, try to get advice from \npersons with more training and experience. \n\n\nClearly you cannot solve every problem. But there is much you can do. By asking \nquestions, carefully examining the child, and using whatever information and resources \nyou can find, you may be able to learn much about what these children need and to \nfigure out ways to help them manage better. \n\n\nABOUT THIS BOOK A7 \n\n\nHOW COMMON ARE DIFFERENT DISABILITIES \n\n\nThe little ‘stick people’ in this chart show how many children might have each \ndisability in an average group of 100 significantly disab'ed village children. These \nfigures are based on records of 700 children seen at PROJIMO, Mexico (1982-1985), \nand other studies. The numbers in your area may be similar or very different from \nthese, depending on local factors. \n\n\nTYPICAL FREQUENCY OF DISABILITIES \nPER 100 SIGNIFICANTLY DISABLED CHILDREN \n(based on records of 700 children seen at PROJIMO, Mexico) \n\n\nPrimary or main disabilities Secondary or additional disabilities \n\n\nA8 \n\n\nMovement disabilities \n\n\nBrain damage and \ncerebral palsy \n\n\nBirth defects \n(includes club feet) \n\n\nInjury, burns, \namputations \n\n\nSpina bifida \n\n\nSpinal cord injury \n\n\nMuscular dystrophy \nand atrophy \n\n\nJuvenile arthritis \nand other joint pain \n\n\nBone infections \n(includes tuberculosis \nof the spine) \n\nHip problems \nLeprosy \n\n\nArthrogryposis \n\n\nOther \nSeeing disabilities \nHearing and speech \ndisabilities \n\n\nFits \n\n\nDevelopmental delay \n(slow learners) \n\n\nPolio CEANARUCAPRRRRARCHE \nTAMEARAA AAT ARS \n\n\nathe \n\n\nPRAY S \n\n\nAAA A \n{ 4h \nRA \n\n\nif 4 \n\n\nt \n\n\nAAR \n{ \n\n\nContractures \n(mostly \n\nwith polio and \ncerebral palsy) \n\n\nSpinal curve \n\n\nDevelopmental delay \n(mostly with \n\n\n_ palsy) \n\n\nFits (mostly with \ncerebral palsy) \n\n\nSeeing (mostly with \ncerebral palsy) \n\n\nHearing and speech \n(mostly with \ncerebral palsy) \n\n\nTRGT EAR \nAER ARE \n\n\n(plus those occurring \ncerebral palsy = 8 per \n\n\n> \n\n\nAGAGARARAS \nRGAK ART AA \n\n\nAREAEG \n\n\nARRAN \n\n\nAT HAGRA \n\n\nAA \n\n\nff \n\n\nwith \n\n\n100) \n\n\n(plus those occurring with \ncerebral palsy = 10 per 100) \n\n\nAAA AG KA \nTE URACH \n\n\n(plus those occurring with \ncerebral palsy = 14 per 100) \n\n\n(plus those occurring with \n\n\nRACHA AA ATA \n\n\n(cerebral palsy = 16 per 100) \n\n\nFa \n\n\nBehavioral \nproblems \n\n\n{HAA \nRAR TY \nM4444 \n\n\nNote: Seeing and hearing disabilities, fits, and developmental delay are listed in 2 places, depending on whether \nthey are the main disability or occur in addition to some other disability. \n\n\nABOUT THIS BOOK \n\n\ni7 \n\n\nHOW THIS BOOK IS ORGANIZED \n\n\nThis book is divided into 3 parts: 1, ‘Working with the Child and Family,” \n2, ‘Working with the Community,” and 3, ‘Working in the Shop.” \n\n\nThe disabilities that villagers usually consider most important are discussed in early \nchapters, beginning with Chapter 7. In many countries, more than half of the disabled \nchildren have either polio or cerebral palsy. For this reason, we start with them. Other \ndisabilities are arranged partly in order of their relative importance, and partly to place \nnear to each other those disabilities that are similar, related, or easily confused. \n\n\nNotice that in the chart on p. A8, certain ‘secondary disabilities’ occur very often. \n(‘Secondary disabilities’ are problems that result after the main disability.) For example, \ncontractures (joints that no longer straighten) can develop with many disabilities. In \nmany villages, there will be more children who have contractures than who have any \nsingle primary disability. For this reason we include some of the important secondary \nproblems in separate chapters. \n\n\nCommon disabilities that are often ‘secondary’ to other disabilities include: \nContractures, Chapter 8 \nDislocated Hips (either a primary or secondary disability), Chapter 18 \nSpinal Curve (either primary or secondary), Chapter 20 \n\n\nPressure Sores (often occurs with spinal cord injury, spina bifida, or leprosy), \nChapter 24 \n\n\nUrine and Bowel Management (with spinal cord injury and spina bifida), Chapter 25 \nBehavior Disturbances, Chapter 40 \nOther disabilities that are often the primary problem but commonly occur with other \n\n\ndisability—usually with cerebral palsy—include fits (Chapter 29), blindness (Chapter \n30), and deafness and speech problems (Chapter 31). \n\n\nIMPORTANT: Some important information in this book applies to many \ndisabilities. In order not to make the book longer than it is now, we have \nnot repeated all of this information in each chapter on specific disabilities. \nInstead we have put it in separate chapters. \n\n\nThis means that to meet the needs of a specific child, you will often have \nto look in several different chapters. We have tried to make this as easy \nfor you as possible (see ‘‘How To Use This Book,\"’ inside the back cover). \n\n\nFOR MANY DISABILITIES IT IS VERY IMPORTANT THAT \ninl a YOU READ INFORMATION FROM SEVERAL CHAPTERS. \n\n\nABOUT THIS BOOK AY \n\n\nLS \n\n\na \n\n\nNote to \n\n\nREHABILITATION PROFESSIONALS, \nPROGRAM PLANNERS, AND THERAPISTS \n\n\nYou may think that this book is ‘too complex’ or ‘too long’ for community health \nworkers or rehabilitation workers, or family members. At first, for many, it may be. \nThis is a book to grow into—a simplified but detailed work book and reference book. \n\n\nBut remember, almost all the ideas and information in this book are right now \nbeing put into practice by village workers with little schooling, together with \ndisabled children and their families. The book was developed for and with a team of \nvillage workers who have an average of 3 years primary school education. \n\n\nSome health workers and parents will be able to make fairly good use of the book, \nor parts of it, without special training. Others will not. \n\n\nThis book is not intended to be a substitute for ‘learning through guided practice’. \nPeople learn best when someone with more experience shows and explains things to \nthem in a real situation (working with disabled children and their families). Skills for \nmaking aids and teaching exercises are also learned best by working with an \nexperienced rehabilitation worker or craftsperson. \n\n\nIn some places, or when a village program is just beginning, this book may at first \nbe used mainly by program leaders, therapists, and instructors to help you learn to \nteach in ways that communicate clearly and that encourage a problem-solving \napproach. The book can also be a resource to help you answer questions that village \nworkers will have after they start working with disabled children. \n\n\nWe have observed that when making decisions about what a child needs, some \nrehabilitation professionals, therapists, aid makers, and surgeons do not think \nenough about the whole child, the situation where she lives, the money problems, or \nthe resources within the family and community. As a result, much too often the \nprofessionals make decisions that are not practical or that sometimes do more harm \nthan good (see Chapter 56). Often their recommendations fail because they have \ntried to fit the child into their textbook, instead of adapting the textbook to fit the \nchild and her situation. This comes partly from many years of conventional \nschooling, which encourages ‘following instructions’ more than ‘thinking things \nthrough’ and ‘being creative’. \n\n\nThere will never be enough highly-trained rehabilitation professionals to attend to \nthe needs of more than a small part of the world’s millions of disabled persons. Most \nrehabilitation and therapy can and should take place in the home and community \nwith loving support of family, neighbors, and friends. \n\n\nA10 =ABOUT THIS BOOK \n\n\n~\\ \n\n\nYou rehabilitation professionals and therapists can play an extremely important \nrole in ‘community-directed rehabilitation’. By simplifying and sharing your \nknowledge and skills, you can reach many more children. But to do this you will \nneed to go out of the large city rehabilitation centers and into neighborhoods and \nvillages. You will need to meet and work with the people on their terms, as learners, \nteachers, and information providers. You can help disabled persons, parents, and \nother concerned individuals to organize small, community-directed centers or \nprograms. You can teach those who have the most interest to become teachers. You \ncan help local craftspersons to figure out or improve low-cost designs for \nrehabilitation aids (and they can help you). You can encourage village leaders to \nimprove paths and entrances to schools and public places. You can help local people \nto understand basic principles and to avoid common mistakes, so that they can be \nmore effective leaders and participants in home and community rehabilitation. \n\n\nIMPORTANT: RESPECT THE KNOWLEDGE AND SKILLS \nOF THE PEOPLE \n\n\nVillagers are often much better than city persons at figuring out how to do \nthings, at using whatever happens to be available, and at making and fixing \nthings with their hands. In short, they are more ‘resourceful’. They have to \nbe to survive! This ‘resourcefulness’ of village people can be one of the most \nvaluable ‘resources’ for rehabilitation in rural areas. \n\n\nBut for this to happen, we need to help people understand basic principles \nand ‘concepts’—not just tell them what to do. Above al!, we need to respect \ntheir intelligence, their knowledge of the local situation, and their ability to \nimprove on our suggestions. \n\n\nWhenever possible, arrange for village workers to learn to use this book with \nguidance from experienced rehabilitation workers. Those rehabilitation workers \nshould be able to listen to the people, respect their ideas, and relate to them as \nequals. \n\n\nFor best learning, the teacher, or \n‘guide’ should stay as much in the \nbackground as possible, offering \nfriendly advice when asked, and \nalways asking the learners what they \nthink before giving instructions and \nanswers. \n\n\nIt is our hope that this book may \nhelp disabled persons, their \nfamilies, village workers, and \nrehabilitation professionals to learn \nmore from each other, and to help A visiting therapist at PROJIMO teaches \nh other to b . bi the older brother of a disabled girl \neacn other to become more capabie, how to do stretching exercises of her \n\n\nmore caring, human beings. hip to correct a contracture. \n\n\nv4 \n\n\nABOUT THIS BOOK \n\n\nAll \n\n\nNOTE ON LANGUAGE \nUSED IN THIS BOOK \n\n\nSpeaking of the Disabled Child — \n‘SHE’ or ‘HE’ \n\n\nMany studies have shown that more boys are disabled than girls. It is sometimes \nargued that this is because boys are more exposed to physical stress and danger, or \nbecause of sex-linked ‘genetic’ factors. \n\n\nBut there may also be other, more disturbing reasons why reports show so many \nmore disabled boys than girls: \n\n\ne@ Of those who are disabled, more of the boys than the girls are taken to medical \ncenters where their disabilities are recorded \n\n\ne Disabled girls often are not cared for as well as disabled boys; therefore more of \nthe girls die when they are babies or small children. \n\n\nIn short, disabled boys often receive better attention than do disabled girls. This, of \ncourse, is not surprising: in most countries, non-disabled boys also get better treatment, \nmore food, and more opportunities than do non-disabled girls \n\n\nMost literature on disabled children speaks of the disabled child as ‘he’. This is partly \nbecause male dominance is built into our language. However, we feel this can only add \nto the continued neglect of the so-called ‘weaker sex’ \n\n\nIn this book, therefore, we have made an effort to be fair. But rather than to always \nspeak of the child as ‘he-or-she’ or ‘they’, which is awkward, we sometimes refer to her \nas ‘she’ and sometimes as ‘he’. \n\n\nIf at times this is confusing, please pardon us. And if we sometimes slip and give \n\n\nmore prominence to ‘he’ than ‘she’, either in words or pictures, please criticize but \nforgive us. We too are products of our language and culture. But we are trying to \n\n\nAb Chat \n\n\nSpeaking of the Author(s): \n‘WE’ or ‘I’ \n\n\nAlthough one person has done most of the writing of this book, many persons have \nshared in its making (see the ‘Thanks’ page at the beginning of this book). Therefore, \nwhen speaking from our authors’ advisers’ viewpoint, we usually use ‘we’. This book \nis a group effort. \n\n\nA12 ABOUT THIS BOOK \n\n\nPART 1 \n\n\nWORKING WITH THE CHILD \nAND FAMILY \n\n\nInformation on \nDifferent Disabilities \n\n\nINTRODUCTION TO PART 1 \n\n\nMaking Therapy \nFunctional and Fun \n\n\nCHAPTER 1 \n\n\nMost disabled people in the world live \nin villages and poor communities where \nthey never see a ‘rehabilitation expert’ or \n‘physical therapist’. But this does not \nalways mean that they have no \n‘rehabilitation’ or ‘therapy’. In many \nvillages and homes, family members, local \ncraftspersons, traditional healers, and \ndisabled people themselves have figured \nout ways for persons with disabilities to \ndo things better and move about more \neasily. \n\n\nWe have seen examples where local \ncarpenters, tinsmiths, leatherworkers or \nblacksmiths have put together simple \ncrutches, carts, wooden legs and other \naids. We know parents who have figured \nout ways of adapting daily activities so \nthat their children can help do farm work \n\n\nTwo words often used by people who \nwork with disabled persons are \n‘rehabilitation’ and ‘therapy’. \n\n\nRehabilitation means returning of \nability, or helping a disabled person \nto manage better at home and in the \ncommunity. \n\n\nTherapy basically means treatment. \nPhysical therapy —or physiotherapy— \nis the art of improving position, \nmovement, strength, balance, and \ncontrol of the body. Occupational \ntherapy is the art of helping a disabled \nperson learn to do useful or enjoyable \nactivities \n\n\nWe speak of ‘therapy’ as an art rather \nthan a science because there are many \ndifferent beliefs and approaches, and \n\n\nor housework—and at the same time get \nmuch of the exercise (therapy) they need. \n\n\nbecause the human feeling that goes \ninto therapy is as important as the \nmethods \n\n\nSometimes the ‘rehabilitation’ that \nfamilies and communities figure out by \nthemselves works better in their situation \nthan do methods or aids introduced by \noutside professionals. Here are 2 examples: \n\n\n1. In India, | met a villager who had lost a leg in \na house-building accident. Using his \nimagination, he had made himself an artificial \nleg with a flexible foot out of strong wire \nwith strips of an old cotton blanket for \npadding. After several months, he had the \nchance to go to a city where a professional \n‘leg maker’ (prosthetist) made him a costly \nmodern fiberglass leg. The man tried using the \nnew limb for a couple of months, but it was \nheavy and hot. It did not let his stump breathe \nlike his ‘wire cage’ leg. And he could not squat \nto eat or do his toilet, as he could with his \nhomemade leg. Finally, he stopped using the \ncostly new leg and went back to the one he \nhad made. For the climate and customs where \nhe lived, it was more appropriate. \n\n\nAll children, as much as possible, should \nget the exercise they need through daily \nwork and play. (Morocco. Photo by \nCharles Trieschmann) \n\n\n4 CHAPTER! \n\n\n2. In asmall village in Mexico, over the years, the community together with its deaf \ncitizens has developed a simple but expressive ‘sign language’ using their hands, \nfaces, mouths, and whole bodies to communicate. As a result, children who are \nborn deaf quickly and gracefully learn to express themselves. They are well \naccepted in the community, and some have grown up to become creative and \nrespected craftspersons. This village method of ‘total communication’ allows the \ndeaf children to learn a useful language more quickly, easily, and effectively than \ndoes the ‘lip reading and speech’ method now taught in the cities. For children \nwho are born deaf, attempts to teach only |ip-reading-and-spoken-language often \nend in cruel disappointment (see p. 264). The ‘special educators’ in the cities \ncould learn a lot from these villagers. \n\n\nDisabled children—if allowed—often show great imagination and energy in figuring \nout ways to move about, communicate, or get what they need. Much of what they do \nis, in effect, ‘therapy’, artfully adapted for and by each child. \n\n\nWith a little help, encouragement, and freedom, the disabled child can often become \nher own best therapist. One thing is certain: she will make sure her therapy is \n‘functional’ (useful), always changing it to meet her immediate needs. A disabled child, \nlike other children, instinctively knows that life is to be lived NOW and that her body \nand her world are there to be explored, used, and challenged. The best therapy is built \ninto everyday activities: play, work, relationship, rest, and adventure. \n\n\nThe challenge, then, for health workers and parents (as well as for therapists), is to \nlook for ways that children can get the ‘therapy’ they need in ways that are easy, \ninteresting, and functional. \n\n\nThis takes imagination and ‘Physical therapy’ to improve control of the head, strength of \nflexibility on the part of all the back, and use of both arms and hands together: \nthose working with disabled \nchildren. But mostly, it takes \nunderstanding. When family \nmembers clearly understand \nthe reasons for a particular \ntherapy and the basic \nprinciples involved, they can \nfind many imaginative ways to \ndo and adapt that therapy. \n\n\n(a) in acity clinic (b) in a village home \n\n\nPhoto: Cheyne Photo: PROJIMO, \nWalk Spastic’s Centre Ajoya, Mexico \n\n\nAppropriate therapy helps the child to enjoy himself, be useful, and \ntake part with others, while mastering the skills for daily living. \n\n\nINTRODUCTION PART 1 5 \n\n\nPhysical therapy and rehabilitation techniques have been developed mostly in cities. \nYet most of the world’s disabled children live in villages and farms. Their parents are \nusually very busy growing the food and doing the chores to keep the family fed and \nalive from day to day. In some ways, this makes home therapy more difficult. But in \nother ways it provides a wide range of possibilities for exciting therapy in which the \nchild and his family can meet life’s needs together. \n\n\nHere is a story that tells how therapy can be adapted to village life. \n\n\nMaricela’s family \ncould not afford \nthese costly things. \nSo back in her \nvillage her father \nused whatever he \ncould find to make \nsimilar aids at low \ncost. First he made \na special seat of \nsticks. \n\n\nMaricela lives in a small village on a river. \nShe has cerebral palsy. When she was 4 years \nold, she was just beginning to walk. \n\n\nBut her knees bumped together when she \ntried to take steps. So she did not try often. \nAlso, her arms and hands were weak and did \nnot work very well. \n\n\nLater he made a better seat with pieces of \nwood, and an old bucket to hold her legs \n\n\nThen, using a \nboard, corn cobs \nand rings cut \nfrom bamboo, \nhe added a smal! \ntable so that she \ncould play games \nto develop hand \ncontrol. \n\n\nHer family saved money and took \nMaricela to a rehabilitation center in the \ncity. After a long wait, a therapist \nexamined her. He explained that Maricela \nneeded to stretch the muscles on the inner \nside of her thighs, so her knees would not \npress together as much. \n\n\na Pamboo ring \n\n\nhi —— corn cob \n\n\n+— wood plank \n\n\nJ \n\n\nHe recommended \nthat her parents do \nspecial exercises with \nher, and that they \nbuy a special plastic \nseat to hold her \nknees wide apart. \n\n\nHe also made a hand exerciser out of bamboo \n\n\nAt first, while they were strange and new, \nMaricela used her special seat and played \nwith her special toys. But soon, she got \nbored and stopped using them. She \nwanted to do the things that other children \ndid. She wanted to go with her father and \n\n\nHe said she also \nneeded exercises to \nstrengthen and \nincrease the control \nof her hands and arms \n\n\nHe suggested buying \nher some special toys, \ngame boards, and aids \nto practice handling \nand gripping things \n\n\nbrother to the cornfield. She wanted to help \nher mother prepare food and wash the \nclothes. She wanted to be helpful and grown \nuy. \n\n(story continued on next page) \n\n\n\") \nrf 0) \n\n\nCHAPTER 1 \n\n\nSo she broke her special toys and refused \nto sit in her special seat. Her parents were \nfurious with her—and she loved it! She \nwould sit for hours with her knees together \nand her legs bent back. Walking began to get \nmore difficult for her, so she did not walk \nmuch. \n\n\nHer parents then visited a smal! \nrehabilitation center in a neighboring village \nThe village team suggested that they look for \nnew ways to help Maricela keep her knees \napart and improve control of her arms and \nhands—ways that would be exciting and help \nher to develop and practice useful skills \ntogether with the rest of her family. Here are \nsome of the ideas that Maricela and her \nparents came up with \n\n\nWhen she was good (and sometimes even \nif she was not) her father would let her help \nshell corn with him and the other children \nBecause she had trouble holding the corn \nand snapping off the grain with her finger: \nher father made a special holder and scraper \n\n\npiece of old \nholes to let saw blade \ngrain drop between \ninto basket 2 sticks \n\n\ncut out space \nstoppers to with nail \nhold board points coming \non basket through bottom, \nto hold ear \nof corn \n\n\nThe basket between her legs held her \nknees apart, and the shelling of the corn \nstrengthened her arms, gave her practice \ngripping, and improved her coordination \nand control. \n\nshelling corn \n(taking the \ndried grain \noff the cobs) \n\n\nIt was hard, important work that Maricela \nfound she could do. And she loved it! \n\n\nMaricela’s mother sometimes invited her \nto help wash the clothes at the river. Maricela \nwould sit at the river’s edge with a big \n‘washing rock’ between her legs. She would \nwash the clothes by squeezing and beating \nthem against the rock—just like her mother. \n\n\nThe rock kept her knees apart and the \nsqueezing and banging strengthened her \nhands and improved her control. But what \nmattered was getting the clothes clean. It \nwas hard work. But she found it easy—and \nfun! \n\n\nComing back from \nthe river, Maricela just \nhad to walk. It was too \nfar to crawl. And \nbesides, she had to help \nher mother carry back \nthe washed clothes. \nThis was hard, but she \ntried hard, and could \ndo it! \n\n\nCarrying the pails of \nclothes helped her learn \nto walk without bending \nand jerking her arms so much. \n\n\nTo help Maricela grip the handle of the \npail easier, her father wrapped a long strip of \nold bicycle inner tube very tightly around \nthe handle. But when Maricela’s hand \nsweated, the smooth rubber got slippery. So \nher father wound a thin rope around the \nrubber. This way, Maricela could hold it \nbetter. \n\n\nAs time passed she learned how to carry a \nbucket of clothes on her head—then a bucket \nof water. To do this took a lot of practice \nwith balance and contro! of movement. She \njust had to keep her legs farther apart to \nkeep her balance. \n\n\nHer mother was \nalmost afraid to let her \ntry carrying the water. \nBut Maricela was \nstubborn—and she did \nit! Maricela also \ndiscovered that if she \nfloated a gourd dipper \n(or a big leaf) on top of \nthe water, it helped \nkeep the water from \nsplashing out. \n\n\nSo, by trying different things, Maricela’s \nfamily, and Maricela herself, learned ways to \ncreate therapy and aids that were effective, \nuseful, and enjoyable. \n\n\nMaricela did learn to walk better, and to \nuse her hands and arms to do many things. \nBut this took a long time. Sometimes she \nwould try something that was too hard, and \nalmost give up. But when her little brother \nwould say she could not do it, she would \nkeep trying until she succeeded. \n\n\nEven when Maricela liked doing \nsomething, because she was a child she \nwould get bored and not keep doing it for \nlong. Her parents always had to look for new \nways for her to get her therapy. It became a \nchallenge and a game for them, too. \n\n\nOf course, Maricela loved horses. So her \nfather made her a rocking horse out of old \nlogs, branches of trees, and a piece of rope \nfor a tail. \n\n\nHer father noticed that she was beginning to \nwalk on tiptoe, so he made special stirrups for \nthe rocking horse. With \nthese, when she rocked, \nher feet stretched up in \na more normal position. \n\n\nThe rocking horse kept her knees apart, \nstrengthened her hands, and helped her \nimprove her balance. Maricela loved her \nhorse and sometimes rocked for an hour or \nmore. When she got off, it seemed she could \n\n\nSoe better. \n\n\nINTRODUCTION PART 1 \n\n\nAfter Maricela had learned to ride the \nrocking horse, she wanted to ride the real \nthing. She begged and begged. So one day \nher father let her ride with him to the corn- \nfield on his donkey. He suggested she ride in \nfront of him where he could hold her. But \nshe insisted on riding behind, like other \nchildren do. \n\n\nSo he fixed some stirrups and let her ride \nbehind. Her legs were spread wide and she \nhung on tightly. It was excellent therapy— \nbut nobody called it that. \n\n\nIn the cornfield she helped her father and \nbrother clean the weeds out from among the \nyoung corn plants. That was good for the \nyoung plants—and for her, too! But after \nseveral trips to the cornfield on the donkey \nwith her father, Maricela begged him to let \nher ride alone. He was nervous, but he let \nher try. \n\n\nShe could do it—and what confidence it \ngave her! Soon Maricela was preparing lunch \nfor her father and brother and taking it to \nthem in the cornfield—all by herself. Now \nshe found she could do many other things \nshe never thought she could. Although she \nwas still awkward, and at times had to look \nfor special ways to do things, she found she \ncould do most anything she wanted or \nneeded to. \n\n\n7 \n\n\nfun \n\n\n7 \n\n\nRecently, some ‘appropriate technology’ groups have tried to adapt standard \n‘rehabilitation aids’ to poor rural communities. However, many of their designs are \nmodeled fairly closely after the same old city originals, using bamboo and string \n\ninstead of plastic and aluminum. Some of these low-cost designs are excellent. But \nmore effort is needed to make use of the unique possibilities for rehabilitation and \ntherapy that exist in the village, farm, or fishing camp. \n\n\nMaricela’s family did just this. The basket of corn, the washing rock, the rocking \nhorse, and the donkey all became ‘therapy aids’ to help Maricela spread her spastic legs, \nand at the same time, to take part in the life of her family and community. \n\n\n8 CHAPTER! \n\n\nThe example of Maricela’s ‘therapy’ cannot and should not be copied—but instead, \nlearned from. In fact, the story suggests that no approach to rehabilitation should be \n\ncopied exactly. Our challenge is to understand each child's needs, and then to look for \nways to adapt her rehabilitation to both the limitations and possibilities within her \nfamily and community. We must always look for ways to make therapy functional and \n\n\nBut not every family shells corn in baskets, washes clothes on rocks, or has a donkey. \nAnd not every disabled child has Maricela’s needs and strengths. So we repeat: \n\n\nWe should encourage each family to observe the specific needs and \npossibilities of their disabled child, to understand the basic \nprinciples of the therapy needed, and then to look for ways to \nadapt the therapy to the child’s and family’s daily life. \n\n\nFed: Ds CoC oe S \nPeDees : \nIT rs NOT BEING ‘NORMAL’ . \nA THAT'S IMPORTANT ==: | \n\n\nme ie \n|. \n\n\non § \"BUT LEARNING TO ACCEPT \noe =— OUR BEING DIFFERENT: TO LIVE* \n\n\n2. \n\n\nAND LOVE AS FULLY AS_ WE _ \nee eee \n\n\nLV \n\n\nSAAS EG \n\n\nDKS) \n\n\n3 47 fe \n“© ’9 Wernev 86 \n\n\nSa \n\n\nIdeas for Sharing 2 \nInformation from This Book \n\n\nMost of the information in this book will be useful to health workers and village \nrehabilitation workers who see many disabled children. Some of the information wil \nalso be useful for the family of a disabled child. However, a family with one disabled \nchild will usually not need, or be able to afford this whole book. It has information \nabout so many different disabilities, that parents may have difficulty finding the \ninformation that applies to their child. \n\n\nAlso, learning from a book is often not the best way to learn something. A lot of \nmethods, aids, and exercises can be learned more easily from other persons, through \nwatching and through guided practice. But after a village worker has taught parents \nhow to do certain exercises, or shown them an example of a homemade aid, printed \ninstruction sheets with clear drawings can be a big help. Sometimes they can make the \ndifference between whether the recommendations are followed at home, or not. \n\n\nThere are certain pages or parts of this book that you may want to give to families \nafter you explain and teach to them selected exercises or activities. For example, to the \nfamily of a girl with arthritis, you may want to give some of the ‘Exercise Instruction \nSheets” at the end of Chapter 42, and the ‘Information Sheet on Aspirin’ on p. 134. \nYou may also want to give them pages from Chapter 16 on arthritis, and to mark the \nexercises and activities that are important to their child \n\n\nTo the family of a young child who is slow to develop, you may want to give pages \nfrom the chapters on child‘development and early stimulation activities (Chapters 34 \nand 35). For a more advanced child you could give the family material from the \nchapters on self-care (Chapters 36 to 39). \n\n\nDepending on the interest and reading ability of the family, you may want to give \nthem a whole chapter (or chapters) about their child’s disability. For example, the \nchapters on cerebral palsy (Chapter 9) or deafness (Chapter 31). An older child who is \nparalyzed from a broken back might appreciate having a copy of the chapter on spinal \ncord injury. Letting him and his family take home the \nchapters On pressure sores and urine and bowel control \ncould even save his life! His family may also want to \ntake home plans for making a low-cost wheelchair, to \nsee if the carpenter and blacksmith in their village \ncould make one. \n\n\nPAGES AND \nIn Project PROJIMO in Mexico, the village CHAPTERS \nrehabilitation team keeps a big file box with copies of FOR GIVING \nthe different pages and chapters that they have found TO PARENTS \nmost useful for giving to families. (In fact, the \nexercise sheets at the end of Chapter 42 were Suggestion: Keep a file of pages, \nOriginally prepared separately to give to families. chapters, and information sheets \nLater, we decided to include them in this book.) to give to families. \n\n\nOU \n\n\nCHAPTER 2 \n\n\nMarking the information that applies to the child \n\n\nOn any page or chapter \nthat you give to parents, Lape ar hone «aes aa \nsome of the information or \nsuggestions will apply more \nthan others to their child. \n\n\nWe suggest that you \ncircle the activities or ae \nsuggestions that would be \nmost helpful to the child You can do the sme thing with the \nin his present condition or wescvivintaeaics \nlevel of development. You meow your hand own \ncould also put an ““X”’ so that he doped one \nthrough anything that should \nnot be done or might be \nharmful for that child. eg) ode en Se on PUR inl Ie BAO \n\n\non a large bal! \n\n\nHere is an example. \nIf the child is spastic and \nbeginning to sit, the first \n3 activities on p. 307 can \nhelp her to improve balance \nand to develop controlled spray cngoel saaeechereemieaaeme bh ge tr \nbody movement. So circle sti pees \nthese. The next 3 \nactivities will still \nbe too difficult and could Rete: Vou con ste Go Dane PhS) = Geir eee \n\n\nexer ) tting the child \nses by $ g 3 falling with his arms \n\n\nincrease spasticity. Put an ogi ecard ecm \n\n\n“ s him backward, sideways. and «4 * = . Tilting him causes him \nforward But it is better to netiecrchincigger arch \nX\"\" through these so the nannaminen © his balance, which is a \n\n\nfamily does not do them. ; picts \n\n\nMaking copies of pages can be \ncostly. Or you may have to go a long \nway for them. Also, there will be \ntimes when you want to give a family \nwritten suggestions or drawings that \nyou have not copied in advance. \n\n\nPerhaps some of the children or \nyoung people who are at the village \ncenter, either for rehabilitation or \nas learners-and-workers, can help \ntrace drawings from the book. If \nthey have some artistic skill, they \ncan make the drawings larger, or make \nthe child in the drawing look like \nthe child that they are to be used mereieg a PROGR tes oak Gemeees \nwith.* this book to the needs of specific children. \n\n\n*\\Ideas for drawing and for copying drawings at larger size are in Helping Health Workers Learn, p. 12-1 to 12-21. \n(See p. 637.) \n\n\n3i \n\n\nSHARING INFORMATION \n\n\n\\f someone prepares a set of large drawings in advance, perhaps a disabled child who \nvisits the village center can trace the drawings of exercises he needs to do at home. \nGiving the child this responsibility from the start makes it more likely that he will do \nthe exercises at home. \n\n\nIf you make your own ‘hand out’ sheets (instead of just copying pages of this book) \nyou can use the local language and villagers’ way of saying things. You can also adapt \nthe drawings to the hair style and dress that people feel ‘at home’ with. \n\n\nWhatever you do, try to keep both your language and drawings simple and clear. \nAvoid unfamiliar words. \n\n\n@— \n\n\nAlso, try to think of ways of adapting exercises or activities to the local situation. \n\n\nFor example, suppose you live ina you might add a drawing like this one. \nfishing village, and want to make copies This will encourage parents to think of \nof a drawing showing an aid for ways to do exercises that involve their \nstrengthening the wrist. Instead of just child in the life and action of their \ncopying a method like this from a book, community. \n\n\nflexible \n\n\nand good for the whole child. \n\n\nRemember: Written pages and drawings can be a big help, but they should not be a \nsubstitute for teaching and showing. To help a family understand activities or exercises \nthat are needed \n\n\n1. First show and explain \n2. Guide them in doing it until they do it right and understand why \n\n\n3. Then, give them the instruction sheet and explain the main points \na \n\n\nThese steps are explained with examples and drawings on p. 382. \n\n\nAs much as you can, try not to use this book for giving exact \ninstructions on how to do things. Instead, encourage everyone to use \nit as a source of ideas, in order to figure out better ways to help \n\ntheir children lead fuller lives and manage better in their communities. \n\n\n32 \n\n\n12 CHAPTER2 \n\n\nREMEMBER... \n\n\nOne of the best ways to share information from this book is to: \n\n\n1. SHOW other people how to do things. \n\n\nVillage rehabilitation \nworkers and family members \nlearn in an outdoor class. \nHere they practice a hip- \nstretching exercise. \n\nBehind them, drawings on \nthe blackboard show which \nmuscles are stretched. \n\n\n2. Then help them LEARN BY DOING it themselves—under your guidance. \n\n\nTeaching a village health \nworker how to stretch a \ntight heel cord (see p. 83.) \n\n\n3. And to help them remember, give them a DRAWING or INSTRUCTION SHEET. \n\n\n: \n\n\nIMPORTANT: Try to help people \nto understand not only what to \ndo, but also why. Perhaps you \n\ncan hold classes using information \nfrom this book. Try to combine \nhands-on practice with discussion \nof principles and reasons. \n\n\nCHAPTER 3 \n\n\nPrevention of Disabilities \n\n\nBecause this is a book on ‘rehabilitation’, it is mostly about children who are already \ndisabled. However, preventing disabilities is also very important. For this reason, in \nmost chapters on specific disabilities, we include suggestions for preventing them. \n\n\nNotice that we place the discussion of prevention at the end of each chapter, not at \nthe beginning. This is because people are usually not concerned about disability until \nsomeone they love becomes disabled. Then their first concern is to help that person. \nAfter we have helped a family to do something for their disabled child, we can interest \nthem in ways to prevent disability in other members of the family and community. \n\n\nWe mention this because when health professionals design community programs, \noften they try to put prevention first—and find that people do not show much interest. \nHowever, when a group of parents comes together to help their disabled children, after \ntheir immediate needs are being met, they may work hard for disability prevention. \n\n\nFor a community program to be successful, start with \nwhat the people feel is important, and work from there. \n\n\nTo prevent disabilities, we must understand the causes. In most parts of the world, \nmany causes of disability relate to poverty. For example: \n\n\n@ When mothers do not get enough to eat during pregnancy, often their babies are \nborn early or underweight. These babies are much more likely to have cerebral \npalsy, which is one of the most common severe disabilities. Also, some birth \ndefects are related to poor nutrition during the first months of pregnancy. \n\n\nWhen babies and young children do not get enough to eat, they get infections \nmore easily and more seriously. Diarrhea in a fat baby is usually a mild illness \nBut in a very thin, malnourished baby, diarrhea often leads to serious \ndehydration, high fever, and sometimes brain damage with fits or cerebral palsy. \n\n\nPoor sanitation and crowded living conditions, together with poor food, make \ndiseases such as tuberculosis—and the severe disabilities it causes—much more \ncommon. \n\n\nLack of basic health and rehabilitation services in poor communities makes \ndisabilities more common and more severe. Often secondary disabilities develop \nthat could be prevented with early care. \n\n\nTo prevent the disabilities that result from poverty, big changes are needed in our \nsocial order. There needs to be fairer distribution of land, resources, information, and \npower. Such changes will happen only when the poor find the courage to organize, to \nwork together, and to demand their rights. Disabled persons and their families can \nbecome leaders in this process. Only through a more just society can we hope for a \nlong-term, far-reaching answer to the prevention of disabilities caused by poverty. \n\n\n34 \n\n\n14 CHAPTERS \n\n\nAlthough the most complete \nprevention of disabilities related Why, since a good vaccine exists, is there \n\n\nstill so much polio in so many countries? \n\n\nto poverty depends on social \nchange, this will take time. \n\nHowever, more immediate actions at \nfamily, community, and national \nlevels can help prevent some \ndisabilities. For example, \n\n\n@ Polio, in certain situations, \ncan be prevented through \nvaccination. (However, \neffective vaccination depends \non much more than good \n\n\nvaccine. See the box.) ————————+ \n\n\nIn places where vaccination \n\nis not available or not fully \neffective, families and \ncommunities can help to lower \nthe chance of paralysis from \npolio in other ways: \n\n\nby breast feeding their \nchildren as long as \npossible (see p. 74). \n\n\nby not letting their \nchildren get unnecessary \ninjections (see p. 18 to 21). \n\n\nEFFECTIVE VACCINATION DEPENDS ON \n\n\nMANY FACTORS: \n\n\nTECHNICAL \nProduction \nand supply \nof safe, \neffective, \nvaccine. \n\n\nECONOMIC (Cost \nof vaccine and \n\nof getting it to \n\nthe children.) \nLeaders in \n\npoorer countries \nmust decide that \nstopping polio \n\nis worth the \nexpense. \n\n\nMANAGEMENT \nKnowledge of \nneeds, planning, \ntransportation, \nand distribution \nof the vaccine \n\n\nKEEPING POLIO VACCINE \nFROZEN (in many \ncountries, 1/3 of \n\nvaccines are spoiled by \n\nthe time they reach the \nchildren.) \n\n\nEDUCATION People must \nunderstand the value of \nvaccination and want to \ncooperate. Health workers \nmust know how important it \nis to keep polio vaccine \nfrozen \n\n\nPOLITICAL Vaccination \nprograms are most \nsuccessful where the \ngovernment fairly \nrepresents the people \n\nand has their full \nParticipation in country- \nwide vaccination \ncampaigns \n\n\nETHICAL (Honesty and \ngood will) Doctors, \nhealth workers, and \ncitizens must try to see \nthat vaccine reaches a// \nchildren. (In some \ncountries, some doctors \nthrow vaccines away and \nfill out false reports, \n\nand health inspectors do \nnot care enough to try to \nstop what is happening.) \n\n\nBrain damage and fits can become less frequent if mothers and midwives take \nadded precautions during pregnancy and childbirth, and if they vaccinate \n\n\nchildren against measles. (See p. 107.) \n\n\nSome birth defects and mental retardation can be prevented if mothers avoid \nmost medicines during pregnancy, and spend the money they save on food. \n\n\nSpinal cord injury could be great \n\n\ny reduced if fathers would spend on education \n\n\nand community safety what they now spend on alcohol and guns. \n\n\nLeprosy could mostly be prevented if people would stop fearing and rejecting \npersons with leprosy. By being more supportive and encouraging early home \ntreatment, the community could help prevent the spread of leprosy, since persons \nbeing treated no longer spread it. (See p. 215.) \n\n\nBlindness in young children in some countries is caused by not eating enough \nfoods with vitamin A. Again this relates to poverty. However, many people do not \nknow that they can prevent this blindness by feeding their children dark green \nleafy vegetables, yellow fruits, or even certain weeds and wild fruit. Also, some \nkinds of deafness and mental retardation can be prevented by using iodized salt \nduring pregnancy (see p. 276 and 282). \n\n\nPREVENTION \n\n\n¢ Disability caused by poisons in TO PROTECT AGAINST PESTICIDE \nfood, water, air, or workplace. POISONING \n\n\nThe recent, common, worldwide @ Stand so that wind blows spray away from you. \nuse of chemicals to kill insects @ Wear protective clothing, covering the whole \nand weeds has become a major \nhealth problem. Often villagers \nuse these pesticides without any \nknowledge of their risks, or of \nthe precautions they should take. \nAs a result, many become \nparalyzed, blind, or disabled in clothes that \n\n\nother ways. —o\" \n\n\nTo prevent these problems, \npeople need to learn about the : sandals) \n\ndangers, not only to themselves @ Wash whole body and change clothes \n\nand their children but to animals, rato es pots spraying. \n\nj ash clothes after spraying. \n\nbirds, land, and to the whole Do not let wash water get into drinking supply. \nbalance of nature’. Less Do not use spray containers for food or water. \ndangerous ways to contro! pests Do not let children play with spray containers. \n\ngive better results over time. Pig. CAUTION: Make sure that children, and \nLaws are also needed to prohibit women who are pregnant or breast \n\nthe most dangerous products feeding, stay away from all pesticides. \nand to provide clear warnings. \n\n\nPoisonous foods in some areas are a major cause of disability. In parts of India, \nthousands of farm workers who are paid with a poisonous variety of lentils suffer \nparalysis from ‘lathyrism’. The poor know the danger but have nothing else to eat. \nFair wages and less corruption are needed to correct this situation. \n\n\nFluoride poisoning (fluorosis), mainly from The 4 Bigeet cenes oF “cringive’ \ndrinking water, is a common cause of bone in India, affecting over 2 million \ndeformities (knock-knees) in parts of India people, are reported to be polio, \nd other place ts) blic health m r iodine deficiency, fluorosis, and \nang otner places. Fublic nea €asures lathyrism. Given the political will, \n\n\nare needed to provide safe water.* all could be completely prevented! \n\n\nDangerous work conditions, poisons in the air, and lack of basic safety measures \nresult in many disabilities. These include burns, amputations, blindness, and back \nand head injuries. In some countries, the use of asbestos for roofs or walls in \nschools, work places, and homes causes disabling !ung diseases. Strict public health \nmeasures and an informed, organized people are needed to bring improvements. \n\n\nCertain dangerous medicines, known to sometimes cause disabilities, are now \nprohibited in the countries that make them, but are still sold in other countries. \n\nFor example, diarrhea medicines containing clioquinol caused thousands of cases of \nbiindness and paralysis in Japan. (A good book discussing dangerous medicines in poor \ncountries is Bitter Pills by Dianna Melrose. See p. 641.) \n\n\nThe high cost, overuse, and misuse of medicines in general adds greatly to the \namount of poverty and disability in the world today. Better education of both doctors \nand people, and more effective international laws are needed to bring about more \nsensible supply and use of medicines \n\n\n*Note: Aithough too much fluoride is harmful, some is necessary for healthy bones and teeth. In some areas \nfluoride needs to be removed from drinking water, in other areas it needs to be added. \n\n\nCHAPTER 3 \n\n\nWHO SHOULD BE RESPONSIBLE \nFOR DISABILITY PREVENTION \n\n\nNotice that many of the specific \npreventive measures we have discussed, \njust like the more general social measures, \ndepend on increased awareness, community oe \nparticipation, and new ways of looking at HAPPEN \nthings. These changes do not just happen. Aaa \nThey require a process of education, \norganization, and struggle led by those \nwho are most deeply concerned. \n\n\nMost able-bodied persons are not very \nconcerned about disability or trying to \nprevent it. Often people think, ‘Oh, that \ncould never happen to me!’’—until it does. \n\n\nThose who are most concerned about \ndisability are usually disabled persons Mi \nthemselves and their families. Based on this | \nconcern, they can become leaders and \ncommunity educators for disability x \n\n\nprevention. Disability can affect everybody, and \nsometime in our lives it usually does. \n\n\nThey can do this in an informal, person-to-person way. \nFor example, \nNO, I WOULDN'T TAKE HER FOR Or disabled children and families can join \nAN INJECTION. IF HER FEVER IS A together to form prevention campaigns. In \neggs bests phen Pars ig one village, mothers put on short plays to \nTHAT'S inform the whole community about the \nWHAT er importance of breast feeding and vaccination \npreilinyeodndd Fg (See p. 74.) In Project PROJIMO, Mexico, \ndisabled rehabilitation workers have helped \nto vaccinate children in remote mountain \n\n\nvillages. \n\n\nIn PART i of this book, where we discuss \ndifferent disabilities, we also include bas\\ \ninformation on prevention. We hope that \nthose of you who use this book for children \nwho are already disabled, will also work \nactively towards disability prevention. \n\n\nPREVENTING SECONDARY DISABILITIES \n\n\nSo far we have talked mainly about preventing original or ‘primary’ disabilities, \nsuch as polio or spinal cord injury. But the prevention of ‘secondary’ disabilities is \nalso very important, and is one of the main concerns of rehabilitation. \n\n\nBy ‘secondary’ disabilities we mean further disabilities or complications that can \nappear after, and because of, the original disability. \n\n\n3% \n\n\nPREVENTICN \n\n\nFor example, consider a child with polio or cerebral palsy who at first is unable to \nwalk. She gradually loses the normal range-of-motion of joints in her legs. Shortened \nmuscles, called ‘contractures’, keep her legs from straightening. This secondary \ndisability may limit the child's ability to function or to walk even more than the \noriginal paralysis \nThis child, after polio The contractures (not /f the contractures had been \ngradually developed the original paralysis) prevented through early and \ncontractures in her kept her from being continued range-of-motion \n\nable to stand or walk exercises, the child would \n\n\nhave been able to stand and \nwalk. \n\n\nMost contractures can be \ncorrected. But it may take a \nlong time and a lot of d \nexpense—perhaps even surgery. \n\n\nIt is far better to: \nJ | PREVENT CONTRACTURES BEFORE THEY START. \n\n\nfoot, and knee. \n\n\nBecause contractures develop as a common complication in many disabilities, we \ndiscuss them in a separate chapter (Chapter 8). Range-of-motion exercises to help \nprevent and correct contractures are described in Chapter 42. Use of plaster casts to \ncorrect contractures is described in Chapter 59. \n\n\nMany other secondary disabilities wil! also develop unless preventive measures are \ntaken. Some examples are pressure sores in children with spinal cord injury (see \nChapter 24), spinal curve in a child with a weak back or with one leg shorter than the \nother (see Chapter 20), head injuries due to fits (see p. 235). Preventive measures for \nmany other secondary disabilities are discussed in the chapters on the specific \ndisabilities. \n\n\nIn several places we discuss problems or disabilities that are commonly caused by \nmedical treatment or orthopedic aids. For example, \n\n\n@ The medicine for fits, phenytoin, produces serious swelling of the gums in some \nchildren. This can partly be prevented by brushing the teeth regularly. (See \np. 238.) \n\n\nCrutches that press hard under the armpit can damage nerves and gradually \nparalyze the hands. Shorter crutches, or lower-arm crutches (like those shown \nabove) prevent this problem. (See p. 393.) \n\n\nSurgery is sometimes done to remove contractures that actually help a child to \nmove or function better. So worse difficulties result. The benefits or possible \nharm of surgery should be carefully evaluated before it is done. (See p. 530.) \n\n\nSome braces or aids that help a child at first, may later actually hold her back. \n(See p. 526 to 529.) \n\n\nTo prevent these mistakes, it is essentia! to evaluate the needs of each child carefully, \nand repeat evaluations periodically. We must take great care to prevent further \ndisability caused by treatment. \n\n\nThe first responsibility of a rehabilitation worker \nor parent, like the healer, should be to: \nDO NO HARM \n\n\n17 \n\n\nCHAPTER 3 \n\n\nIn addition to secondary disabilities that are physical, others may be psychological \nor social (affecting the child’s mind, behavior, or place in the community). \n\n\nSome disabled children develop serious behavior problems. This is often because \nthey find their bad behavior brings them more attention and ‘rewards’ than their good \nbehavior. Chapter 40 discusses ways that parents can help prevent tantrums and bad \nbehavior in disabled children. \n\n\nThe biggest secondary handicap for many disabled children (and adults) usually \ncomes from the lack of understanding and acceptance by other people. PART 2 of this \nbook talks about how the community can be involved in taking a more active, \nsupportive role in relating to the disabled and helping them to meet their needs. In \nPART 2 we also discuss what disabled persons and their families can do, in the \ncommunity, to promote better understanding and prevent disability from becoming a \nserious handicap. \n\n\nPrevention of secondary disability is a basic part of rehabilitation. \n\n\nTHE NEED FOR MORE SENSIBLE AND \nLIMITED USE OF INJECTIONS \n\n\nThe overuse and misuse of medicines in the world today has become a major cause \nof health problems and disabilities. This is partly because medicines are so often \nprescribed or given wrongly (for example, certain medicines taken in pregnancy can \ncause birth defects, see p. 119). And it is partly because both poor families and poor \n\nnations spend a great deal of money \non overpriced, unnecessary, or \ndangerous medicines. The money \ncould be better spent on things that \nprotect their health—such as food, \nvaccinations, better water, and more \nappropriate education. Some \nmedicines, of course, when correctly \nused are of great importance to health. \nBut most are not. Of the 30,000 \nmedicinal products sold in most \ncountries, the World Health \n\n\nIn most of the world, doctors, health workers, Organization says that only about 250 \nand the people make giving and getting \ninjections too big a part of health care are needed. \n\n\nIn many countries, — \ninjections have become the : eae | PRESCRIBE \n\n\n‘modern magic’. People Tarte we SO MANY \ndemand them because doctors INJECTIONS e ‘ INJECTIONS \nand health workers often BECAUSE BECAUSE \n\n. My DOCTOR MAN PATIENTS \nprescribe them, and doctors PAE SCRIBES HAVE FAITH \nand health workers prescribe THEM. d IN THEM. \nthem too often because people \n\n\ndemand them. \n\n\nPREVENTION \n\n\nHOW INJECTIONS DISABLE CHILDREN \n\n\nGiving injections with an unclean \nneedle or syringe is a common cause \nof infection. Sometimes these \ninfections can lead to paralysis, or \nspinal cord injury (see the story on \np. 192), or death. \n\n\nAlso, some injected medicines can \ndo harm. Dangerous allergic reactions, \npoisoning, and deafness are sometimes \ncaused by injecting certain medicines— \noften when they are not needed. \n\n\nOveruse by doctors and midwives of \n\n\nThis child was injected with a needle that was not sterile injectable hormones to speed up child- \n(clean). The dirty needle caused an infected abscess birth and ‘give force’ to the mother \n\n\n(pocket of pus) that in time burst and drained. The child . . \nhad been injected for a cold. It would have been better has become a major cause of babies \n\n\nto give him no medicine at all. born with brain damage, cerebral \npalsy, and fits in many countries. \n\n\nNRE \nThe disability most often caused by injections is \nparalysis from polio. Some experts say that each year up \nto 2 million children are paralyzed by polio because of \n\n\ninjections. Nearly all of these injections are given when \nthey are not needed. \n\n\nIt happens like this. Children who are infected by the \npolio virus usually only have signs of a bad cold or ‘flu’. 1 out of every 3 cases of \nMost get well in a few days, without developing polio is caused by injections. \nparalysis. But the risk of paralysis increases if the child's \nmuscles are injured or irritated. Injections of any kind of medicine irritate the muscles. \nMessages from the irritated muscles travel up the nerves to the spina/ cord, and cause \nchanges that let the polio virus produce paralysis \n\n\nUnfortunately, when children develop a cold or ‘flu’ caused by the polio virus, their \nparents often take them to a doctor or health worker for an injection. Many times the \nresult is paralysis, which is usually worse in the leg on the side that was injected. Many \npeople used to think that paralysis in a leg after an injection was caused because the \nneedle ‘hit a nerve’. We now know that in most cases the paralysis was caused by polio. \nBecause it was brought on or ‘provoked’ by an injection, this is called ‘provocation \npolio’. \n\n\nIt is very important that mothers—and doctors—remember that children should not \nbe given injections when they have signs of a cold with fever or ‘flu’. It might be polio, \nand an injection could bring on paralysis. \n\n\nIf injections are given to children only when they are really \nneeded, millions of cases of polio could be prevented. \n\n\n20 3s CHAPTER3 \n\n\nThe worldwide epidemic of unnecessary injections each year sickens, kills, or \ndisables millions of persons, especially children. An international campaign is needed to \nre-educate doctors. health workers, traditional healers (many of whom also now \noveruse injections), and the people themselves. \n\n\nCombatting misuse and overuse of medicines is as important a preventive measure as \nis vaccination, clean water, or the correct use of latrines. \n\n\nHealth workers, schoolteachers, and community organizers should all work to \n‘de-mystify’ or take the magic out of injections, and to help peopie always to weigh \nthe possible risks and benefits before using any medication. \n\n\nFor skits and ideas on teaching people about the danger of unnecessary injections, \nsee Helping Health Workers Learn, Chapters 18, 19, and 27. \n\n\nNote: When used correctly, certain injected medicines are important \n\n\nto health. Vaccinations, including those that are injected, are very \nimportant to protect a child’s health and prevent disability. However, \nto avoid paralysis from polio, it is best not to give vaccinations \n\n\n(immunizations) or any other injection when a child has a fever or \nsigns of a cold. This could be a mild polio infection, and giving an \ninjection could cause paralysis. \n\n\nAVOID UNNECESSARY \nINJECTIONS \n\n\nWAR AS A CAUSE OF CHILD DISABILITY \n\n\nArmed violence is increasing. Since 1980, 45 \ncountries have been involved in 40 wars, with over \nfour million soldiers. In today’s wars, more civilians \nthan soldiers are killed or disabled, and most are \nwomen and children. |n World War One, only 5 \npercent of persons killed or injured were civilians. \nToday, 80 to 90 percent are civilians. At least 3 times \nas many people are injured as are killed. \n\n\nThe increased poverty and ‘hard times’ caused by \nwar also lead to many disabilities. There are 25 to 30 \nmillion refugees, many living under dangerous and \nunhealthy conditions. One-third of the world’s \nchildren lack adequate food and basic health care. \nMillions are homeless. Yet in 1985, world leaders \nspent 1,000 billion US dollars on war and arms—twice \n\n\nas much as in 1981. by a ‘Contra’ \n\n\nbomb. The Contras are rebel troops \n\n\n, supported by the United States \nWar, terrorism, and torture have become tools of rn cso quetieen the cow \n\n\nthe powerful for economic, political and social government in Nicaragua. (Photo by \ncontrol. When the peoples of poor countries dare to Marc Krizack, Links) \n\nget rid of their dictators and form popular \ngovernments that work toward fairer distribution, the Terrorism is too often fought \nrich, powerful countries often try to destroy those with terrorism. During the U.S. \nnew governments. They pay for terrorism, long wars, attack on Libya in April, 1986, \nand the destruction of schools, health centers, and bombs hit a school for disabled \nproduction. The result is still more poverty, disease, children. Such actions do not \nand disability. stop terrorism; they merely kill \nies . . and disable innocent persons. \nTo help change this situation, we disabled persons “AN EYE FOR AN EYE WILL \n\n\nof the world must join with all who are disadvantaged MAKE THE WHOLE WORLD \nor treated unfairly, to struggle for a new, more truly BLIND.”’—Mahetma Gandhi. \nhuman, world order. \n\n\nExamining and Evaluating cre ae \nthe Disabled Child \n\n\nTo decide what kind of special help, if any, a disabled child \nmay need, first we need to learn as much as we can about the \nchild. Although we may be concerned about her difficulties, we \nmust always try to look at the whole child. Remember that: \n\n\nA child's abilities are more \nimportant than her disabilities. \n\n\nThe aim of rehabilitation is to help the child to function \nbetter at home and in the community. So when you examine a \nchild, try to relate all your observations to what the child can \n\n\ndo, cannot do, and might be able to do. LOok Fiast \nAT MY \nSTRENGTHS, \n\n\nWhat a child is and does depends partly on other persons. So wi Rachael \nwe must also look at the child’s abilities and difficulties in j \nrelation to her home, her family, and her village or neighborhood. \n\n\nTo evaluate a child’s needs, try to answer these questions: y \n\n\n@ What can the child do and not do? How does this compare with other children the \nsame age in your community? \n\n\nWhat problems does the child have? How and when did they begin? Are they \ngetting better, worse, or are they the same? \n\n\nIn what ways are the child's body, mind, senses, or behavior affected? How does \neach specific problem affect what she does? \n\n\nWhat secondary problems are developing? (Problems that result after and because \nof the original problem.) \n\n\nWhat is the home situation |ike? What are the resources and limitations within the \nfamily and community that may increase or hold back the child’s possibilities? \n\n\nIn what way has the child adjusted to her disability, or learned to manage? \nTo find the answers to these questions, a health or rehabilitation worker needs to do \n3 things: \n\n\n1. Observe the child carefully—including her interaction with the family and with \nother persons. \n\n\n2. Take a ‘history’. Ask the parents and child (if old enough) for al! information they \ncan provide. Obtain medical records if possible. \n\n\n3. Examine the child to find out how well and in what way different parts of her \nbody and mind work, how developed they are, and how much they affect her \nstrengths, weaknesses or problems. \n\n\nBE SURE TO LOOK AT THE WHOLE CHILD-—NOT JUST THE DISABILITY \n\n\n+2 \nad \n\n\nCHAPTER 4 \n\n\nObservation of the child can begin from the first moment the health worker or \nrehabilitation worker sees the child and her family. It can begin in the waiting area of a \nvillage center, the home, or the street, and should continue through the history-taking, \nexamination, and follow-up visits. Therefore, we do not discuss ‘observation’ separately, \nbut include it with these other areas. \n\n\nIt is usually best to ask questions BEFORE beginning to examine the child—so that \nwe have a better idea what to look for. Therefore, we will discuss history-taking and \nthen examination. But first a word about keeping records. \n\n\nRECORD KEEPING \n\n\nFor a village rehabilitation worker who helps many children, writing notes or records \ncan be important for following their progress. Also, parents of a disabled child may \nfind that keeping simple records gives them a better sense of how their child is doing. \n\n\nSix sample RECORD \nSHEETS are on pages 37 to \n41, 50, 292, and 293. You \ncan use these as a guide for \n\n\nSample RECORD SHEETS RECORD SHEET \nincluded in this book page \n\n\n37 and 38 \n\n\nChild history \n\n\ngetting and recording basic \ninformation. But you will \nwant to follow with more \ndetailed questions and \n\n\nPhysical examination . \n\n\nTests of nervous system . eer \nFactors affecting child development \n\n\nMeasuring a child's progress . \n\n\nexamination, depending on . 292 and 293 \n\n\nwhat you find. \n\n\nChild development chart . \n\n\nSheets 1 and 2 will be useful for most disabled children. Sheets 3, 4, and 6 are for \nchildren who may have brain damage or seem slow for their age. Sheet 5 is a simple \nform for evaluating the progress of children 5 years old or older. \n\n\nHISTORY TAKING \n\n\nOn pages 37 and 38 you will find a record sheet for taking a child’s history. You can \nuse it as a guide for the kinds of questions it is important to ask. (Of course, some of \nthe questions will apply more to some children than others, so ask only where the \ninformation might be helpful.) \n\n\nWhen asking questions, we rehabilitation workers must always remember that \nparents and family are the only real ‘experts’ on their child. They know what she can \nand cannot do, what she likes and does not like, in what ways she manages well, and \nwhere she has difficulties. \n\n\nHowever, sometimes part of the parents’ knowledge is hidden. They may not have \nput all the pieces of knowledge together to form a clear picture of the child’s needs and \npossibilities. The suggestions in this chapter, and the questions on the RECORD \nSHEETS, may help both rehabilitation workers and parents to form a clearer picture of \ntheir child’s needs and possibilities. \n\n\nRehabilitation workers and parents can work \ntogether to figure out the child’s needs. \n\n\nEXAMINATION \n\n\nEXAMINING THE DISABLED CHILD \n\n\nAfter finding out what we can by asking questions, our next step is to examine the \nchild. In as friendly a way as possible, we carefully observe or test what parts of the \nchild work well, what parts work poorly, and how this affects the child’s ability to do \nthings and respond to the world around him. \n\n\nCAUTION: Although we sometimes examine separately different aspects of the \n\nchild’s body and mind, our main purpose is to find out how well the child’s body \nand mind work together as a whole: what can the child do and not do, and why? \nThis information helps us decide how to help the child to do things better. \n\n\nIn examination of a disabled child, we may check on many things: \n\n\n@ The senses: How well does the child see? dd Ode hear? ) fee|? r~r~XK and blood processing \nsystem system system system \n(respiratory (urinary (circulation (digestive \nsystem) tract) system) system) \n\n\nRehabilitation workers need to work in close cooperation with health workers. \n\n\nA detailed examination of a// a child's parts and functions could take hours or days. \nFortunately, in most children this is not necessary. Instead, start by observing the child \nin a general way. Based on the questions you have already asked and your general \nobservations, try to find anything that seems unusual or not quite right. Then examine \nin detail any body parts or functions that might relate to the disability. \n\n\n44 \n\n\nCHAPTER 4 \n\n\nPart of the art of examining a child is KNOWING WHEN TO STOP. It is important \nto check everything that might help us understand the child's needs. But it is equally \nimportant to win the child’s confidence and friendship. Too much examining and \ntesting can push any child to the point of fear and anger. Some children reach their \nlimit long before others. So we must learn how much each child can take—and try to \nexamine the child in ways that she accepts. \n\n\nSome children require a much more complete examination than others. For example \n\n\nuan lost one hand in an accident 2 years \n\nago, but otherwise seems normal. Probably \n\nhe will need little or no physical \n\nexamination other than to see how he uses \n\nhis arms, stump, and hand. You will also \nwant to check how \nmuch he can do with \nhis other hand, with \nonly his stump, and \nwhen using both \ntogether. \n\n\nThe Physical \nExamination Form \n(RECORD SHEET 2 \non p. 39) is probably \nthe only examination \nform you need to fill \nout. \n\n\nHowever, it would be wise to learn about \nhow Juan’s family and others treat him \nnow, and how he feels about himself and \nhis ability to do things. Does he keep his \nstump hidden when he is with strangers? \nWith family members? What are his hopes \nand fears? You can write this information \n\n\nn the back of the form. \n\n\nuncontrolled movements. She does not play with toys or respond \nmuch to her parents. \n\n\nfon is 2 years old and still does not sit by herself. She has strange \\ \n\n\nAna seems to have many problems. \n\n\nWe wil! need to check: \n\n\nhow well she sees and hears. \n\nhow strong, weak, or stiff different \nparts of her body are. \n\nin what ways her development is \nslow (what she can do and not do). \nhow much she understands. \n\nsigns of brain damage, and how \nsevere. \n\nher sense of balance and position. \nwhat positioning or support gives her \nbetter control and function. \n\n\nIt may take weeks or months of repeated examining and testing \nto figure out all of Ana’s difficulties, and how to best help her \nto function better. It could be a mistake to try to do all the \nneeded examining at one time. \n\n\nTo record all the useful information on a child like Ana, you will \nfind RECORD SHEETS 1, 2, 3, 4, and 6 helpful. ) \n\n\nExamining techniques: Winning the child’s confidence \n\n\nDepending on how you go about it, the physical examination can help you become a \nchild's friend or turn you into his enemy. Here are a few suggestions: \n\n\ne@ Dress as one of the people, not as a \nprofessional. White uniforms often \n\n\nscare a child—especially if at some : 4 \ntime he was injected by a nurse or a § YOUR CONFIDENCE \n\n\ndoctor. \n\n\nan interest in the child as a person. \n\n\n=e Tage , BEFORE \nBefore starting the examination, take y EY EXAMINING \nSpeak to him in a gentle, friendly way. >. \n\n\nWE TRY TO WIN, \n\n\nA we BEGIN / \n\n\nHelp him relax. Touch him in ways \n\n\nthat show you are a friend. \n\n\nApproach the child from the same \nheight, not from above. (Try to have \nyour head at the same level as his.) \n\n\nStart the examination with the child \nsitting or lying on mother’s lap, on the \nfloor, or wherever he feels most safe \n\n\nand comfortable. \n\n\nEXAMINATION 25 \n\n\nPLEASE ASK HER \nTO STRAIGHTEN \n\n\nHER KNEE AS . \nMUCH AS SHE CAN. OUCH MY FINGER \nWITH YOUR FOOT, \n\n\ne@ If the child seems DARLING. \nnervous about a \nstranger touching \nor examining her, \nhave the parent do \nas much of it for \nyou as possible. This \nwill let the mother \nknow that you \nrespect and want to \ninclude her. And she \nmay learn more. \n\n\nNOw TRY TO \n\n\n@ Make the waiting area and \nplace where you do the \nexamining as pleasant and \nas much like home as you \ncan. Have lots of toys, \nfrom very simple to \ncomplex, where the \nchildren can choose and \nplay with them. By \nwatching if, how, for how \nlong, with what, and with \nwhom a child plays, you \ncan learn a lot about what \na child can and cannot do, \nhis level of physical and \nmental development, the \ntypes of problems he has, \nand the ways he has (or \nhas not yet) adapted to \nthem. \n\n\nWatching how a child plays— \n| by herself, with people, and \n\n\nae 6 a7 \naw with toys—is an essential 1 ~< é \n_ part of evaluating the child. ia) Lf (NLS \n\n\n*0 \n\n\n26 CHAPTER 4 \n\n\n@ Try to make the examination interesting and fun for the child. Turn it into a game \nwhenever possible. For example: \n\n\nWhen you want to test a child’s ( Or ee eee, \n‘eye-to-hand coordination’ (for - \npossible balance problems or \n\nbrain damage) you might make a \n\ngame out of having the child \n\ntouch the nose of a doll. Or \n\nhave her turn ona flashlight \n\n(torch) by pushing its button \n\n\nAlso, when he begins to get \nrestless, stop examining for \n\na while and play with him, or \nlet him rest. \n\n\nGEST \n\n\ntf It is best to examine a child when he is we//-rested, \n“,.7 4) well-fed, and in a ‘good mood’—and when you are, too. \n= (We know this will not always be possible.) \n\n\n@ When achild is weaker or has less control on one side than the other, \nfirst test the stronger side, and then the weaker side. \n\n\nNOW LET'S SEE IF YOU \nPLEASE LIFT THIS KNEE CAN LIFT YOUR OTHER \nOCF THE FLOOR, KNEE OFF THE FLOOR. \n\n\nO.K. THANKS \nFOR TRYING. \n\n\nBy testing the good side first, you start by giving the child encouragement with what \nhe can do well. Also, if the child does not move the weaker side, you will know it is \nbecause he cannot, and not because he does not understand or is not trying. \n\n\nGOOD FOR \ne As you examine the child, give Ane You, MENA! \nher lots of praise and < pote sg \nencouragement. When she tries Le ST aS YOURSELF / \nto do something for you and 2 \ncannot, praise her warmly for \n\n\ntrying. \n\n\nAsk her to do things she can \ndo well and not just the things \nshe finds difficult, so that she \ngains a stronger sense of \nSUCCESS. \n\n\nEXAMINATION \n\n\nTESTING RANGE OF MOTION OF JOINTS \nAND STRENGTH OF MUSCLES \n\n\nChildren who have disabilities that affect how they move often have some muscles \nthat are weak or ‘para/yzed’. As a result, they often do not move parts of their bodies \nas much as is normal. \n\n\nLoss of strength and active movement may in time lead to a stiffening of joints or \nshortening of muscles (contractures, see Chapter 8). As a result, the affected part can \nno longer be moved through its complete, normal range of motion. \n\n\nACTIVE MOVEMENT PASSIVE MOVEMENT \n\n\nWhen the shoulder \nmuscles are \nparalyzed, the \nchild can no \nlonger actively \n\nlift his arm. \n\n\nNormally the shoulder \nmuscles can raise the arm \nuntil it is straight up. \n\n\nAt first the \nparalyzed arm can \nbe lifted straight \n\nup with help. \n\nThis is called \nPASSIVE MOTION. \n\n\nUnless the normal range \nof motion is kept through \ndaily exercises, the \nPassive range of motion \nwill steadily become less \nand less. \n\n\nshoulder \nmuscles , \n\n\nsmall \nand weak \n\n\n(( \n\n\nshoulder \nmuscles \nused to \nraise arm \n\n\nof, \n\n\ntcp) £0 RANGE \n\n\nLifting the arm like this \nVE moTio \n\n\nwith the arm’s own muscles \n\n\nis called ACTIVE MOTION. Now the arm cannot be \n\n\nraised straight up, even \nwith help. \n\n\nIn the physical examination of a child with any weakness or paralysis of muscles, or \njoint pain, or scarring from injuries or burns, it is a good idea to test and record both \nRANGE OF MOTION and MUSCLE STRENGTH of all parts of the body that might \nhave contractures or be affected. There are 2 reasons for this: \n\n\n@ Knowing which parts of the body have contractures or are weak, and how much, \ncan help us to understand why a child moves or limps as she does. This helps us to \ndecide what activities, exercises, braces, or other measures may be useful. \n\n\n@ Keeping accurate records of changes in muscle strength and range of motion can \nhelp tell us if certain problems are getting better or worse. Regular testing \ntherefore helps us evaluate how well exercises, braces, casts, or other measures are \nworking, and whether the child’s condition is improving, and how quickly. \n\n\nFor testing range of motion and muscle strength, it helps to first know what is \nnormal. You can practice testing non-disabled, active persons. They should be of the \nsame ages as the disabled children you will test. Age matters because babies are usually \nweaker and have much more flexible joints than older children. For example: \n\n\nA baby’s back and \nhips bend so much \nhe can lie across \nhis straight legs. \n\n\nA young child bends \nless but can usually \ntouch his toes with \nhis legs straight. \n\n\nAround 11 to 14 it \n\nis narder to touch toes. \nHis legs grow faster and \nbecome longer than his \nupper body. \n\n\n48 \n\n\nLater, upper body growth \ncatches up with legs. \n\nHe can again touch toes \nmore easily. \n\n\nCHAPTER 4 \n\n\nIn different children (and sometimes in the same child) you may need to check range \nof motion and strength in the hips, knees, ankles, feet, toes, shoulders, elbows, wrists, \nhands, fingers, back, shoulder blades, neck, and jaw. Some joints have 6 or more \nmovements to test: bending, straightening, opening, closing, twisting in, and twisting \nout. See, for example, the different hip movements (range-of-motion exercises) on \np. 380 in Chapter 42 \n\n\nTo test both ‘range of motion’ and ‘strength’, first check ‘range of motion’. Then \nyou will know that when a cl it, it is Not just because of \nweakness. \n\n\ng cannot straiqnten ator \n\n\nRange-of-motion testing: Example: \n\n\nKnee With your hands, \nsupport the joint \non each side as \n\n\nyou Straighten it. \n\n\n1. Ask the \nchild to \nstraighten \nit as much \nas she can \n\n\nt straighten \n\nRast tall tne way \n\nYOUR FOOT row fer vou car \nAND TOUCH \nAy fineece \n\n\nagentiy see \nstraighten \n\n\nt without forcing. \n\n\nIf at first the (see Chapter 8 \n\njoint will not \n\nIf it gradually straightens, spasticity (muscle spasms) \nmay be what makes it difficult (see p. 79). (If it \nstops before it straightens completely, contractures \nmay also be developing.) \n\n\nStraighten, keep \ntrying with gentle \ncontinuous pressure \nfor 2 or 3 minutes \n\n\nNOw '!T ii, \nSTRAIGHTENS \nFor exampie, a / \n\n\nfA ee” \n\n\nFor this reason, \neach time you test \nrange of motion to \nmeasure changes, \nbe sure the child \n\nis in the same \nposition. \n\n\nIf a joint will \nnot straighten \ncompletely, try not \nwith the child as much witt \nin different } \npositions . as \n’ hips straight \n\n\nknee often does \nstraignter \n\n\nthe hips bent \n\n\nwith the \n\n\nPosition affects how much certain joints straighten or bend. This is true in any child, but \nespecially in a child with spasticity (see pages 101 to 103). \n\n\nIn addition to \nchecking how \n\n\nTHATS ALL IT \nWitt BEND’ \n\n\nIf joints are kept straight and never bent, they \nmay stiffen or develop contractures that do not \n\n\nlet them bend. (This can happen with joint \ninfection, arthritis, and other conditions, or \nwhen a joint is kept in a cast for a long time.) \n\n\nmuch a joint \nstraightens, \ncheck how much \nit bends. \n\n\n«= he same thing can \nhappen to the child \nwith weak arms who \nuses crutches (or \ncrawls). \n\n\nA child who walks on a weak leg often \n‘locks’ her knee backward to keep from \nfalling. In time, the knee stretches \n\nback more and more, like this. ———___> \n\n\nAlso check \nfor too much \nrange of \nmotion. \n\n\nUsually the best positions for checking range of motion are the same as those for \ndoing range-of-motion and stretching exercises. These are shown in Chapter 42. \n\n\nFor methods of measuring and recording range of motion, see Chapter 5 \n\n\n49 \n\n\nEXAMINATION 29 \n\n\nPrecautions when testing for contractures \n\n\nTesting range of motion of the ankles, knees, and hips is important for evaluating \nmany disabled children. We have already discussed knees. Here are a few precautions \nwhen testing for contractures of ankles and hips. \n\n\nAnkle With the knee bent, the foot will \nTest the range of motion usually bend up more. But for \nwith the knee as straight walking, we need to know how far \n\n\nas it will go. it bends with the knee straight. \ni= normal ) \nS upward \nbend \n\n\nFeel the tight \nheel cord here. \n\n\nNote: Tocheck ankle range of motion in a child with spasticity: \nSo first bend his neck, body, Then slowly straighten his \n\n\nWith his body and knee straight, and knees and then slowly knee while keeping the \nit may be hard to bend the ankle. bend up the ankle. ankle bent. \n\n\nOther precautions for testing ankle range of motion are on p. 383. \n\n\nHip \n\n\nTo check how far the hip joint \n\nstraightens, have the child hold his +— \nother knee to his chest, like this, so \n\nthat his lower back is flat against the | | Feel the tight cord here \ntable. If his thigh will not lower to the \n\ntable without the back lifting, he has a nye oy \nbent-hip contracture. (See p. 79.) edge of a table. \n\n\nCAUTION The hips will often straighten \nmore at an angle to the body. So be sure to \nlower the leg in a straight line with the \nbody, or you can miss contractures that \nneed to be corrected before the child can \nwalk. \n\n\nCHAPTER 4 \n\n\nMuscle testing \n\n\nMuscle strength can be anywhere between normal and zero. Test it like this \n\n\nTest the strength of all muscles that might be affected. Here are some of the muscle \ntests that are most useful for figuring out the difficulties and needs of different \n\n\nchildren. \n\n\nIf the child can lift the \nweight of leg all the way, \npress down on it, to check \nif she can hold up as much \nweight as is normal for a \ngirl her age. If she can, \n\nher strength is NORMAL. \n\n\nPress down \nstrongly. \n\n\nrates \n\n\nNORMAL \nstrength \n\n\nIf she can hold \nsome extra weight, \nbut not as much \nas is normal, she \n\n\nPress down \ney \n\n\nGOOD \nstrength \n\n\nGOOD \n\n\nIf she can just hold up \nthe weight of her leg, \nbut no added weight, she \nrates FAIR. \n\n\nIf she cannot hold up the \nweight of her leg, have her \nlie on her side and try to \nstraighten it. If she can, \n\n\nIf she cannot straighten her knee at \n\nall, put your hand over the muscles as \nshe tries to straighten it. If you can \n\nfeel her muscles tighten, rate her TRACE. \n\n\nshe rates POOR. \n\n\nMuscles move, \nbut not leg: \n\n\nTRY AS HARD AS YOU \nCAN TO STRAIGHTEN \nYOUR LEG. \n\nTRACE \n\n\nstrength strength \n\n\nstrength \n8g No muscle \n\n\nmovement: \n\n\nZERO \nstrength \n\n\nNote: These tests are simple and mostly test the strength of groups of muscles. \nPhysical therapists know ways to test for strength of individual muscles. \n\n\nae NORMAL \nfoot-lift \nmuscle \n\n\nIf the child can \nwalk, see if she \ncan stand and walk \non her heels and \nher toes. \n\n\nAnkle and Foot \n\n\nDOWN BEND IN BEND OUT \n\n\n— \n\n\nNORMAL \ncalf-—— \n\n\nmuscle \n\n\nNote: Sometimes when the muscles that \nNormally lift the feet are weak, the child uses \nhis toe-lifting muscles to lift his foot. \n\n\nEXAMPLES OF REASONS FOR TESTING \n1. If strength to lift up the foot is \nWEAK and strength to push down \nis STRONG, tiptoe contractures C \nmay develop—unless steps are \ntaken to prevent them. (See p. \n383.) \n\n\n. Anankle with POOR or very uneven \nstrength may be helped by an \nankle brace. But if strength is \nFAIR, exercise may strengthen it— \nand a brace may weaken it more! \n\n\nIf he lifts \n\nhis foot with \nhis toes bent \nup, like this, \n\n\nsee if he can \n\nlift it with his \ntoes bent down, \nlike this. \n\n\nL AQ, \n\n\nAlso notice if the foot tips or pulls more to \none side. This may show ‘muscle imbalance’. \n(See p. 78.) \n\n\n. Lifting the foot with only \nthe toe muscles may lead \nto a high-arch deformity. \n\n\nL \n\n\nEXAMINATION \n\n\nTo learn about which muscles move body parts in different ways, as \nyou test muscle strength, feel which muscles and cords tighten. \n\n\nEXAMPLES OF REASONS FOR TESTING \n\n\n1. POOR or NO strength \nSTRAIGHTEN for straightening knee \n\n} may mean an above-knee \nbrace is needed. \n\n\nStronger muscles \nin back of the \n\n\nYou can feel Feel the muscles Feel the f thigh than in \\ \nthe muscle tighten on the tight cords 7 | front can lead \ntighten on top back of the pull here. to a bent-knee \n\n\nof the thigh thigh contracture. \n\n\nHips \n\n\nROTATING HIP OUT ROTATING HIP IN \nOPENING CLOSING (and leg in) (and leg out) \n\n\npA Pe \n‘o ) \n\n\n} | \n\n\n| \n\n\nSTRAIGHTENING \n\n\nBENDING Feel the butt lf the hip has contractures, \nmuscles tighten. test with legs off end of table. \n\n\npadding \n\n\nTEST FOR WEAK SIDE-OF-HIP MUSCLES IN THE CHILD \nWHO CAN STAND \n\nSIDEWAYS LIFT Have the child stand on the weaker leg. \n\nFeel the side-of-hip muscles tighten NORMAL NOT NORMAL \n\nThe child stands The hip tilts Or the child shifts \nstraight. The down on the his whole weight so \nhip tilts up on lifted side. it balances over the \nthe lifted leg. weak hip. \n\n\nThis child dips \nto the side on \nNote: Weak hip muscles sometimes each step of \nlead to dislocation of the hip. Be sure vee or ) the weak leg. \nto check for this, too. (See p. 155.) — (This is often \nTesting side-of-hip muscles is of-hip seen with \nimportant for evaluating why a child muscles polio.) \n\nlimps or whether a hip-band may be \nneeded on a long-leg brace Note: Dipping to one side when walking is caused more by weak \nside-of-hip muscles than by a shorter leg. But a shorter leg can \nmake dipping worse. \n\n\nct \nJC \n\n\nCHAPTER 4 \n\n\nStomach and Back \n\n\nTo find out how strong the stomach muscles To test the back muscles, \nare, see if the child can do ‘sit ups’ (or see if he can bend \nat least raise his head and chest). backward like this. \n\n\nSitting up with knees bent Sitting up with knees Feel the muscles tighten \n\nuses (and tests) mainly Straight uses the hip- on either side of the \n\nthe stomach muscles. Feel bending muscles and backbone. Notice if \n\nstomach muscles tighten. stomach muscles they look and feel the \nsame or if one side \nseems stronger. \n\n\nYou can check a child's trunk If achild’s \ncontrol and strength of stomach and \n\n\n° back | sure to check \nstomach, back, and side eegpbirngrey for curvature \n\n\nmuscles like this. Have him may need ak of the spine— \nhold his body upright over braces with T presale \nhis hips, then lean forward nx AD my muscie imbalance \nand back, and side to side, ewheucher. A T\\ or weakness of \n\n\nand twist his body. the trunk. \n\n\nIMPORTANT: Be \n\n\nShoulders, Arms, and Hands \n\n\nWhen a child's legs are severely Therefore, an \nparalyzed but she has FAIR or important test pa \nbetter trunk strength, she may be is this: If she can, \nable to walk with crutches /f her she has a \nshoulders, arms, and hands good chance \nare strong enough. for walking \nwith crutches. \n\n\nCan she lift her \nbutt off the \nseat like this? \n\n\nIf she cannot lift herself, check the strength in her shoulders and arms: \nSHOULDERS \n\n\nPuen bach g \nDow we \n\n\n2 \n\n\nMuscles Muscles \ntighten here. tighten here. \n\n\nlf the shoulder pushes ¢ Or, if her elbow \n\ndown strongly but her range of motion is \nelbow-straightening | | normal, she may learn \nmuscles are weak, she elbow AF to ‘lock’ her elbow \nmay be able to use a oppor | back like this. \n\ncrutch with an elbow | However, this can lead \nsupport. | to elbow problems. \n\n\nEXAMINATION \n\n\nYou may want to make a chart something like this and hang it in your examining \narea, as a reminder. \n\n\nIn muscle \ntesting, it \n\nis especially \nimportant to \nnote the \ndifference \nbetween FAIR \nand POOR. \n\n\nThis is \nbecause FAIR \nis often \nstrong enough \nto be fairly \nuseful (for \nstanding, \nwalking, or \nlifting arm \n\nto eat). \nPOOR is \nusually too \nweak to be \nof much use. \n\n\nStrong enough \nto be useful \n\n\nEVALUATING STRENGTH OR WEAKNESS OF MUSCLES \n\n\nCAUTION: To avoid misleading results, check \nrange of motion BEFORE testing muscle strength. \n\n\nA. \n\n\nStrength \nrating \n\n\nie muscles \nNY, or bent-hip \n\n\ncontractures. \n(Be sure to \ncheck for \nthese.) \n\n\nof the \n\n\nbackbone \n\n\nVg S pace \n\n\nUre \n\n\nEXAMINING THE \nNERVOUS SYSTEM \n\n\nSometimes physical disability \nresults from problems in the \nmuscles, bones, or joints \nthemselves. But often it comes \nfrom a problem in, or damage to, \nthe nervous system. \n\n\nDepending on what part of the \nnervous system is affected, the \ndisability will have different \npatterns. \n\n\nFor example, polio affects only \ncertain action nerves at points in \nthe spinal cord (or brain stem). It \ntherefore affects movement. It \nnever affects sensory nerves, so \nsight, hearing, and feeling stay \nnormal. (See Chapter 7.) \n\n\nEXAMINATION 35 \n\n\nTHE NERVOUS SYSTEM \n\n\nThe nervous system \n\nis the body's \ncommunication system. \nThe ‘central \nswitchboard’ is the \nbrain, from which \nelectrical messages \nrun back and forth, to \nall parts of the body, \nthrough ‘wires’ \n\ncalled nerves. \n\n\nSensory nerves bring \nmessages from parts \nof the body about \nwhat the body sees \n(eyes), hears (ears), \nsmells (nose), and \nfeels (skin). \n\n\nAction nerves (motor \nnerves) carry messages \nto parts of the body, \ntelling muscles to move. \n\n\nThe brain is \nthe main \ncontrol \ncenter of \nthe nervous \nsystem. \n\n\nThe ‘trunk \nline’ of the \nnerves is \n\nthe spinal \ncord. It runs \nfrom the \nbrain down \nthe middle of \nthe spine. \nNerves come \nout from \nbetween \neach back \nbone and \ncommunicate \nto a part \nlower down \nin the body. \n\n\nA spinal-cord injury, however, can damage or cut both the sensory and action \nnerves, so that both movement and feeling are lost. (See Chapter 23.) \n\n\nUnlike polio and spinal-cord injury, which come from damage to nerves in the \nspine, cerebral palsy comes from damage to the brain itself. Because any part or parts \nof the brain may be damaged, any or all parts of the body may be affected: movement, \nsense of balance, seeing, hearing, speech, and mental ability. (See Chapter 9.) \n\n\nTherefore, how completely you examine the workings of the nervous system will \ndepend partly on what disability the child appears to have. If it is fairly clear the \ndisability comes from polio, little examination of the nervous system is needed. But \nsometimes polio and cerebral palsy can be confused. If you have any suspicion that the \ndisability might be caused by brain damage, you will want to do a fairly complete exam \nof nervous system function. Damage to the brain or nervous system can cause problems \n\n\nin any of these areas: \n\n\n®@ seeing (See Chapter 30.) \n\n\nhearing (See Chapter 31.) \n\n\nunusual or strange behaviors; \nsigns of self-damage (See page 364.) \n\n\nuse of mouth and \ntongue, and speech \n(See pages 313 to 315.) \n\n\n@ eye movement or \nposition \n(See pages 40 and 301.) \n\n\nmuscle tone (patterns of unusual \nfloppiness, tightness, spasms, or \nmovements). \n\nfits or seizures (See Chapter 9.) \n(epilepsy) \n\n(See Chapter 29.) \n\n\nmental ability; \n\nlevel of development \n(See pages 278 and 288.) reflexes; muscle jerks \n(See pages 40 and 88.) \nbalance, coordination, \nand sense of position \n\n\n(See pages 90 and 105.) \n\n\nfeeling \n(pain and touch) \n(See pages 39 and 216.) \n\n\nurine and bowel control \n(See Chapter 25.) \n\n\nMethods for testing some of these things are included on the next few pages and on the \nRECORD SHEETS 2, 3, and 4. Other tests that you will need less often, we include \nwith specific cisabilities. Refer to the page numbers listed above. \n\n\nUb \n\n\nCHAPTER 4 \n\n\nEVALUATION OF A CHILD WHOSE \nDEVELOPMENT IS SLOW \n\n\nFor the child who cannot do as much as other children do at the same age, a special \ndevelopmental evaluation may be helpful. Additional information about the child's \nmother during pregnancy, or any difficulties during or after birth may explain possible \ncauses. Measurement of the distance around the head may show possible causes of \nproblems or other important factors. Repeated head-size measurements (once a month \nat first) may tell us even more. \n\n\nFor example, a child who has had meningitis (brain infection) at age 1, and \n> whose head almost stops growing from that age on, will probably remain quite \nretarded. We should not expect a lot. However, if the child's head continues to \n= grow normally, the child may have better possibilities for learning and doing \n= more (although we cannot be sure). \n\n\nA child who is born with a ‘sack on the back’ (spina bifida, see p. 167) may have a head \nthat is bigger than average. If the head continues to grow rapidly, this is a danger sign (see \np. 41 and 169). Unless the child has surgery, she may become severely retarded or die. If, \nhowever, the monthly measurements show that the head has stopped growing too fast, \nthe problem may have corrected itself. She may not need surgery. \n\n\nRECORD SHEET 4, on page 41, covers additional questions relating to child \ndevelopment, and includes a chart for recording and evaluating head size. \n\n\nTo help the child who is developmentally delayed, you will first want to evaluate her \nlevel of physical and mental development. Chapter 34, pages 287 to 300, explains ways \nto do this. \n\n\nYou can use the Child Development Chart on pages 292 and 293 to find a child’s \ndevelopmental level, to plan her step-by-step activities, and to evaluate and record her \nprogress. We have marked this 2-page chart, RECORD SHEET 6. \n\n\nRECORD SHEETS \n\n\nOn the next 5 pages are the sample RECORD SHEETS that we discussed on p. 22. \nYou are welcome to copy and use them. However, they are not perfect. They were \ndeveloped for use by the village rehabilitation team in Mexico, and we are still trying \nto improve them. Before you make copies, we suggest that you adapt them to meet the \nneeds of your area. \n\n\nBe sure you have copies made of the RECORD SHEETS \nyou will need before you need to use them. \n\n\nIn addition to the 4 RECORD SHEETS here, you may also want copies of RECORD \nSHEET 5 ‘‘Evaluation of Progress,’ page 50, and RECORD SHEET 6, “Child \nDevelopment Chart,\"’ pages 292 and 293. \n\n\nNote on RECORD SHEET 1 (CHILD HISTORY): \n\n\nThe box at the top of RECORD SHEET 1 is to be filled out after you examine the child. It gives \nbrief, essential information. This will make it easier to find out which disabilities you have seen \nmost often, and to check on what you still need to do for different children. \n\n\nThe last few questions on page 2 of RECORD SHEET 1 are for a study PROJIMO is doing on \nmedical causes of disability. Adapt them to study special concerns in your area. \n\n\nEXAMINATION 37 \n\n\nMovement RECORD \nDeformity Future action: : SHEET \n\n—— come back again ; \nBlindness . (page 1) \nDeafness refer to specialist \nSpeech \nFits \nBehavior other \nOther \n\n\nFile \nNumber \n\n\nvisit at home \n\n\nTYPE OF DISABILITY \n\n\nSpecific disability if known: \n\n\nCHILD’S HISTORY (First visit) \n\n\nName: \nDate of birth: Address: \n| \nMother: \nFather: Telephone: \nHow did you learn about the program? \n\n\nWHAT IS THE CHILD’S MAIN PROBLEM? \n\n\nWhen did it begin? How? (Cause?) \nOther problems? \nIs the disability improving?____ Getting. worse?____ Aout the same? \nExplain: \nHow do you hope your child will benefit from coming here? \n\nDo other family members or relatives have a similar problem? \nHas the child received medical attention? What? \nWhere? \nUse any braces or other aids? _ What? \nHas he used any in the past?___ Explain: \n\n\nHow is the child’s general health? \nIs he fat? Very thin? Other? \nHears and sees well? _--_-_EE—sdEExpiain: \nComment on the child’s developmental abilities or difficulties: normal for age? \nhead control \nuse of hands \ncreeping or crawling \nStanding, walking \nplay \nfeeding or drinking \ntoileting \npersonal hygiene \ndressing \nDoes the child speak? _____»_ How much or wee ||? L______ Began. wher? \nWhat other things can the child do? \n\n\nWhat things can the child not do? \n\n\nWhat new skills or abilities would you like to see your child gain? \n\n\nCHAPTER 4 \n\n\nIs the child mentally normal? \n\n\nRetarded?_______ How severely? \n\n\nRECORD \nSHEET \n1 \n\n\n(page 2) \n\n\nWhy do you think so? \n\n\nDoes the child have fits? How often? \n\n\nDescribe: \n\n\nTakes medicine? _--__. What? \n\n\nFor what? Results (good or bad): \n\n\nBehavior normal for age? \n\n\nBehavioral or emotional problems? Explain: \n\n\nGoes to school? What year? \n\n\nWith whom does the child live? \n\n\nNumber of brothers and sisters: — \nFather works? At what? \n\n\n_ Ages: \n\n\nAVERAGE EARNINGS \n\n\nMother works? At what? \n\n\nThe child seems: well-cared for? spoiled or overprotected? \n\n\nself-confident? withdrawn? \n\n\nneglected? happy? \nother? \n\n\nImportant details of family situation: \n\n\nWhat has the family done, made, or obtained to help the child function better? \n\n\nOther observations, information or drawings: \n(Use an additional sheet if necessary.) \n\n\nHistory of illness Date Vaccinations: How many Allergies \n\n\nmeasles \nchicken pox \n\n\nwhooping cough \n\n\npolio \n\n\nD.P.T. \n\n\nmeasles \n\n\nother BCG (TB) \nOther \n\n\nHow much have you spent for your child’s disability? For what? \n\n\nWere disability or complications caused by improper medical treatment or therapy? \n\n\nExplain: \n\n\nFOR CHILDREN WITH POLIO: \nWas your child injected within 2 weeks before getting polio? \n\n\nIf so, was he or she injected on the side that became most paralyzed? \n\n\nug \n\n\nEXAMINATION 39 \n\n\nSAMPLE RECORD SHEET FOR PHYSICAL EXAM \nRECORD \nChild’s name (...) SHEET \n\n\nFile number is \\ 2 \nR b \n\n\nMark on the drawings \nwhere you find the problems. \n\n\nUse lines and circles together \nwith abbreviations shown Ow-Jee at \non this page. For example: —« \n\nR L \n\n\nWhere necessary, make new 24 2% cre \ndrawings on another sheet. 4 \n\n\nParts of body affected Strength or weakness of muscles: Use this code \n\n\nNORMAL lifts and holds ‘} POOR” moves some but \nagainst strong 2 cannot lift = \nresistance Mf own weight ii \n\n\nmoves against TRACE barely moves \nLorR other some resistance 1 \n(indicate) \n\n\n— lifts own weight ZERO no sign of \nOW: Pain OW-} pain in joints but no more 0 movement \nOW-M pain in muscles Pi \n\n\nOnone \n+little \n\n\n++a lot Wd T: ability to feel, touch, pain, etc. Problems with \n+++so much that she __ *Eyes or sight. \ndoes not move it aa | ef RorL | normal | *reduced hae: \n\n\n———P \n\n\nCTR: contractures SP: spasticity \n\n\ntight muscles do | —— *tight muscles ee —— *Ears or hearing. \nnot yield with yield slowly other 4) What: \nPressure with pressure \n\n\nme Deep tendon reflexes: : : \nwife? oy *nothing | *little normal *extreme \nSoy ; 0 + ++ ++++ \n= Right knee \n\n\nLeft knee \nOther \n\n\nSpine \n\n\nsideways \nhunchback curve swayback bump \n(kyphosis) (scoliosis) (lordosis) (TB?) DL: dislocations: \n\n\nHT: hips tilt \n\n\ndf hi (BS \n\n\nR leg shorter __ \\eaittow \n\n\nL leg shorter __ el \n\n\nother \n\n\ncurve fixed___ curve can straighten_— \n(See p. 161.) \n\n\n*Spina bifida *Spinal cord injury Other problems \nback already operated date what level _. *pressure sores \n\n\nsoft sac \n\n\nhead already operated date —_— *unusual \n4 movements \nextent of paralysis \" : — \nowe ; \ni — *fits \n\n\ncontrol \n“targe head extent of feeling lost = — *poor balance \n(hydrocephalus) Bladder _ *developmental \n\n\ndelay \n\n\ncontrol \n\n\nIMPORTANT: This form does not cover all the tests *If you check any problem area marked with a star (*), \nand information you will want to record when a more complete check of the nervous system is \nexamining a child. Put other information on the back of needed. You can use the RECORD SHEETS 3, 4, and 6. \nthis sheet. Or use separate sheets or forms. \n\n\nGU \n\n\n40 3s CHAPTER4 \n\n\nRECORD SHEET: ADDITIONAL TESTS AND OBSERVATIONS OF THE \n\nNERVOUS SYSTEM aa \nThese tests are often not needed but may sometimes be useful when you are not 3 \nsure if a child has brain damage. For other signs of brain damage, see Chapter 9 \non Cerebral Palsy. For tests of seeing and hearing, see p. 447 to 454. \n\n\nEye movement Balance \n\n\n—— eyes jerk, flutter, or roll up unexpectedly and With the child in a sitting or standing position, \nrepeatedly (brain damage, possible epilepsy — gently rock or push him off balance. \np. 233) ___CHILD DOES NOT TRY TO KEEP FROM FALLING \n—— one eye looks in a different direction or moves (poor balance—sign of brain damage in child over 1 \ndifferently from the other (possible brain damage) year) \nMove finger or toy yl —— CHILD TRIES NOT TO FALL by putting out his \nin front of eyes hands (fair balance) \nfrom side to side —— CHILD KEEPS FROM FALLING by correcting \nand up and down. a> body position (good balance) \n\n\n— eyes follow smoothly (normal) \n\n\n—— eyes follow in jumps or jerks (possible brain \ndamage) \n\n\nEye to hand coordination \n\n\n—— moves finger from nose to \nobject and back again ‘ Have child stand with feet together. \n\n\nalmost without error— __ balance difficulty with eyes open— \nwith eyes open, and also may be brain damage (or muscle-joint \nclosed (normal) problem) \n\n—— misses or has difficulty —— has much more \nwith eyes open (poor difficulty with \ncoordination, poor balance, eyes closed \nor loss of position sense) (loss of position \n\nsense) \n\n\n—— balance difficulty much greater \nwith eyes closed (probably nervous \nsystem damage) \n\n\n‘Knee jerks’ and other ‘muscle jump’ reflexes \n\n\nBody movements . With the leg relaxed and partly bent, tap the \n—— awkwardness or difficulty in controlling cord just below the knee cap. \n\n\nmovements NORMAL REDUCED OVER KEEPS \n\n\n—— sudden or rhythmic uncontrolled movements ACTIVE JUMPING \n—— Parts of body twist or move strangely when child = = \n\ntries to move, reach, walk, speak, or do certain 4 \n\nthings \\\\ 74 y ( $ \\ \n\n\n(All these may be signs of brain damage; The leg moves )) . \n\nsee Chapter 9.) S SS The knee __-very /ittle ee wy \nA jumpsa or not at all. A slight \n\nDetails of any of the above: little. tap causes One tap \n\na big jump. Causes the \nTypical of limb to \nspasticity jerk many \n\n\nother floppy nie a 2 \n. ° . rom cereodra imes. \nFits of different kinds (See Chapter 29.) paralyses. ociy,tpledt | Wanner \n\n\n—— sudden loss of consciousness with strange cord injury, with spinal \nmovements, > tap the heel and other cord injury \n\n\n\\\\ cord and | brain or and some \n3 othercords | spinal cord cerebral \n7 —- \na\\ near joint. | damage. palsy. \n\n\nTypical of \npolio, muscular \ndystrophy, and \n\n\n—— brief periods of strange movements or positions, \n—— blank stares, __ eye fluttering, _ twitching. \n\n\nDevelopmental delay: Is the child unable to do Great toe reflex \nmany different things that others her age can do? \n\n\nWhich? (See Chapter 34.) Stroke the foot toward the toe witha \n\n\nsomewhat pointed object (like a pen). ——»— \n\n\n—— head control — sucking NORMAL NOT NORMAL \n—— use of hands —— eating (in achild over 2) thie is a sign of \nr \n\n\n«*% \n\n\n— rolling —— playing Pe ~ brain or spinal \n_—— creeping and crawling —— communication or cord damage \nme a (Babinski’s sign) \nsittin speech : \n—_ 8 ; May occur ina \n—— Standing and walking —— behavior toes bend down toes bend up normal child \n—— self-care activities and spread under 2 years. \n\n\n61 \n\n\nEXAMINATION \n\n\nRECORDS OF FACTORS POSSIBLY AFFECTING CHILD DEVELOPMENT RECORD \n(mainly for children with possible brain damage or developmental delay) SHEET \n\n\n4 \n\n\nAdded history \n\n\nWas the child born before 9 months? _____ at how manny months? \n\n\nWas the child born smaller or thinner than normal? weight at birth? \n\n\nWas the birth of the child normal?___ slow or difficult? \n\n\nExplain: \nDid the child seem normal at birth? ________ If not, describe problems: delayed breathing? \n\n\nvery floppy? __-__ other? \nDid the mother have problems in pregnancy? German measles at months. \nOther? Medicines or drugs during pregnancy: What? \n\n\nAge of mother _____and father_________ att. time f child’ birth. \n\n\nPhysical exam \n\n\nDoes the child show signs of brain damage? (Use RECORD SHEETS 3 and 4.) \nWhat? \n\n\nDoes the child show signs of Down syndrome (mongolism)? \nWhat? (wide, slanted eyes _______,, crease in hand - , other . See p. 279.) \nOther physical signs, possibly related to retardation \n\n\nDoes the child’s head seem smaller _____ or larger —__ than normal? \nDistance around head? cm. Difference from normal \nAverage at her age (from chart) cm. Difference from average \n\n\nAVERAGE DISTANCE AROUND HEAD IN FIRST 18 YEARS OF LIFE \n\n\nRecord of the child’s head size \n\n\nr - T —_—— \n4 —_ \n\n\nmal \n\n\nCo \nOn the chart put a dot on \n\n\nwhere the up-and-down \n\nline of the child’s age Measure around \ncrosses the sideways line the widest part \nof her head size: of the head. \n\n\nIf the dot is be/ow the \nshaded area the head is \nsmaller than normal. The \nchild may be microcephalic \n\n\n(small-brained, see p. 278). \n\n\nIf the dot falls above the \nshaded area, the head is \n\nbigger than normal. The \nchild may have \n\n\nhydrocephalus (see p. 169). _/” Note: Boys’ heads average from %4 to 1 cm. larger than \ngirls’ heads. Also head size may vary somewhat with \ndifferent races. If possible get local charts. \n\n\n->————— DISTANCE AROUND HEAD IN INCHES ——————> \n\n\nA A. 4 i i i A i 4 i \n2 4 6 8 10 12 14 16 18 20 22 2 4 6 8 10 12 14 16 18 \n———————_ ACE IN MONTHS ————» <——— AGE IN YEARS ——> \n\n\nUse the chart for a continuing record. Every month put a new dot on the chart.* If the difference \nfrom normal increases, the problem is more likely to be serious. For example, \n\n\nBrain not Brain ape! Head too big; Large head. \n\ngrowing much. growing well. growing fast. ant, 4 Probably \n\nProbably -— Probably not Hy drocephalus -— P nota \n\nmicrocephalic. hd +h serious. el. or tumor. Ta © problem. \n+4 ++ Getting worse. \n\n\n*Filling out this chart every month is especially important for children with spina bifida or suspected \nhydrocephalus (see p. 169). If you do not know how to use the chart, ask a local schoolteacher. \n\n\nLas 12 \n\n\n~~ \nae \n\n\n+—————— DISTANCE AROUND HEAD IN CM. —————_> \n\n\n41 \n\n\n42 = CHAPTER4 \n\n\nSimple Ways to Measureand 9 “\"\"\" § \nRecord a Child’s Progress \n\n\nIt is important to keep records of each child's progress. Careful records help workers \nand parents to follow the change in the individual child, and to evaluate the \neffectiveness of advice, therapy, and aids. \n\n\nWe need a clear view of the progress of the whole child in all areas—physical, mental, \nand social. The Child Development Chart on p. 292 and 293 will help us to do this for \nyounger children. For children over 5, at the end of this chapter there is a simple chart \n(RECORD SHEET 5) for evaluating a child’s increasing ability to do things. \n\n\nWhen the parents and child themselves regularly measure and record a child's \nprogress, they become more aware of gradual improvements. This encourages them to \ncontinue with important exercises, aids, and activities. \n\n\nUnfortunately, the standard way of recording physical deformities and contractures \nrequires knowledge of angles, degrees, and symbols that many people do not \nunderstand. For evaluation to become a family tool, we need a way to measure, record, \nand interpret information that is as simple, clear, and enjoyable as possible. Here are \nsome ideas. \n\n\nMEASURING JOINT POSITIONS AND CONTRACTURES \n\n\nYou can make a simple 1. Rivet the pieces 2. Line them up \nmeasuring tool using é; together on one end. exactly with \n\n\nflat pieces of wood, spice \nplastic, or cardboard. \n(Tongue depressors work \n\n\n. Do this again \n\n\nwell ) every 1 or 2 March ~ \n: weeks to see \n3. Trace the Aprit “—s \n\n\nOther simple methods ak on if the joint is \nfor recording joint paper. prion \npositions are on p. 79. piace \n\n\nThe ‘flexikin’ —an aid to measure and encourage progress \n\n\nFlexikins are cardboard dolls with joints. Disabled \nand non-disabled children can make and play with \nthem. They are so easy to use that even parents who \ncannot read can measure and record their children’s \ncontractures. Because the periodic measurements are \nrecorded as a line of pictures, anyone can see the child’s \nprogress at a glance. \n\n\nWe have found that when families \nfollow their child’s progress using \nflexikins, both the child and parents are a \nmore likely to keep doing stretching Children making and playing with \nexercises. As a result, many contractures _ flexikins. In the PROJIMO \ncan be partly or completely straightened _ village rehabilitation center, \n. : he h d th is | d f all the flexikins used are made \nFlexikins—front and! the home, and there Is less need for by disabled children and the \nside view models casting and surgery. local school children. \n\n\n64 \n\n\nCHAPTER 5 \n\n\nExamples of how flexikins are used \n\n\nVillage rehabilitation workers have \njust made a brace for a child with \npolio whose leg bends back \nseverely. They want to know if \nthe leg will gradually get better \n(bend back less). So they ask the \nmother to measure it every month. \n\n\nThe mother \nplaces the \nflexikin’s \n\nleg in the \n\nsame position # \nas her son’s \n\nleg, bent \n\nback as far \n\nas it goes. \n\nShe then \n\ntraces it \n\nonto a large sheet of paper. \n\n\nFEBQ \n\n\nbt MAR APR MAY \n6 10 10 \n\n\nJUNE JUY4 AUGT7 SEPT! \n\n\nCUM \n\n\nEach month she does \nthe same and records \nthe date. (In April her \nson did not use the \nbrace for 2 weeks and \nshe saw the knee was \ngetting worse. This \nconvinced both mother \nand boy of the \nimportance of using the \nbrace.) \n\n\nThe flexikins can be used to record a wide variety of positions, deformities, \ncontractures, and limitations in range of motion, mainly of the arms and legs but also \n\n\nof the neck, back, hips, and body: \n\n\nhead leans \nPd \n\n\nsway back backward \n\n\nneck forward \nhand bent up \n\n\nknees bent \nbackward \n\n\nknees together \nand feet separated \n\n\nL \n\n\nfeet turned inward\" \n\n\nlactone \n\n\ncontracture \n\n\nhunch-backed \n\n\ncontracted \nbent (twisted) \ndownward \n\n\nforward \n\n\ntrunk \ntwisted \n\n\nYou can draw both \narms and legs. First \none and then the \nother, like this: \n\n\nelbow \nand hand \ncontracted \n\n\ncontracted \n\n\na this shoulder higher \n\n\nthan the other \n\n\nspine curved \n\n\nhip tilts \nto one side \n\n\n(Draw the spine by \n\n\nlooking at the child \nafter you have \n\n\nmarked each vertebr \nwith a marker.) \n\n\nas wy \n\n\nIn addition to using the small flexikins for record keeping, you can make large \nflexikins for group teaching. Or use them to keep body proportions correct when \nmaking drawings for instruction sheets. \n\n\nNote: For recording contractures, we have found the side-view flexikin more useful \nthan the front-view one. The side-view flexikin is also easier to make. It is probably \nthe only one you will need for evaluating a child’s progress. \n\n\nFLEXIKIN \n\n\nHow to make the flexikins \n\n\n1. Trace the patterns of different pieces (p. 47 and 48) onto very thick paper or thin, \nfirm cardboard. Or use old X-ray film. \n\n\nYou can do this using carbon paper. \n(Make your own carbon paper by \ncompletely blackening a sheet of \n\n\npaper with a soft-leaded pencil.) \ncardboard \n\n\nOr you can glue a copy of \nthe pattern sheet directly GLUE carbon paper \n\n\nto the cardboard. \npattern sheet \n\n\n({f your program plans to make many \nflexikins, or have children make \n\nthem, we suggest you have the patterns \nprinted or mimeographed directly \n\non sheets of thin, firm cardboard.) \n\n\n\\) \n2. Cut out the pieces with strong scissors, SD —- piece of razor \n\n\nshears, or a piece of razor blade. blade in the split \nend of a stick \n\n\n. Place the pieces \ntogether as shown \nin the drawings. ~“—— Put this piece \nMake sure the \npieces that overlap \nwith dotted lines ~“——. and put this piece, \n\n\ngo behind those \nwith complete lines. behind this. \n\n\nbehind this piece, \n\n\n4. Fasten the pieces together at the black dots with rivets, pins or thread. \n\n\nUse the Or string the joints Or use sewing pins; \nsmallest together with thread Or use thin \n\nrivets you or yarn (this does wire or string \n\ncan find. not work as well). and tie knots. \n\n\nnoe ee cut here and put a drop \nof very strong glue \n(like epoxy) here. \n\n\nRivets usually work best. First punch a hole through each black dot. Put the rivets \nthrough and hammer them just enough so that the cardboard joints are tight enough to \nhold their positions but can be moved without tearing. \n\n\n66 \n\n\n46 CHAPTERS \n\n\nYou can copy this sheet, or one like it, and give it to parents together with a flexikin. \nBe sure that you also show them how to use it and then watch them use it. \n\n\nINSTRUCTIONS FOR USING THE FLEXIKIN \n\n\nWe have given you a ‘flexikin’ so that you can measure and see the progress that \nyour child is making with his exercises or aids. \n\n\nWe suggest you take a new measurement every \nDo it like this: \n\n\n. Have your child take the position you want \nto measure (for example, straighten his \nknee as much as he can). \n\n\n. Put the flexikin in \nexactly the position \nthe child is in. To do : . \nthis hold the flexikin GN \nat a distance between = fay \nyour eye and the child il Ny Ay \nso that it appears the one \nsame size as the child. WY \nThis will let you line \nit up exactly. \n\n\n. Without moving the Pal example \n\n\nposition of the flexikin, — , 5 phere \ntrace it onto a large piece | \nA oar & exercises \n—e \n\n\nof paper. The first time have helped \ntrace the whole body. straighten a \nEach time measure the contracted \n\nchild in the same posture. knee. \n\n\nFor later recordings, you only need to trace the part or parts you are measuring \nEach time you record a measurement, write the date. \n\n\nIn certain cases you may want to | Make 2 columns. \nmeasure how far the child can In one, record Problem: Right Mame: Marfa Lopez \nstraighten an arm or leg by how far the child Nona \n\n. Date (1983) Range-of Motion: \nherself, a a Ma Riayat hg can move it by “T cilgaane tno \nto straighten it Tor ner (little by herself. In the \nlittle without forcing). other column MorchI OA, OAR \nrecord how far April WNW ay \nshe can move it May! AY ——~) \nwith help. June 10 ay \n\n\nSS July5 ~~) —J \n\n\nHere you see the -——> August 6 =~ \nCAUTION: When you progress of a leg (she got with \nstraighten the limb, until it became ag bees ae \nsupport it close to straight and a brace . pene with \n\nthe joint. This could be made for it, | SOS =\" Sine \nprevents injury. \n\n\nFLEXIKIN \n\n\nEVALUATING THE PROGRESS OF THE WHOLE CHILD \n\n\nA simple way for rehabilitation workers and parents to evaluate how a child is \nprogressing as a whole is to keep a record of her ability to do different things. Each \nmonth, or during each visit to the community rehabilitation center, the child's \ndifferent abilities are reviewed, tested, or observed. Any changes are recorded. \n\n\nFor children under 5 years old, one way of evaluating a child's development is to use \nthe RECORD SHEET 6 (p. 292). This chart shows the developmental levels \n(‘milestones’) for different skills and activities. The first time the child is evaluated, \ncircle the drawing that shows what the child can do in each area. \n\n\nEach time the child is evaluated, on the same sheet, again circle the appropriate \ndrawing, but use a different color (or a dotted, dashed, or zigzag line). This way, you \ncan see where the child is moving ahead well and where he is behind. \n\n\n4 Mts with \n{hand ‘ . twists and moves \n\n\n; \n\n\nCasily while sitting \n\n\nDk \n\n\n‘« pis br cr awts \nms. \n\n\nhel \n\n\nbegins to reach \ntowards objects \n\n\n“ee |< \n\n\nSen 2 1 eyes aa on \n\\ Pst laces J tar object \n\n\na \n\n\n$ responds to enjoys Thy omic understa hears clearly and understands \nat aloud none mother's vone muse most wmople language \n\n\nFor evaluating the progress of children over age 5, the charts on the next page may \nhelp. Two different approaches are used. Chart A is more objective (requires less \npersonal judgment or opinion) but does not allow for small improvements. Chart B is \nmore subjective (is based more on personal judgments). It considers quality of \nimprovement, not just quantity. You can try both and see which you think gives truer, \nmore useful results. \n\n\nTo use Chart A: For each skill, circle whether the child can do it ‘‘without help,” \n“with a little help,’’ or ‘‘with lots of help.’’ Add all the numbers you circle. Compare \nthe scores of the first and second visits. For example: \n\n\nFirst visit | Second visit Here we see the \n| child has \n| \n| \n| \n| \n\n\nwithout little lots of \n\nhelp help help \nHow does the child eat? 4 Q) 0 \nHow does the child drink? 4 @) 0 \n\n\nwithout little lots of improved his \nhelp help help eating skills but \n@ : 0 not his drinking \n\n\n4 @) 0 skills. \n\n\nTo use Chart B: In each area, on the second visit, circle whether the child is doing a \nlot better, a little better, or the same. Add it all up. The higher the score, the more the \nchild has improved. \n\n\nNOTE: We question whether the use of numbers may not be misleading. But \nwe think the questions themselves may be a useful guideline. None of \n\nthese evaluation forms will show all areas of change or improvement. \n\nThey are not substitutes for detailed notes, drawings, and a good memory! \n\n\nfau \n\n\nCHAPTER 5 \n\n\nEVALUATION OF PROGRESS — CHILD OVER AGE 5 \n\n\nName Age \n\n\nRECORD \nSHEET \n5 \n\n\nDisability \n\n\nCHART A \nDaily activities \n\n\nFirst visit (date \n\n\nlittle \nhelp \n\n\nwithout \nhelp \nFeeding \n\n1. How does the childeat? .. . . « «© « © « 2 \n2. How does the childdrink? . . . . . . 2 \n\n\nDressing and washing \n3. Does child wash face and body? \n4. Does child dress? . ‘ \n5. Does child put on orthopedic equipment? . \n\n\nBowel and bladder care and control \n6. Does child stay clean (bowel control)? . \n7. Does child clean herself after shitting? . \n8. Does child stay dry during the day? \n9. Does child stay dry at night? \n\n\nMobility /transfers \n10. Does child move from chair to bed and back? \n11. Does child move from floor to bed and back? \n\n\nMovement \n\n12. Walks on flat surface? \n\n13. Walks on uneven surface? \n\n14. Climbs up and down stairs? . \n\n15. Uses a wheelboard or wheelchair? \n16. Does child crawl? . \n\n\nSocial activities/communication \n\n17. Does child help with housework or farm work? \n18. Does child play with other children? \n\n19. Does child go to school? . : \n\n20. Does child speak? , \n\n21. Does child communicate with signs « or gestures? \n\n\n) \n\n\nlots of \nhelp \n\n\nSecond visit (date ) \n\n\nlittle \nhelp \n\n\nlots of \nhelp \n\n\nwithout \nhelp \n\n\n4 2 \n\n\n0 0 \n0 4 2 0 \n\n\n| \n| \n| \n| \n| \n| \n| \n| \n| \n| \n| \n| \n| \n| \n| \n| \n| \n| \n| \n| \n| \n| \n| \n| \n\n\nCHART B \nQuality of activities \n\n\nFirst visit \n\n\nmake notes for \ncomparison here \n\n\nDoes child move about better? \n\nDoes he sit in a better position? . : \n\nDoes he walk better (straighter, with less limp, or \nwith less support)? : \n\nDoes he walk farther, faster, or easier? ‘ \n\nAre his joints straighter (less contractures) ? \nhip?. \nknee? \nankle? \n\nCan the child do things he could not do before? \nfeeding? cant \nbathing? \ndressing? \ntoileting? ‘ \n\nDoes he play with things better? \n\nDoes he speak or communicate better? \n\nDoes he get along with other children better? . \n\nDoes he seem happier or more self-confident? . \n\nHas he improved or got worse in other ways? . \nIn what ways? \n\n\n| \n| \n| \n| \n| \n| \n| \n| \n| \n| \n| \n| \n| \n| \n\n\nSecond visit \n\n\na little \nbetter \n\n\nmuch \nbetter \n\n\nsame worse \n\n\nnN \noo \n\n\n4 \n4 \n\n\nnh \n\n\nNR \n-FHotrt SHAH HHAHHA HAH \n\n\nNM CWOHNHNMNN NNN NNN ND NY ND LP \noooocoocjcoooocjoooq”;tooco \n\n\n= \n=) \n\nmad \n~, \n\n\nGuide for ew 6 \nIdentifying Disabilities \n\n\nThis chapter has a chart, 7 pages long, to help you find out what disability a child \npossibly has, and where to look up that disability in this book. \n\n\nIn the first column of the chart, we list the more noticeable signs of different \ndisabilities. Some of these signs are found in more than one disability. So in the second \ncolumn we add other signs that can help you tell apart similar disabilities. The third \ncolumn names the disability or disabilities that are most likely to have these signs. And \nthe fourth column gives the page numbers where you should look in this book. (Where \nit says WTND and then a number, this refers to the page in Where There Is No Doctor.) \n\n\nIf you do not find the sign you are looking for in the first column, look for another \nsign. Or check the signs in the second column. \n\n\nThis chart will help you find out which disabilities a child might have. It is wise to \nlook up each possibility. The first page of each chapter on a disability describes the \nsigns in more detail. \n\n\nIMPORTANT: Some disabilities can easily be confused. Others \nare not included in this book. When you are not sure, try to \n\nget help from someone with more experience. At times, special \ntests or X-rays may be needed to be sure what the problem is. \n\n\nFortunately, it is not always necessary to know exactly what disability a child has. \nFor example, if a child has developed weakness in his legs and you are not sure of the \ncause, you can still do a lot to help him. Read the chapters on disabilities that cause \nsimilar weakness, and the chapters on other problems that the child may have. For this \nchild, you might find useful information in the chapters on polio, contractures, \nexercises, braces, walking aids or wheelchairs, and many others. \n\n\nSometimes it is important to identify the specific disability. Some disabilities require \nspecific medicines or foods—for example, night blindness, rickets, or cretinism. Others \nurgently need surgery—for example, spina bifida or cleft lip and palate. Others require \nspecial ways of doing therapy or exercises —for example, cerebral palsy. And others \nneed specific precautions to avoid additional problems—for example, spinal cord injury \nand leprosy. For this reason, it helps to learn as much about the disability as you can. \nWhenever possible, seek information and advice from more experienced persons. \n(However, even experts are not always right. Do not follow anyone’s advice without \nunderstanding the reasons for doing something, and considering /f and why the advice \n\n\napplies to the individual child.) \n\n\nIn addition to this chart, 2 other guides for identifying disabilities are in this book: \n\n\nGUIDE FOR IDENTIFYING CAUSES OF JOINT PAIN, p. 130. \nGUIDE FOR IDENTIFYING AND TREATING DIFFERENT FORMS OF FITS \n(EPILEPSY), p. 240. \n\n\nCHAPTER 6 \n\n\nGUIDE FOR IDENTIFYING DISABILITIES \n\n\nSIGNS PRESENT AT OR SOON AFTER BIRTH \n\n\nIF THE CHILD HAS THIS \n\n\nAND ALSO THIS HE MAY HAVE \n\n\nSEE PAGE \n\n\nborn weak \nor ‘floppy’ \n\n\nslow to begin \nto lift head \nor move arms \n\n\noften a difficult birth \n\ndelayed breathing \n\nborn blue and limp \n\nor born before 9 months and very smal! \n\n\ncerebral palsy \ndevelopmental delay \n\n\n87 \n277 \n\n\nround face \nslant eyes \n\n\n: cretinism \nthick tongue \n\n\nDown syndrome (mongolism) \n\n\nsmall head, \nor small top \npart of head \n\n\nmicrocephalia (smal! \nbrain) mental retardation \n\n\ndevelopmental delay for \nother reasons \n\n\nnone of above \n\n\ndoes not suck \nwell or chokes \non milk wt! \n\n\nor food w Fs \nu \n\n\npushes milk back out with tongue \n\n\nk cerebral palsy \nor will not suck \n\n\ncannot suck well check for cleft palate \nchokes or milk comes out nose \n\n\npossibly severe retardation \n\n\none or both \nfeet turned \nin or back \n\n\nno other signs club foot \n\n\nhands weak, stiff ee. f \nor clubbed » \n\n\nsome joints stiff, in bent ; S \nor straight positions a \n\n\narthrogryposis \n\n\ndark lump on back spina bifida \n\n\n‘bag’ or \ndark lump \non back \n\n\nclubbed feet \n\nor feet bend \n\nup too far —© \n\nor feet lack movement and feeling \n\n\nspina bifida \n\n(sometimes no ‘bag’ is \nseen, but foot signs may \nbe present) \n\n\nhead too \nbig; keeps \ngrowing \n\n\nhydrocephalus (water on \nmay develop the brain) \n@ eyes like \n‘setting SUN! —— \n@ increasing mental \nand/or physical disability \nblindness \n\n\nAt birth, this is usually \na sign of spina bifida. \n\n\nin an older child, \npossibly tapeworm in \nbrain, or a brain tumor \n\n\nupper !ip and/or \nroof of mouth \nincomplete \n\n\ncleft lip (hare lip) \n\n\nand cleft palate \n\n\ndifficulty feeding o> \nlater, speech difficulties @B) \n\n\nbirth deformities, 2) \ndefects, or \n\n\nmissing parts \n\n\nmeds \n\n\nSee \n\n\n@ birth defects \n\n@ amputations \n\n@ Down syndrome \n\n@ developmental delay \n\n\n(may or may not be associated \nwith other problems) \n\n\nabnormal \nstiffness \nor position \n\n\nfrom birth \n\nsome muscles weak \n\nsome joints stiff \n\nhead control and mind normal \n\n\narthrogryposis \n\n\nMuscles tighten more in certain spastic cerebral palsy \npositions. \n\n\n: : Note: muscle tightness \nmay grip thumb tightly \n\n\n(spasticity) usually does \nnot appear until weeks \nor months after birth. \n\n\nDISABILITY GUIDE \n\n\nIF THE CHILD HAS THIS \n\n\nAND ALSO THIS \n\n\nHE MAY HAVE \n\n\nSEE PAGE \n\n\none arm \nweak or in \nstrange \nposition \n\n\ndoes not move the arm much ¢ \ns \nholds it like “. i” \n\n\nErb’s palsy (weakness \nfrom damage to nerves in \nshoulder during birth) \n\n\nleg on same side often affected \n\n\nhemiplegic (one-sided) \ncerebral palsy \n\n\ndislocated hip \nat birth \n\n\nleg held \ndifferently, \nshorter; fla \ncovers part \nof vulva \n\n\nOn opening legs \nlike this, leg \n‘pops’ into place \nor does not open \nas far. \n\n\ndislocated hip from birth \n(often both hips) \n\n\nmay be present with \n\n\n@ spina bifida \n@ Down syndrome \n@ arthrogryposis \n\n\nAlso see p. 156. \n\n\nslow to respond \nto sound or to \n\n\n(may be due to one ora \n\n\nlook at things ey. i> combination of problems) \n\n\nCheck for signs of \n\n\ndevelopmental delay \ncerebral palsy \nblindness \n\ndeafness \n\n\nSIGNS IN CHILDREN \n\n\nslower than other \nchildren to do things \n(roll, sit, use hands, \nshow interest, walk, talk) \n\n\nslow in most or all areas: \n\n\nDevelopmental delay, \ncheck for signs of \n\n\nround face \nslant eyes \nsingle deep \ncrease in hand \n\n\nDown syndrome (mongolism) \n\n\nmovements and response slow \n\nskin dry and cool , \nhair often low on forehead (5) \npuffy eyelids \n\n\ncretinism \n\n\nhas continuous \n\nstrange movements or \npositions, and/or can \nstiffness ae \n\n\nVv \n\n\ncerebral palsy \n\n\nalso check tor \n\n@ blindness \n\n@ deafness \n\n@ mainutrition \n\n\ndoes not respond \nto sounds, does \nnot begin to \nspeak by age 3 \n\n\nmay respond to some \nsounds but not others \n\n\nCheck for ear infection (pus) \n\n\nCheck for \n\n\n@ deafness \n\n@ severe developmental \ndelay (with or without \ndeafness) \n\n@ severe cerebral palsy \n\n\ndoes not turn head to \nlook at things, or reach \nfor things until \n\nthey touch her \n\n\nEyes may or may not look normal \n\n\n@ blindness and/or \n\n@ severe mental \nretardation \n\n@ severe cerebral palsy \n\n\nEyelids or \neyes make \nquick, \njerky, or \nstrange \nmovements. \n\n\nCheck for one or a \ncombination of these. \n\n\n@ blindness \n\n@ fits \n\n@ too much medicine \n\n@ cerebral palsy \n\n@ other problems affecting \nor damaging the brain \n\n\n53 \n\n\nao \n\n\nCHAPTER 6 \n\n\nIF THE CHILD HAS THIS \n\n\nAND ALSO THIS \n\n\nHE MAY HAVE \n\n\nSEE PAGE \n\n\nAll or part of body makes \nstrange, uncontrolled \nmovements. \n\n\nbegins suddenly, child \n\nmay fall or lose consciousness \nchild is normal (or more normal) \nbetween ‘fits’ \n\n\nepileptic fits \n\n(Pattern varies a lot in \ndifferent children—or \neven in the same child.) \n\n\n233 \n\n\nslow, sudden, or rhythmic ¢ \nmovements; fairly \ncontinuous (except in sleep); \nno loss of consciousness \n\n\nathetoid cerebral palsy \n\n\n(Note: Fits and cerebral \npalsy may occur in the \nsame child.) \n\n\nBody, or parts of it, \nstiffens when in certain \npositions: poor control \n\nof some or all movements. \n\n\ndifferent positions \nin different children \n\n\nBody may stiffen \nbackward and legs \ncross. \n\n\nspastic cerebral! palsy \n\n\nPARTS OF BODY WEAK OR PARALYZED \n\n\nfloppy or limp weakness \nin part or all of body \n\n\nno loss of feeling in \naffected parts \n\n\nno spasticity \n(muscles that tighten \nwithout control) \n\n\nnormal at birth \n\n\nusually began \nwith a ‘bad cold’ \nand fever before \nage 2 \n\n\nirregular pattern of parts weakened. \nOften one or both legs—sometimes \narm, shoulder, hand, etc. \n\n\nbegins little by little \n\nand steadily gets worse ff \\ \nabout the same on } \nboth sides of body \n\noften others in the family \n\nalso have it \n\n\n@ muscular dystrophy \n\n\n@ muscular atrophy \n\n\n2, \nCss yy fom \na a \n\n\nParalysis starts in legs and moves \nup; may affect whole body. \n\n\nor, pattern of paralysis variable \n\n\ntick paralysis \nGuillain-Barré paralysis \n(usually temporary) \n\n\nparalysis from pesticides, \nchemicals, foods (lathyrism) \n\n\nlump on back (See p. 57.) \n\n\ntuberculosis of spine \n\n\nfloppy or limp weakness \n\n\nusually some loss of \nfeeling \n\n\none or both \n\nhands or feet \n\ndevelops slowly in older \nchild. Gets worse and worse. \n\n\nPt... \n\n\nleprosy \n\n\nborn with bag on back \n(Look for scar.) \n\nfeet weak, often without \nfeeling \n\n\nspina bifida \n\n\nusually from back or neck injury \nweakness, loss of feeling below \n\nlevel of injury \n\nmay or may not have muscle spasms \nloss of bladder and bowel control \n\n\nspinal cord injury \n\n\nparaplegia \n(lower body) \n\n\nquadriplegia \n(upper and \nlower body) \n\n\ninjury to nerves going to \none part of body \n\n\nhand weakness sometimes caused \nby using crutches wrongly \n\n\nDISABILITY GUIDE \n\n\nIF THE CHILD HAS THIS \n\n\nAND ALSO THIS \n\n\nHE MAY HAVE \n\n\nSEE PAGE \n\n\nweakness usually \nwith stiffness or \nspasticity of \nmuscles \n\n\nno loss of feeling \n\n\nusually affects body in \none of these patterns \n\n\n% 2. \nwhole body \n\n\none side both legs \n\n\n@ 1: cerebral palsy \n(or stroke, usually older \npersons) \n\n\n@ 2and 3: cerebral palsy \n\n\n@ occasional other causes \n\n\nMuscles tighten and resist \nmovement because of joint pain. \n\n\nJOINT PAIN \n\n\n(many causes—see below) \n\n\nJOINT PAIN \n\n\none or more \npainful joints \n\n\n< \n\n\nslyoe ; \\ \n@ begins with or without fever .) \n@ gradually gets worse, but there \nare better and worse periods \n\n\n2 \n\n\njuvenile arthritis \n\n\nother causes of joint pain \nSee chart on joint pain \n\n\nWALKS WITH DIFFICULTY OR LIMPS \n\n\ndips to one \nside with \neach step \n\n\none leg often weaker and shorter \n\n\nCheck for \n@ polio \n@ cerebral palsy \n@ dislocated hip \n\n\nusually begins age 4 to 8 \nmay complain of knee pain \n\n\ndamaged hip joint \n\n\nwalks with \nknees \npressed \ntogether \n\n\nmuscle spasm and tightness \nupper body little affected \n\n\nspastic diplegic or \nparaplegic cerebral palsy \n\n\nstands and walks \nwith knees \ntogether and \nfeet apart \n\n\nno other problems \n\n\nfeet less than 3” \napart at age 3 \n\n\nnormal from ages 2 to 12 \n\n\nfeet more than 3\" \napart at age 3 \n\n\nIN \nIN \n\n\nknock-kneed \n\n\nwalks awkwardly \nwith one \nfoot tiptoe \n\n\nmuscle spasms and poor control \non that side. Hand on that \nside often affected. \n\n\nhemiplegic cerebral palsy \n\n\n(stroke in older persons) \n\n\nwalks awkwardly \nwith knees bent \nand legs \n\nusually \nseparated \n\n\njerky steps, poor balance \nsudden, uncontrolled movements \nthat may cause falling \n\n\nathetoid cerebral palsy \n\n\nslow ‘drunken’ way of walking \nlearns to walk late and falls often \n\n\npoor balance (ataxia) — \n\noften with cerebral palsy \nDown syndrome (mongolism) \ncretinism \n\n\nwalks with \nboth feet \ntiptoe \n\n\nweakness, especially in legs and feet \ngradually gets worse and worse \n\n\nmuscular dystrophy \n\n\nlegs and feet stiffen \n(spasticity of muscle) \n\n\nspastic cerebral palsy \n\n\nno other problems \n\n\nnormal? (some normal children \nat first walk on tiptoes) \n\n\n46k \n\n\nib \n\n\n55 \n\n\n56 CHAPTER 6 \n\n\nIF THE CHILD HAS THIS AND ALSO THIS \n\n\nHE MAY HAVE \n\n\nSEE PAGE \n\n\ni \n\n\nwalks with hand(s) pushing \nthigh(s) or with knee(s) weak thigh muscle \nbent back ~ \n\n\ndifficulty \nlifting leg \n\n\n' \n\n\npolio \n\nmuscular dystrophy \narthritis (joint pain) \nother causes of muscle \nweakness \n\n\nFoot hangs \n\ndown weakly \n\n(foot drop) Child lifts foot high \nwith each step so that \nit will not drag. \n\n\npolio \n\nspina bifida \n\nmuscular dystrophy \nmuscular atrophy \n\nnerve or muscle injury \nother cause of weakness \n\n\ndips from \n\n\nside to side 2. \nwith each ‘ \nstep &, \ndue to muscle weakness at \nside of hips, or double \n| dislocated hips, or both \n\n\npolio \n\ncerebral palsy \n\nspina bifida \n\nDown syndrome \nmuscular dystrophy \nchild who stays small \narthrogryposis \ndislocated hips (may \noccur with any of the \nabove) \n\n\nwalks with \n\none (or both) r 5) \n\nhip, knee, or , : \n\nonkin that J joints cannot be slowly \n\n] straightened when child \nrelaxes (see page 79) \n\n\nStays bent \n\n\nJ/ \ny ( \n\n\n@ contractures \n(shortened muscles) \n@ joined or fused joints \n\n\nmay be secondary to \n@ polio \n\n\n@ joint infection \n@ other causes \n\n\nJoints can gradually be \nstraightened when child relaxes \n\n\nspasticity, often \ncerebral palsy \n\n\nKnees wide apart when under 18 months old \n\n\noften normal \n\n\nfeet together (bow \n\n\nlegs). Waddles or Any combination of these \nips TrOM sie tO @ Joints look big or thick \n@ Child is short for age \n@ Bones weak, bent, or break \neasily \nArms and legs may seem \ntoo short for body, or \n‘out of proportion’. \nBelly and butt stick outa lot \n\n\nside (if he walks) \n\n\nConsider \n\n@ rickets (lack of vitamin \nD and sunlight) \n\n@ brittle bone disease \n\n@ children who stay very \nshort (dwarfism) \n\n@ cretinism \n\n@ Down syndrome \n\n@ dislocated hips \n\n\nflat feet no pain or other problems \n\n\nnormal in many children \n\n\n@ Pain may occur in arch of foot. \n@ Deformity may get worse. \n\n\nmay be problems in \n@ cerebral palsy \npolio \nspina bifida \nDown syndrome \n\n\nBACK CURVES AND DEFORMITIES \n\n\nsideways Curve \n\nof backbone \nWhen child bends \nover, look for a \nlump on one side. \n\n\n‘scoliosis'—may occur alone \nor as complication of \n\n\n@ polio \n\n@ cerebral palsy \n\n@ muscular dystrophy \n\n@ spina difida \n\n@ other physical disability \n\n\nDISABILITY GUIDE \n\n\nIF THE CHILD HAS THIS \n\n\nAND ALSO THIS \n\n\nHE MAY HAVE SEE PAGE \n\n\nbelly often sticks out \nmay be due to \ncontractures here, or \nweak stomach muscles \n\n\nrounded back \n\n\nS \n\n\n‘lordosis’—may occur in: \n\n\npolio 59 \nspina bifida 167 \ncerebral palsy 87 \nmuscular dystrophy 109 \nDown syndrome 279 \ncretinism 282 \nchild who stays small 126 \nmany other disabilities 161 \n\n\nhard, sharp bend \nof or bump in \nback bone ™. \n\n\nStarts slowly and without pain \noften family history of \ntuberculosis \n\nmay lead to paralysis of \n\nlower body \n\n\n‘kyphosis’—often occurs with: \n\n\narthritis © \n\nspinal cord injury \nsevere polio \n\nbrittle bone disease \n\n\ntuberculosis of the spine \n\n\ndark soft \nlump over \nbackbone \n\n\npresent at birth \n\nsometimes only a soft or slightly \nswollen area over spine \nweakness and loss of feeling in \nfeet or lower body \n\n\nspina bifida \n(‘sack on the back’) \n\n\nOTHER DEFORMITIES \n\n\nmissing body parts \n\n\na“ \n\n\nborn that way = \n\n\nborn with missing or \nincomplete parts \n\n\naccidental or surgical loss of limbs \n(amputation) \n\n\namputations \n\n\ngradual loss of fingers, \n\ntoes, hands, or feet, é \noften in persons who z \nlack feeling \n\n\n@ osteomyelitis (bone \ninfections) \n\n\nsometimes seen with \n\n\n@® leprosy (hands or feet) \n@ spina bifida (feet only) \n\n\nhand problems \n\n\n(For hand problems from \nbirth, see p. 305.) \n\n\nfloppy AL ; \nParalysis \\ \n(no spasticity) ; aa \n\n\nwithout care may lead to \ncontractures so that \nfingers cannot be opened \n\n\nmay occur with \n\n\n@ polio \n\n@ muscular dystrophy \n\n@® muscular atrophy \n\n@ spinal cord injury (at \nneck level) \n\n@® leprosy \n\n@ damage to nerves or \ncords of arms \n\n\nAll may lead to contractures \n\n\nuncontrolled muscle eS iy, \n\n\ntightness (spasticity) \nstrange movements \nor hand in tight fist \n\n\nspastic cerebral palsy \n\n\nmay lead to contractures \n\n\nburn scars and deformities =23 \n\n\nburns \n\n\nclubbing or \nbending of feet \n\n\n(For club feet from \nbirth, see p. 114.) \n\n\nmay begin as floppy weakness and \nbecome stiff from contractures, \nif not prevented \n\n\nOF \n\n\nmay occur with many physical \ndisabilities, including \n@ polio \ncerebral palsy \n@ spina bifida \n@ muscular dystrophy \n@ arthritis \n@ spinal cord injury \n\n\n57 \n\n\n- 68 CHAPTERG \n\n\nDISABILITIES THAT OFTEN OCCUR WITH \n\n\nOR ARE SECONDARY TO OTHER DISABILITIES \n\n\nDevelopmental delay: \n\n\ncaused by slow or \n\n\noften seen in \n\n\nhild si incomplete brain function @ mental retardation 277 \n7 , paragiad or by severe physical @ cerebral palsy 87 \nprt eis disability, or both @ severely or multiply 283 \nuse her Body disabled children \nor develop \nbasic skills caused by overprotection \n\ntreating children like some delay can occur with 287 \nbabies when they could do almost any disability \nmore for themselves \nContractures often secondary to: \n* Ily due to muscle , \n: peciakls vs @ polio 59 \njoints that no longer weakness or spasticity \n: @ cerebral palsy 87 \nstraighten because > ina bifida 167 \nmuscles have shortened e@ Often, muscles that pull a joint . ota 135 \none way are much weaker than 4 id des tees 109 \nJoints those that pull it the other 6 dg Lethal 127 \nhy way (muscle imbalance). \na will not ay Senet @ amputations 227 \n/) ne FH _, Straighten @ leprosy 215 \n* ie \nif #6 \noI ee ——wn sometimes due to scarring \ni burns 231 \nfrom burns or injuries \nbehavior problems common with \nmay come from \n@ mental retardation 277 \n© brain damage @ fits (epilepsy) 233 \n@ difficulty understanding things © cerebral palsy 87 \n® overprotection \n@ difficult home situation and for emotional reasons, \nwith \n(Some children with epilepsy @ spinal cord injury 175 \nfrom brain damage may pull out @ muscular dystrophy 109 \nhair, bite themselves, etc.) @ deafness 257 \n@ learning disability 365 \noe 7 sp ca @ often over-active or nervous disabil 365 \noer Senay eee @ sometimes behavior problems well Saal La \nintelligent. \nSpeech and @ often, but not always, may occur with \ni i f \ncommunication problems due to deafness or @ deafness 257 \nretardation (or both) \n@ developmental delay 287 \n@ Some children can hear ‘ \nsoe @ cerebral palsy 87 \ndatas noe @ Down syndrome 279 \n@ cretinism 282 \n@ children who stay small 126 \n@ brittle bone disease 125 \nre @ cleft lip and palate 120 \nstill (Deafness may occur \ncannot together with these and \nspeak. other disabilities.) \nother problems that Main disability Common secondary disabilities \nsometimes occur secondary 4 \nto other disabilities @ blindness 243 \n@ deafness 257 \n@ cerebral palsy e 233 \n(Some of thesewehave § 0 Nee OO \nwher included in this @ many disabilities with paralysis @ spinal curve 161 \nchert.) 0 aaa a nawenenucel \n@ pressure sores 195 \n@ persons who have lost @ osteomyelitis (bone 159 \nfeeling: leprosy, spinal infection) \ncord injury, spina bifida @ loss of urine and bowel 203 \ncontrol \n\n\nMy \n\n\nPolio \n\n\nInfantile Paralysis \n\n\nCHAPTER 7 \n\n\nHOW TO RECOGNIZE PARALYSIS CAUSED BY POLIO \n\n\ne@ Paralysis (muscle weakness) \nusually begins when the child \nis small, often during an \nillness like a bad cold with \nfever and sometimes diarrhea. \n\n\nParalysis may affect any \nmuscles of the body, but is \n\n\nmost common in the legs. muscies that \n\n\nMuscles most often affected straighten \n\n\nare shown in the drawing. or bend hip, \n\n\nor that \nParalysis is of the ‘floppy’ type spread or \n. close legs \n(not stiff). Some muscles may \nbe only partly weakened, \n\n\nMUSCLES COMMONLY WEAKENED BY POLIO \n\n\nshoulder muscles \n\n\nmuscles behind \narm (weakness \nstraightening \n\n\n_— arm) \n\n\nback muscles \n(either side \nof backbone) \n\n\nthumb \n\n\nothers limp or floppy. muscles \n\n\nIn time the affected limb may \n\n\nthat \nstraighten \n\n\nnot be able to straighten all — \n\n\nthe way, due to shortening, or contractures \n\n\n‘contractures’, of certain causing \nmuscles tight cords \n\n\nmuscles ———e \n\n\nThe muscles and bones of the that lift \naffected limb become thinner foot \nthan the other limb. The affected limb \ndoes not grow as fast, and so is shorter. \n\n\nUnaffected arms or legs often become extra strong to make up for parts that are \nweak. \n\n\nIntelligence and the mind are not affected. \nFeeling is not affected. \n\n\n‘Knee jerks’ and other tendon reflexes in the affected limb are \nreduced or absent. (!n cerebral palsy, ‘knee jerks’ often jump more \nthan normal. See p. 88.) Also, the paralysis of polio is ‘floppy’; \nlimbs affected by cerebral palsy often are tense and resist when \nstraightened or bent (see p. 102). \n\n\nThe paralysis does not get worse with time. However, secondary problems like \ncontractures, curve of the backbone and dislocations may occur. \n\n\nOf children who become paralyzed by polio: Sih sis Soler hemi \n\n\n30% recover 30% have 30% have of difficulty breathing \ncompletely mild moderate ‘ or swallowing). \n\nin the paralysis. or severe \n\nfirst weeks paralysis. \n\nor months. \n\n\nCHAPTER 7 \n\n\nBASIC QUESTIONS AND ANSWERS ABOUT POLIO \n\n\nHow common is it? In many countries, polio—or ‘poliomyelitis’— \nis still the most common cause of physical disability in children. \nIn some areas, at least one of every 100 children may have some \nparalysis from polio. Where vaccination programs are effective, \npolio has been greatly reduced. \n\n\nWhat causes it? A virus (infection). The infection attacks parts of \nthe spinal cord, where it damages only the nerves that control \nmovement. In areas with poor hygiene and lack of latrines, the \npolio infection spreads when the stool (shit) of a sick child \nreaches the mouth of a healthy child. Where sanitation is better, \npolio spreads mostly through coughing and sneezing. \n\n\nDo all children who become infected with the polio virus \nbecome paralyzed? No, only a small percentage become \nparalyzed. Most only get what looks like a bad cold, with \nfever. However, if a child with a ‘cold’ caused by the polio \nvirus is given an injection of any medication, the irritation \ncaused by the injection can bring on paralysis. (See warning \non p. 19.) \n\n\nIs the paralysis contagious? No, not after 2 weeks from » ee \nwhen a child first gets sick with polio. In fact, most polio is ~ és < \nspread through the stoo/ of non-paralyzed children who LE \nhave ‘only a cold’ caused by the polio virus. severe parayses \n\n\neget et CZ \n\n\nAt what age do children get polio? |n areas with poor sanitation, polio most often \nattacks babies from 8 to 24 months old, but occasionally children up to age 4 or 5. As \nsanitation improves, polio tends to strike older children and even young adults \n\n\nWho does it most often affect? Boys, a little more than girls. Unvaccinated children \nmuch more often than vaccinated children. (See p. 74). Young children who are given \ninjections unnecessarily are paralyzed by polio more often those who are not. \n\n\nHow does the paralysis begin? |t begins after signs of a cold and fever, sometimes with \ndiarrhea or vomiting. After a few days the neck becomes stiff and painful and parts of \nthe body become limp. Parents may notice the weakness right away, or only after the \nchild recovers from the acute illness. \n\n\nOnce a child is paralyzed, what changes or improvements can be expected? Often the \nparalysis will gradually go away, partly or completely. Any paralysis left after 7 months \nis usually permanent. The paralysis wi!l not get worse. However, certain secondary \nproblems may develop—especially if precautions are not taken to prevent them. \n\n\nWhat are the child’s chances of leading a happy, productive life? Usually very good— \nprovided the child is encouraged to do things for himself, to get the most out of \nschool, and to learn useful skills within his physical limitations (see p. 497). \n\n\nCan persons with polio marry and have normal children? Yes. Polio is not inherited \n(familial) and does not affect ability to have children. \n\n\nSi \n\n\nSECONDARY PROBLEMS TO LOOK FOR WITH POLIO \n\n\n(By secondary problems, we mean problems that do not come from the original \ndisease or disability, but appear later, as complications.) \n\n\nCONTRACTURES OF JOINTS \n\n| 3 TYPICAL CONTRACTURES IN POLIO \nA contracture is a shortening of A child with paralysis who crawls around like this and \n\nmuscles and tendons (cords) so that never straightens her legs will gradually develop \n\n\nthe full range of limb movement is contractures so that her hips, knees, and ankles can no \nprevented. longer be straightened. \n\n\nUnless preventive steps are taken, \njoint contractures will form in many wrist \nparalyzed children. Once formed, \noften they must be corrected before \nbraces can be fitted and walking is \npossible. Correction of advanced \ncontractures, whether through \nexercises, Casts, or surgery (or a \ncombination), is costly, takes time TYPICAL DEFORMITIES \nand causes discomfort. Therefore OF ANKLE AND FOOT \nearly prevention of contractures is \n\n\nvery important. ! \nA full discussion of contractures, - cy \ntheir causes, prevention, and \\y \n\n\ntreatment is in the next chapter beading \n(Chapter 8). Methods and aids for down at bending bending bending \n\n\ncorrecting contractures are described ankle (tiptoe = down at out at in at \nin Chapter 59. contracture) mid-foot ankle ankle \n\n\nfingers \n\n\nOTHER COMMON DEFORMITIES \n\n\nWeight bearing (supporting the body's weight) on weak joints can cause deformities, \nincluding: \n\n\nOVER-STRETCHED JOINTS DISLOCATIONS \n\n\npartly WARNING: \n—«—— dislocated Dislocations \nknee like these are \n\n\ndislocated joints sometimes \nknee points (especially knee, caused by \nforward foot, hip, stretching \nfoot points shoulder, elbow, contractures \nerr i thumb) incorrectly. \nto the side) partly \n(See p. 28.) \ndislocated foot \n\n\nbending swayback.. \nout at Tout out of partly or \nknee— line with back-knee completely \n\n\nknee (when \n\n\nSPINAL CURVE a severely paralyzed child \n\n\nMore serious curve of the ‘ dislocated \nspine is caused by muscle ARS shoulder \nweakness of the back or \n\nbody muscles. The curve elbow bent \ncan become so severe backward \nthat it endangers life by Z \nleaving too little room \nleg. for the lungs and heart. \n\n\nAt first, the spinal \ncurve straightens \nwhen the child is \npositioned better. \nBut in time the \ncurve becomes more \napparent fixed (will not \nhunchback straighten any more). \nfrom bulge For information \ndislocated of ribs on spinal curves, \ncontracture hip see Chapter 20. \n\n\nMinor curve \nof spine can \nbe caused by \ntilted hips, \nas a result \nof a short \n\n\n62 CHAPTER? \n\n\nWHAT OTHER DISABILITIES CAN BE CONFUSED WITH POLIO? \n© Sometimes cerebral palsy can be mistaken for polio—especially cerebral palsy of \nthe ‘floppy’ type. \n\n\nHowever, cerebral palsy usually affects Polio has a more irregular \nthe body in typical patterns: pattern of paralysis \n\n\nall arm and both \nCEREBRAL 4 leg on legs POLIO \nPALSY limbs same \nside \n\n\nIn cerebral palsy, usually you can find other signs of brain damage: over-active \nknee jerks and abnormal reflexes (see p. 88), developmenta! delay, awkward or \n\\ uncontrolled movement, or at least some muscle tenseness (spasticity ) \n\n\n@ In muscular dystrophy, paralysis begins little by little and steadily gets worse \n(see p. 109) \n\n\nHip problems (see p. 155) can cause limping, and Note: Polio \nmuscles may become thin and weak. Check hips for can occur \npain or dislocations. (Note: Dislocated hip may also | before or \noccur secondary to polio.) )) after a child \n( has any of \nCb @ Clubbed foot is present from birth (see p. 114) these other \nproblems \nCheck \n\n\naretully \n\n\n‘Erb’s palsy’, or partial paralysis in one arm and \nhand, comes from birth injury to the shoulder \n(see p. 127) \n\n\n@ Leprosy. Foot and hand paralysis begins gradual! \nGi in older child. Often there are skin patches and loss \nof feeling (see p. 215) \n\n\n- , - wy Pr oersgees \n@ Spina bifida is present from birth. There is ( —@~—— » ALWAYS \n\n\nreduced feeling in the feet, and often a lump Xe wn EXAMINE THE \n(or scar from surgery) on the back (see p. 167) Vv Ch BACK INA \nCHILD WITH \n@ Injuries to the spinal cord (see p. 175) or te at Se \nto particular nerves going to the arms pod a c % \n-~ L o \nlegs. There is usually a history of a severe ; on § FEELING \n\n\n4 \nAY \nTuberculosis of the spine can cause gradual or \\\\ \\ \nsuddenly increasing paralysis of the lower body \nLook for typical bump on spine (see p. 165) \n\ncs \n\n\n&< \n\n\nOther causes of paralysis or muscle weakness. There are many causes of floppy \nparalysis similar to polio. One of the most common is ‘Guillain-Barré’ paralysis. \nThis can result from a virus infection, from poisoning, or from unknown causes \n\nIt usually begins without warning in the legs, and may spread within a few days to \nparalyze the whole body. Sometimes feeling is also reduced. Usually strength \nslowly returns, partly or completely, in several weeks or months. Rehabilitation \nand prevention of secondary oroblems are basically the same as for polio \n\n\nWHAT CAN BE DONE? \n\n\nDURING THE ORIGINAL ILLNESS, when the child first becomes paralyzed: \n\n\nNo medicines help, either during the first illness, or later \n\n\nRest is important. Avoid forceful exercise because this may increase paralysis \nAvoid injections. \n\n\nGood food during recovery helps the child become stronger. (But take care that the \nchild does not eat too much and get fat. An overweight child will have more \nproblems with walking and other movements.) For suggestions about good food, see \nWhere There /s No Doctor, Chapter 11 \n\n\nPosition the child to \n\nbe comfortable and to \navoid contractures. At \nfirst the muscles wil! \n\nbe painful, and the \nchild will not want to \nstraighten his joints. \nSlowly and gently try to \nstraighten his arms and \nlegs so that the child \n\nlies in as good a Note: To reduce pain, you may need to put cushions under the knees, \nposition as possible. but try to keep the knees as straight as you can \n\n(See Chapter 8.) \n\n\nGOOD POSITION BAD POSITION \n\n\nArms, hips, and legs as Bent arms, hips, and \nStraight as possible. legs. Feet in \nFeet supported. tiptoe position \n\n\nFOLLOWING THE ORIGINAL ILLNESS: \n\n\nContinue with good food and good positions. \n\n\nAs soon as the fever drops, start exercises to prevent contractures and return \nstrength. Range-of-motion exercises are described in Chapter 42. Whenever \npossible, make exercises fun. Active games, swimming, and other activities to keep \nlimbs moving as much as they can are important throughout the child's \nrehabilitation. \n\n\nCrutches, leg braces (ca/ipers), and other aids may \nhelp the child to move better and may prevent \ncontractures or deformities \n\n\nIn special cases, surgery may be needed to correct \ncontractures, or to change the place where strong muscles \nattach, so that they help do the work of weak ones. When \na foot is very floppy or bends to one side, surgery to join \ncertain bones of the foot may help. But because bone \nsurgery stops the growth of the foot, usually it should not \nbe done before age 12 or 13. \n\n\nEncourage the child to use his body and mind as much as \n\npossible, to play actively with other children, to take care of his daily needs, to \nhelp with work, and to go to school. As much as possible, treat him like any other \nchild. \n\n\nCHAPTER 7 \n\n\nREHABILITATION OF THE CHILD WITH PARALYSIS \n\n\nAll children paralyzed by polio can be helped by \ncertain basic rehabilitation measures—such as exercise \nto keep a full range of motion in the affected limbs. \n\n\nHowever, each child will have a different \ncombination and severity of paralyzed muscles, and \ntherefore will have his own special needs. \n\n\nFor some children, normal exercise and play may be \nall that are needed. Others may require special \nexercises and playthings. Still others may need braces \nor other aids to help them move about better, do things \nmore easily, or keep their bodies in healthier, more For this child, walking \np : . s a provides exercise that stretches \nuseful positions. Those who are severely paralyzed may \n\n\nhis legs and feet, and prevents \nbe helped most by a wheelboard (trolley) or wheelchair. contractures. (Tilonia, India) \n\n\nEvery child needs to be carefully examined and evaluated in order to best meet his \nor her particular needs. The earlier you evaluate a child’s needs, and take steps to meet \nthem, the better. \n\n\nUnfortunately, in \nmost areas where polio is \nstill common, village \nrehabilitation programs \ndo not exist or are just \nbeginning. Many children \n(and adults) who have \nbeen paralyzed for a long \ntime already have severe \n\n\ndeformities or joint \n\ncontractures. Often This child, who had polio as a It took several months of \nbaby, already had severe exercises at home and then a \n\nthese must be corrected contractures in the hips, knees, series of plaster casts in the \n\nbefore a child can use and teet. (PROJIMO) village rehabilitation center \n\n\nbraces or in to walk to straighten the contractures \n. beg ore. so he could walk with braces. \n\n\nBecause contractures are such a common problem, not only with polio but with \nmany other disabilities, we discuss them separately in the next chapter. Before \nevaluating a child with polio, we strongly suggest you read Chapter 8 on contractures. \n\n\nWARNING: Before deciding on any aid or procedure, carefully \nconsider its advantages and disadvantages. For example, some \ndeformities may be best left uncorrected because they actually help the \nparalyzed child stand straighter or walk better (see p. 530). And some \naids or braces may prevent a child from developing strength to walk \nwithout aids (see p. 526). Before decidirg what aid or procedure to use, \nwe suggest you read Chapter 56, ‘Making Sure Aids and Procedures Do \nMore Good Than Harm.” \n\n\nPROGRESS OF A CHILD WITH POLIO: \nTHE CHANGING NEEDS FOR AIDS AND ASSISTANCE \n\n\n1. exercises to keep full 2. supported sitting 3. active exercises \nrange of motion, in positions that with limbs supported, \nstarting within days help prevent to gain strength and \nafter paralysis contractures maintain full motion \nappears and continuing \nthroughout 4, a; P< \n\n\n. exercise in water— \nwalking, floating, and \nswimming, with the \nweight of the limbs \nsupported by the water \n\n\n. wheelboard or wheelchair with supports to prevent 6. braces to prevent \nor correct early contractures. contractures and \n\n\nj prepare for walking \n\n\nNote: These also provide good arm exercise \nin preparation for walking with crutches. \n\n\n7. parallel bars for 8. walking machine or 9. crutches modified as \nbeginning to balance ‘walker’ walker for balance \nand walk , and extra \n\n\nsupport \n\n\n10. under arm 11. forearm and perhaps 12. acane or no arm \ncrutches crutches in time supports \nat all \n\n\nNote: These pictures are only an example—but most of the steps are necessary for \nmany children. Chiidren who begin rehabilitation late may also have contractures or \ndeformities requiring corrective steps not shown here. \n\n\n© \nOD \n\n\nCHAPTER 7 \n\n\nEVALUATING A CHILD’S NEEDS FOR AIDS AND PROCEDURES \n\n\nStep 1: Start by learning what you can through talking with the child and family (see \nChild's History, p. 37 to 38). As you do this, watch the child move about. Observe \ncarefully which parts of the body seem strong, and which seem weak. Look for any \ndifferences between one side of the body and the other—such as differences in the \nlength or thickness of the legs. Are there any obvious deformities, or joints that do not \nseem to straighten all the way? If the child walks, what is unusual about the way she \ndoes it? Does she dip forward or to one side? Does she he!p support one leg with her \nhand? Is one hip lower than the other? Or one shoulder? Does she have a humpback, a \nswayback, or a sideways curve of the back? \n\n\nThese early observations will help you know what parts of the body you most need \nto check for strength and range of motion. Often, by watching a child you can begin to \nget an idea about what kind of aids or assistance may help. For example \n\n\nCarmen appears to She will probably \nhave severe never walk, and will \nparalysis need a wheelchair or \naffecting both wheelboard \n\nlegs and her right \narm. Weakness in \nher trunk (main \npart of the body) \nappears to have \ncaused a severe \nS-shaped curve of \n\n\nYou may want also to \nmake her a body brace, \nor help her in other \nways to sit more \nupright and try to \n\n\nkeep the spine from \n\n\nSai spine bending more \n\n\nr \n\n\nPedro appears to have severe paralysis in his legs and hips. It \nlooks as if his hips, knees, and feet cannot straighten _' \n(contractures). Weak stomach muscles and severe hip // { \ncontractures may be the cause of his swayback \n\n\nBecause his arms look \nstrong, Pedro will ee mnag? Ey \nstrap T casts \n\n\nprobably be able to sradually straighten \n\n\nwalk with crutches and straighten knees and of rng \nleg braces. But first hips ankles weakness, \nhis contractures must x \\ he may \nbe straightened.——>_ { i aap abet \n\n\nwith a \nIf the contractures \n\n\ncannot be straightened \nby gradual stretching, \n\n\nhip band \n\n\n‘ he may need surgery \n\n\now) \n\n\na. \n\n\nManuel walks with the help of a stick. He appears to have paralysis \nmainly in his right leg and foot. Because of weak thigh muscles, he \n‘locks’ his knee backward in order to bear weight on it. This ‘back- \nkneeing’ has become more and more extreme as the cords behind the floppy \nknee stretch. The foot is very unstable and flops to one side. The \n\nweaker leg looks somewhat shorter—and for walking is much shorter \n\nbecause of the bent-back knee and bent-over foot. \n\n\nback-knee \n\n\nHe might be able to walk without the stick if he uses a below-knee \n\n\nbrace to stabilize his foot. (See p. 550.) \npad holds \n\n\nknee forward \n\n\nBut the back-knee would become worse and worse until he could \nnot walk. So probably he should have a long-leg brace. The brace firm ankle \nmight allow his knee to bend backward just a little for stability \nTes that no knee lock is needed. \n\n\nsupport \n\n\nraised sole —___ \n\n\nOnis leans forward and pushes her weak left thigh Or she may need Or she may oe \nwith her hand when she walks. Her left knee an above-knee need a below \ncannot quite straighten. Her weak leg looks a brace with a knee brace that \nlittle shorter than the other. strap to pull helps push her \n\n\n‘ the knee back knee back. \n\n\n: 5 Exercises to get her knee \n\nstraighter or so it can bend very \n\nslightly backward may be all nes \nthat is needed for Afia to walk knee \nwithout using her hand back \n\n\nPad \n\n\nThe brace bends the foot down just a little, \nso that by bearing weight on toes (rather than \nheel) her knee is pushed back. \n\n\nTo get a better idea about which of the three solutions may work best for Afia, you will need \nto do a careful physical examination, testing range of motion and muscle strength of the hip, \n\n\nknee, and ankle joints. \nae ) \n\n\nStep. 2: This is the physical examination. |t shou!d usually include: \n\n\n1. Range-of-motion testing, especially where you think there might be contractures. \n(See ‘‘Physical Examination,” p. 27 to 29, and ‘‘Contractures,”’ p. 79 and 80.) \n\n\n2. Muscle testing, especially of muscles that you think may be weak. Also test \nmuscles that need to be strong to make up for weak ones (such as arm and \nshoulder strength for crutch use). (See p. 27 and p. 30 to 33.) \n\n\n3. Check for deformities: contractures; dislocations (hip, knee, foot, shoulder, \nelbow); difference in leg length; tilt of hips; and curve or abnormal shape of the \nback. (See p. 34.) \n\n\nCHAPTER 7 \n\n\nStep 3: After the physical exam, again observe how the child moves or walks. Try to \nrelate her particular way of moving and walking with your physical findings (such as \nweakness of certain muscles, contractures, and leg length). (For an example, see p. 70.) \n\n\nStep 4: Based on your observations and tests, try to figure out what kind of exercises, \naids, or assistance might help the child most. Consider the advantages of different \npossibilities: benefit, cost, comfort, appearance, availability of materials, and whether \nthe child is likely to use the aid you make. Ask the child and parents for their opinions \nand suggestions \n\n\nStep 5: Before making a final brace or aid to fit the child, if possible test to see how \nwell it may work by using a temporary aid or old brace from another child. For \nexample, \n\n\nIfa re iki But before nailing and \nchild’s on the glueing in the lift, \nankle outer side quickly make a trial \nbends of the sole one of cardboard or \nover to like this, something else and \nthe may help to fasten it temporarily \noutside keep the to the sandal or shoe \nlike foot with tape or string. \nSvs: straighter. Then have the child \nwalk. \n\n\nNote: For afew children, a lift like this will help \nFor many it will not. \n\n\n| Ask the child what she thinks. \n\n\nStep 6: After the child, her parents, and you have decided what kind of brace or aid \nmight work best, take the necessary measurements and make the brace or aid. When \nmaking it, once again it is wise to put it together temporarily so that you can make \nadjustments before you rivet, glue, or nail it into its final form. (See p. 540.) \n\n\nStep 7: Have the child try the brace \nor aid for a few days to get used to \nit and to see how well it works. Ask \nthe child and parents if it seems to \nhelp. Does it hurt? Are there any \nproblems? How could it be \nimproved? Is there something that \nmight work better? Make what \nadjustments are necessary. But \nremember that no brace or aid is \nlikely to meet the needs of a child \nperfectly. Do the best you can. \n\n\nMari and Chelo making a child’s Brace \n\n\nSY \n\n\nPOLIO 69 \n\n\nHere is a story of how workers in a small village rehabilitation program figured out \nwhat kind of aids a child needed. How many of the steps we have just discussed did \nthey follow? Was each step important? \n\n\nA STORY: A BRACE FOR SAUL \n\n\nSaul’s mother \n\n\nOne day a mother from a neighboring “Don't worry, Saul. Maybe we can do \nvillage arrived at the village center with her something simpler,’ said Mari. ‘But first \n6 year old son, Saul. Mari and Chelo, 2 of let’s examine you, okay?’’ Saul nodded \nthe village rehabilitation workers, welcomed \nthem warmly. Learning that Saul had polio \nas a baby, they asked him to walk, and then \nto run, while they watched carefully. Saul \nlimped a lot and one leg looked thinner and \n\n\nshorter. With each step it bent back at the THAT'S AS \n\n\nOn muscle testing Saul, they found he \ncould not straighten his knee at all. But he \nhad fair strength for bending his knee back \n\n\n‘He walks quite well, really,’’ said Mari. \n“But he has to ‘lock’ his knee back in order \nto put weight on it. That knee is going to \nkeep stretching back and some day it will \ngive out.” \n\n\n“A long-leg brace would protect his and his hip forward \nknee,’’ suggested Chelo \n\n\n“Oh, please, no!\"’ said Saul’s mother. \n“A year ago we took Saul to the city and \nthe doctors had a big metal brace made for \nhim. It cost so much we are still in debt! \nSaul hated it! He would always take it off \nand hide it. We tried and tried to get him to \nuse it, but he wouldn’t.”’ \n\n\n_- \n\n\nLy and good strength for bending his hip back \n\n\n“That's not surprising,’’ said Mari. ‘‘Often \na child who can walk without a brace will \nrefuse to use one—even if he walks better \nwith it. We could make him a long-leg brace \nout of plastic. It would be much lighter. \nWhat do you say, Saul?’’ Sau! began to cry. \n\n\n70 \n\n\nCHAPTER 7 \n\n\n“With the hip and thigh strength he has, \nhe should almost be able to stand on that leg \nwithout the knee bending back,\"’ said Mari. \n“Saul, let’s see you try it like this. Pretend \nyou're a stork!'’ For a moment Saul could \ndo it. ““Good!\"’ said Mari. ‘‘Every day stand \nlike that and see how high you can count \nwithout letting your knee go back. Every day \ntry to beat your old record! Okay?” \n\n\n“Okay,” said Saul. \nSounds like fun!”’ \n\n\n@ \n\n\n“The stork exercises may help,” said \nChelo. ‘But | still think he needs a brace. At \nleast at first.”’ \n\n\nWe must weigh the advantages against the \ndisadvantages,’ said Mari. ‘‘A long-leg brace \nwould keep his knee straight. But it could \nweaken the muscles he needs to strengthen. \nSince the brace would keep his leg from \nbending back, he wouldn't have to use his \nmuscles to do it \n\n\nA long-leg brace \n\n; might weaken the \n\n…[truncated]", "summary": "ED 288 319 AUTHOR TITLE INSTITUTION REPORT NO PUB DATE NOTE AVAILABLE FROM PUB TYPE EDRS PRICE DESCRIPTORS ABSTRACT EC 200 797 Werner, David Disabled Village Children. A Guide for Community Health Workers, Rehabilitation Workers, and Families. First Edition. Hesperian Foundation. Palo Alto, CA. ISBN-0-942364-06-6 May 87 703p. Hesperian Foundation, P.O. Box 1692, Palo Alto, CA 94302 ($9.00, 12 or more, $7.00 each). Guides - Non-Classroom Use (055)…", "source_url": "https://archive.org/details/micro_IA41153324_0501", "pdf_url": "https://archive.org/details/micro_IA41153324_0501", "doc_date": "1987-05-00", "case": "hesperian", "sub_case": "Werner, David, Hesperian Foundation, Palo Alto, CA.", "tags": ["hesperian"], "page_count": 0} {"title": "Where There Is No Dentist Murray Dickson", "content": "Where There \nIs No Dentist \n\n\nby Murray Dickson \n\n\nwith an Introduction by David Werner, \nauthor of Where There Is No Doctor \n\n\nCompiled by noonya \n\n\nLibrary of Congress Cataloging in Publication Data \nCatalog card No. 82-84067 \n\n\nDickson, Murray \n\nWhere there is no dentist. \n\nIncludes index. \nPalo Alto, CA: Hesperian Foundation \nISBN: 0-942364-05-8 \n\n\nFirst edition, November 1983 \nSeventh Printing, July 1996 \n\n\nPUBLISHED BY: \n\n\nThe Hesperian Foundation \nP.O. Box 1692 \n\nPalo Alto, California 94302 \nU.S.A, \n\n\nCopyright ©1983 by The Hesperian Foundation \n\n\nThis book is certainly not intended to be the last word in community \ndental care. It is only a beginning. The author hopes to rewrite and \nimprove the book with suggestions from readers. \n\n\nNote on the use, adaptation, and translation of this book: \n\n\nEach country is special, with its own \nparticular customs, health needs, and \nways of caring for people. \n\n\nThis book, therefore, must be adapted \nby dental workers in each country, using \nthe language that is common to the local \nhealth workers there. \n\n\nThe author would be pleased to assist \nin any way with those who would translate \nor adapt the book. \n\n\nThe Hesperian Foundation encourages others to copy, reproduce or adapt \nto meet local needs, any or all parts of this book, including the illustrations, \nprovided the parts reproduced are distributed free or at cost \n\n—not for profit. \n\n\nAny organization or person who wishes to copy, reproduce or adapt, any or \nall parts of this book for commercial purposes, must first obtain permission \nto do so from the Hesperian Foundation. \n\n\nPlease contact the Hesperian Foundation before beginning any transla- \ntion or adaptation to avoid duplication of efforts, and for suggestions \nabout adapting the information in this book. The foundation would appreci- \nate receiving a copy of any materials in which text or illustrations from this \nbook have been used. \n\n\nWe would like to rewrite this book and incorporate many of your ideas. \nIf you have a suggestion, please write to Murray Dickson at The Hesperian \nFoundation. Better yet, if you write your own manual, please set aside \ntwo copies and send one to The Hesperian Foundation, Box 1692, Palo \nAlto, California 94302, USA. Send the other to AHRTAG (Appropriate \nHealth Resources and Technologies Action Group), 29-35 Farringdon \nRoad, London EC1M 3JB, England. Both organizations would like to help \npass along your ideas to others. \n\n\nTHANKS \n\n\nWhere There Is No Dentist is here to fill a need. To many people, it has seemed that \nthe existing books about dental care were either too incomplete or too complicated. \nIf this book fills that need, it is only because a number of people worked hard to make \nit happen. To them | owe my sincere thanks. \n\n\nMuch has happened since that day in Papua New Guinea when David Werner's \nletter arrived. His challenge was simple: ‘‘Since no one else has written a dental manual \nlike this, why don’t you?”’ With David's encouragement and constant support, | was \nable to take teaching notes and produce a suitable draft that was the basis for this \nbook. To you, David, for your patience in helping me learn, my heartfelt thanks. \nThanks also to Trude Bock and Bill Bower for the home, food, direction, and support, \nduring a short visit to The Hesperian Foundation in which the book took a definite \nturn for the better. \n\n\nMichael Blake deserves special mention. As editor of Where There Is No Dentist, it \nwas he who took the manuscript and nursed it along to completion. Michael's \ncommitment to finishing the book was vital, and | sincerely appreciate it. \n\n\ny thanks go to Maggie Leung for typing the final draft, and to those dedicated \npersons who helped get the book into final form: Annaloy Nickum (page design); \nHal Lockwood (typesetting and paste-up); Paul Chandler, Serena Clayton, and Elaine \n~ Rossi (proofreading); Pat Bernier (typing); and Howard Uno (photostats). \n\n\nFor their outstanding drawings, | am exceedingly grateful to: June Mehra, Janet \nElliott de Jacques, Michael Marzolla, Joan Thompson, Mindy Mead, Arlene Ustin- \nCartagena, and Lynn Gordon. My own drawings in the manual appear amateurish in \ncomparison. \n\n\n| want to thank the many persons who reviewed the manuscript and offered \nvaluable suggestions: Ken Cripwell, Bill Bower, Jeff Vore, Aaron Yaschine, Rosalie \nWarpeha, Norma Francisco, Mike Muller, Marcia Anderson, Phil Haskett, Bert Bail, \nTom Coles, Sunil Mehra, and John Rogers. In particular, thanks to Chris Lennox who, \nfaced with stressful times in Papua New Guinea, found time to read through two \ndrafts; and to David Morley for his ideas for improving the book and his assistance \nwith its eventual publication. \n\n\nFor their financial help, | am grateful to the Ella Lyman Cabot Trust, Muttart \nFoundation, the Canadian Organization for Development through Education, and the \nJames C. Penney Foundation. \n\n\n| thank the C.V. Mosby Company and Dr. Kenneth Snawder for permission to \nadapt several drawings from the Handbook of Clinical Pedodontics, and the \nMedical Missionary Association (6 Canonbury Place, London N1 2NJ, U.K.) \nfor permission to use parts of David Halestrap’s book Simple Dental Care. \n\n\nThis book is based upon several! years of practical experience, made possible by \nthe Canadian Organization CUSO, For this opportunity, and for CUSO’s active interest \nand involvement in this book, | most gratefully say thanks. \n\n\nFinally, | want to acknowledge my family’s contribution. For weeks on end, my \nwife, Gerri, faithfully read and discussed with me each part of the book as it changed \nand was rewritten. She did this cheerfully, at a time when she was fully occupied ina \ngraduate study program. For much longer than | had anticipated, Gerri and our two \nboys, Michael and Brennan, had to tolerate my preoccupations. \n\n\nMy parents endured my wanderings and search for answers to human problems \nwith Jove and a growing sense of understanding. It is my only disappointment that \nthey did not live to see this book in its final form. \n\n\nCONTENTS \n\n\nINTRODUCTION, by David Werner \n\n\nPart One: Learning and Teaching about Teeth and Gums \n\n\nChapter 1: Your Own Teeth and Gums .. 2... .0.0.0 00000 ee eee 1 \n\nChapter 2: Teaching Family and Friends In Your Community ............. 9 \n\nChapter 3: Teaching Children At School. . 1... es 17 \n\nChapter 4: School Activities for Learning About Teeth and Gums. ......... 33 \n\nChapter 5: Taking Care of Teeth and Gums .......... 0.0000 eee ee 59 \nPart Two: Treating Dental Problems \n\nChapter 6: Examination and Diagnosis ......... 2.0.00 eee eee 7) \n\nChapter 7: Treating Some Common Problems .............00 00050 ee 81 \n\nChapter 8: Sealing Teeth: 340. 2 aca eects Das hee bee ee ek Ad 12) \n\nChapter 9: Injecting Inside the Mouth ....... 0... cee eee 129 \n\nChapter 10: Cement Fillings... 0... 0. ce ee 137 \n\nChapter 11: Taking Out a Tooth... 2.0... es 147 \nREFERENCE PAGES: 4 nc..0 hac Seed eae a Sie en Ge SPE He 163 \n\nThe Dental Kit \n\nRecords, Reports, and Surveys \n\nStory Telling \n\nDental Health Teaching Materials \n\nVOCABULARY? tos syece ted, be te at el nth tog LER oh sled ode tN Aes caan sols dan 182 \n\n\nINTRODUCTION \n\n\nby David Werner \n\n\nA healthy tooth is a living part of the body. It is connected by \n‘life-lines’ of blood and nerve to a person’s heart and brain. To separate \nthe tooth from the body, or even to interrupt those ‘Hfe-lines’, means \ndeath to the tooth. It also means pain and injury to the body, to the \nperson. \n\n\nLet us look at it another way. The health of the teeth and gums is \nrelated to the health of the whole person, just as the well-being of a \nperson relates to the health of the entire community. \n\n\nBecause of this, the usual separation between dentistry and general \nhealth care is neither reasonable nor healthy. Basic care of the teeth and \ngums—both preventive and curative—should be part of the ‘know-how’ of \nall primary health care workers. Ideally, perhaps, Where There /s No \nDentist should be a part of Where There Is No Doctor. Think of it as a \ncompanion volume, both to Where There Is No Doctor and Helping Health \nWorkers Learn. \n\n\nMurray Dickson has taken care to write this book in a way that will \nhelp the readers see dental care as part of community health and \ndevelopment. The approach is what we call ‘people centered.’ \n\n\nWhere There Is No Dentist is a book about what.people can do for \nthemselves and each other to care for their gums and teeth. It is written \nfor: \n\n\ne village and neighborhood health workers who want to learn more \nabout dental care as part of a complete community-based approach \nto health; \n\n\ne school teachers, mothers, fathers, and anyone concerned with \nencouraging dental health in their children and their community; \nand \n\n\ne those dentists and dental technicians who are looking for ways to \nshare their skills, to help people become more self-reliant at lower \ncost. \n\n\nJust as with the rest of health care, there is a strong need to \n‘deprofessionalize’ dentistry—to provide ordinary people and community \nworkers with more skills to prevent and cure problems in the mouth. \nAfter all, early care is what makes the dentist’s work unnecessary—and \nthis is the care that each person gives to his or her own teeth, or what a \nmother does to protect her children’s teeth. \n\n\nWhile dental disease is decreasing in richer countries, it is on the increase \nin most poor countries. One reason for this is that people are eating fewer \ntraditional (unrefined) foods and more pre-packaged commercial foods, \noften sweetened with refined sugar. \n\n\nEven as the need for dental care is growing, there are still far too few \ndentists in poor countries. Most of those few work only in the cities, \nwhere they serve mostly those who can afford their expensive services. \n\n\nPeople in many countries cannot afford to pay for costly professional \ndental care. Even in rich countries, persons who do not have dental \ninsurance often do not get the attention they need—or go into debt to \nget it. \n\n\nTwo things can greatly reduce the cost of adequate dental care: popular \neducation about dental health, and the training of primary health workers \nas ‘dental health promoters’. In addition, numbers of ‘community dental \ntechnicians’ can be trained—in 2 to 3 months plus a period of \napprenticeship—to care for up to 90% of the people who have problems \nof pain and infection. \n\n\nDentists’ training usually includes complicated oral surgery, root canal \nwork, orthodontics (straightening teeth), and other complex skills. Yet \nmost dentists rarely do more than pull, drill, and fill teeth—skills that \nrequire a fraction of the training they have received. The simpler, more \ncommon dental problems should be the work of community dental \ntechnicians who are on the ‘front lines’ (the villages), with secondary \nhelo from dentists for more difficult problems. \n\n\nWould this reduce quality of service? Not necessarily. Studies have \nshown that dental technicians often can treat problems as well as or better \nthan professional dentists. In Boston (U.S.A.), for example, a study \nshowed many of the basic treatments commonly given by dentists to be \ndone just as well, and often better, by dental technicians with much \nshorter training. \n\n\nFortunately, in some countries skilled dental technicians have managed \nto become the major providers of the most needed dental services. In \nIndia, there are still ‘street-corner’ dental technicians with foot-pedal \ndrills, who drill and fill teeth at remarkably low cost, \n\n\n{n Honduras, dental technicians (who learn largely from each other, \nstarting as heloers) have formed their own union. Their political strength \nrecently was tested when, in the town of Trujillo, a dentist tried to put a \ntechnician out of business. The local technician had removed an infected \nroot left mistakenly by the dentist. The technician had commented on \nthe dentist's carelessness, and the dentist heard about it. The dentist sent \na policeman who shut down the technician's office and took away his \ntools. However, the dental technicians’ union took this to court. They \nargued their rights to practice dentistry, because they are the only persons \n\n\nworking in marginal communities where dentists’ prices are too high for \nthe people. The court decided in favor of the technicians, and ordered the \ndentist to return the technician’s tools-and pay him for work Jost. \n\n\nIn other countries dentists and community dental workers work in \ncloser harmony. In Guatemala, Ecuador, Papua New Guinea, and \nMozambique, dental technicians are now recognized by the Ministries of \nHealth. In’ Papua New Guinea and Ecuador, professional dentists train and \nsupervise them to provide dental care to school children. In Ecuador, they \nwork mostly as dentist assistants, bringing high quality services to more \npeople while decreasing costs. The ‘dental therapists’ in Papua New Guinea \nare trained to extract, drill, and fill teeth, as well as to work on prevention \nof dental problems in school children. \n\n\nIn Guatemala and Mozambique, dentists from the dental school have \ntrained village health promoters as dental workers who work with people \nof all ages. Their training includes community dental health education, \ncleaning of teeth, extractions, and drilling and filling. These health \nworkers are provided with the few basic instruments needed to provide \nthese services. \n\n\nIn Project Piaxtla, Mexico (with which | and the Hesperian Foundation \nhave worked for many years), visiting dentists have also helped train \nvillage ‘dentics’. They, in turn, now teach basic dental skills to the part- \ntime village health workers. These village dentics, some of whom have had \nonly 3 to 6 years of primary school, now practice—and teach—a wider \nrange of dental skills than the average dentist. Their activities include \ndental health campaigns with school children, community puppet shows \nabout low-cost dental self-care, cleaning of teeth, extractions, drilling and \nfilling, and the making of dentures (false teeth). Several of the dental \n\n‘workers can now do root canal work—a special treatment to remove the \ncentral nerve in order to save an infected tooth. One of the village dentics, \nremembering what he had seen a dentist do, taught himself how to do \nroot canals when his girlfriend had an infected front tooth that he did not \nwant to pull. (He had also learned to check the tooth from time to time \nafterward to make sure this treatment had been successful.} \n\n\nWe still have much to learn about dental health. Dentists need to learn \nfrom the knowledge of the local people, as well as the people from the \ndentists. \n\n\nWe have learned that villagers with little formal education often can \nlearn skills with their hands—such as tooth extractions, puppetry, or \nsurgery—much faster than university students (who have never learned to \nuse their hands for much more than pushing pencils). We also have \nobserved that the best way to learn dentistry is not through school but \nthrough practice, helping someone with more experience who is willing \nto teach. \n\n\nWhere There Is No Dentist has 2 parts. The first part (Chapters 1-5) \ndiscusses teaching and learning about preventive care. |t begins by \nencouraging the health worker to examine herself and her family. To be \na good example is the best way to teach. \n\n\nThe second part (Chapters 6-11) talks about diagnosing and treating \ncommon dental problems. It is especially for those who live where they \ncannot reach or afford a dentist. A poor neighborhood in the city can be \nas distant and neglected as a far-off village. This second part is intended \nmainly for health workers who have helped organize people to meet their \nown needs. \n\nMurray Dickson—a Canadian with primary care experience in Northern \nCanada, Nigeria, Paoua New Guinea, and Mozambique—has written this \nbook in clear, simple language: He takes care to use popular names instead \nof unfamiliar scientific words. For example, instead of speaking of ‘dental \nplaque’ the author speaks of the ‘coating of germs on the teeth,’ Such \nsimple language does not weaken the message. The message is stronger \nbecause everyone understands. \n\n\nThe author has said: \n\n\n| am sure some dentists will disagree with parts of this book. Some \npoints of disagreement may be small, like the failure to use accepted \ndental terminology. Other ideas, particularly the suggestion that non- \ndental people can be trained to pravide many kinds of treatments, may \nmake some dentists angry. \n\n\nThe book is meant to be a source for argument and discussion. This \nway, it may stimulate others to write the kind of manual that is really \nneeded in their countries. \n\n\nWe hope that this will be only the first volume of Where There Is No \nDentist. \\t takes the reader as far as simple extraction (pulling) of teeth \nand placement of temporary fillings. As we have seen, village workers can \nalso learn a wide range of more difficult dental skills. We hope that later \nvolumes of Where There /s No Dentist will include permanent fillings, \nhomemade portable drilling equipment (many kinds have been developed), \nthe making of false teeth, and root canal treatment. There is no reason \nwhy village workers cannot learn all of these skills and practice them at \nlow cost to serve the millions who are unserved today. \n\n\nThe people must answer to the people’s needs. The health of teeth and \ngums, along with general health, will improve only when people take the \nlead in caring for themselves. The challenge for dentists and other health \nprofessionals is to allow and encourage this to happen. \n\n\nCHAPTER 1 \n\n\nYour Own Teeth \nand Gums \n\n\nNext time you-look in a mirror, look at your teeth and the skin (gums) \naround them. Look in your children’s mouths, too. Look at both gums . \nand teeth, because the health of one often depends on the health of the \nother. To be strong, teeth need healthy gums. Healthy gums need clean \nteeth. \n\n\nEEE \nel Ze \n\n\nmK \nWhat can good \nteeth give you? \n\n\ne GOOD HEALTH \ne GOOD LOOKS \n\ne GOOD SPEECH \ne GOOD EATING \ne GOOD BREATH \n\n\nAnd when you think of your teeth, think of your gums. Gums are \nimportant for holding each tooth in place. \n\n\nYou need strong teeth to eat different kinds of foods. Different foods \nare important for health. Nuts, maize, fruits, and meat are some of the \nbest foods—but they are difficult to bite and chew if your teeth are loose \nand hurting! \n\n\nYou can usually tell if your teeth and gums are healthy or not. Look at \nthe pictures on pages 71 and 72 and compare them with your own mouth. \nIf you find a problem in your mouth, look for its name in Chapter 6 and \nlook for its treatment in Chapter 7. ; \n\n\nMost important: when you are not sure of a \n\n\nproblem or how to treat it, talk to an \nexperienced dental worker. \n\n\nlf you notice a problem early, often you can stop it from getting worse. \nIt is even better to prevent the problem from starting. You can do this \nif you know how to keep your teeth and gums healthy. , \n\n\nBY EATING ONLY \nGOOD HEALTHY \n\n\nLearn to take care of your own teeth and gums before you try to teach \nothers. A good example is one of your best teaching tools. People will \nsee that you are healthy, and they wil! want to know why. When you tell \npeople ways to care for their teeth, they will believe you if they know \nthat you do these things yourself. First take care of your own teeth and \ngums. Then teach your family what you have learned. They, too, will be \ngood examples for others to see. \n\n\nEAT ONLY GOOD HEALTHY FOODS \n\n\nThe best food is food that you grow or raise yourself. Mix different \nkinds of food together and eat several times a day. This helps your body \nas well as your teeth and gums to stay strong and healthy. Traditional \nfood is usually good food. \n\n\nSweet food, especially the kind you buy from the store, can mix with \ngerms and make cavities—holes in the teeth. Soft food sticks to the teeth \neasily and it, too, can make a coating of germs and food on the teeth that \nstarts an infection in the gums—gum disease. \n\n\nSoft and sweet food and drinks with a \nlot of sugar are bad for both teeth and gums, \n\n\nBreast feed to help a child’s teeth Do not give a baby anything to drink \ngrow and stay strong. An older child from a bottle. Sweet tea, sugar water \n\n\ncan drink from a cup. or fruit juice can easily make holes \nin the child’s teeth. \n\n\nNO \nGOOD FOR TEETH BAD FOR TEETH \n\n\nEven milk has sugar that can wash over the baby’s teeth and cause cavities when \nit comes from a bottle. \n\n\nCLEAN YOUR TEETH EVERY DAY \n\n\nIf you do not clean properly, the food that is left on your teeth can \nhurt the teeth as well as the gums near them. \n\n\nHIDING PLACES \n\n\nBits of food stay longer in grooves and \n‘hiding places’. This is where both tooth \nand gum problems start. \n\n\ngrooves 1TOprevent problems you must take special \nontop —_ care to keep these protected places clean. \n\n\nIt is better to clean your teeth carefully \nbetween \n\n\nNEMEC ~ the teeth - Ne every day than to clean poorly many \n_near the gums times a day. \n\n\nHere are 3 places where problems start. \n\n\nUse a soft brush to clean your teeth. Buy one from the store (be sure it \nsays soft on the package), or make a brush yourself. To make a brush: \n\n\n1. Use a small branch, 2. Cut a piece that is still \nyoung bamboo, strong green and soft. \ngrass or the skin from , \nsugar cane or betel nut. \n\n\nS \n3. Chew one end to make 4. Sharpen the other end so \nit stringy like a it can clean between the \n\n\nteeth (see pages 69-70). \n\n\nYou can twist the fiber from inside a coconut husk into a kind of brush. \nFirst rub it and shake away the loose bits. Then use the end to clean your \nteeth. \n\n\nWhatever kind of brush you use, be sure to clean your back teeth as \nwell as your front teeth. Scrub the tops and sides where the grooves are. \nThen push the hairs between the teeth and scrub (page 67). \n\n\nToothpaste is not necessary. \nCharcoal or even just water is \nenough. When your teeth are \nclean, rinse away the loose \npieces of food. \n\n\nCAVITIES, TOOTHACHES AND ABSCESSES \n\n\n‘Cavities’ are holes in teeth. Cavities are made by the infection called \ntooth decay. if you have a black spot on your tooth, it might be a cavity. \nlf that tooth hurts some of the time, such as when-you eat, drink, or \nbreathe cold air, it probably has-a cavity in it. \n\n\nYou will get cavities in your teeth if you eat sweet food and then do \nnot clean your teeth. If you see a cavity starting in your mouth or feel a \ntooth hurting you, get help right away. A cental worker knows how to \nfill the cavity so you can keep that tooth. Do this before the pain gets \n\n\nIf you do When decay touches When infection \nnot fill a cavity, the nerve inside, reaches the inside \nit grows bigger. the tooth aches, of a tooth, it \n\nIt also grows even when you try is called a tooth \ndeeper. to sleep. abscess. \n\n\nA tooth with an abscess needs treatment at once, before the infection \ncan go into the bone (page 87). In most cases the tooth must be taken out. \n\\f it is not possible to do this right away, you can stop the problem from \ngetting any worse if you follow these steps: \n\n\n1. Wash the inside of your mouth with warm \nwater. This removes any bits of food \ncaught inside the cavity. \n\n\n2. Take aspirin for pain. See page 88 for \namount. \n\n\n3. Reduce the swelling: \ne hold warm water inside your mouth near \nthe bad tooth. \n\n\ne Wet acloth with hot water and hold it \nagainst your face. Do not use water hot \nenough to burn yourself! \n\n\nA tooth abscess can cause \nswelling like this. \n\n\n_ SORE BLEEDING GUMS \n\n\nHealthy gums fit tightly around the teeth. Gums are infected if they \nare loose, sore, and red, and if they bleed when the teeth are cleaned. \nInfection in the gums is called gum disease.~ \n\n\nGum disease, like tooth decay, happens when acid touches the teeth \nand gums. This acid is made when sweet and soft foods mix with germs \n(see page 48). \n\n\nHEALTHY TEETH AND GUMS CAVITIES AND GUM DISEASE \n\n\nInfection from gum disease can spread into the root fibers and bone (see \npage 40). But you can stop gum disease and prevent it from coming back. \nThere are two things to do: clean your teeth better and strengthen your gums. \n\n\n1. Even if your gums are sore and they bleed, you must still clean the \nteeth beside them. If more food collects on the teeth, the gum \ninfection will get even worse. Get a soft brush (see p. 4) and use it \ngently. This way you will not hurt the gums when you clean. \n\n\n2, To make your gums stronger and more able to fight the infection: \ne Eat more fresh fruits and green leafy vegetables, and fewer soft \nsticky foods from the store. \ne Rinse your mouth with warm salt water. Do this every day, even \nafter your gums feel better. \n\n\n(1) Mix some salt with a cup of warm water. (2) Take a \nmouthful and rinse. (3) Spit it out. Repeat until all of the salt \nwater is finished. \n\n\nMORE SERIOUS GUM DISEASE \n\n\nPainful gums that bleed at the slightest touch need special treatment. \nIf you have this problem, ask for help. A dental worker can explain what \nis happening and what needs to be done. A dental worker can also scrape \nthe teeth and remove the tartar that is poking the gums, making them sore. \n\n\nAt home, you can do some things to help. \n\n1. Clean your teeth near the gums with a soft brush. Gently push the \n\n’ brush between the tooth and the gum. It may bleed at first, but \nas the gums toughen, the bleeding will stop. \n\n2. Make your food soft, so it is easier to chew. Pounded yam and soup \nare good examples. \n\n3. Eat plenty of fresh fruits and vegetables. If it is difficult for you to \nbite into fruit, squeeze it and drink the juice. \n\n4. Start rinsing your mouth with a mixture of hydrogen peroxide and \nwater. You can get hydrogen peroxide from your clinic or your \npharmacy (chemist). \n\nThe strength of hydrogen peroxide is important. Ask for a 3% \nsolution, and mix it evenly with water—that is, 1/2 cup of hydrogen \nperoxide with 1/2 cup of water. \n\n\nWARNING: Read the label to be sure the solution is 3%. A \n\n\nmixture with more than 3% hydrogen peroxide can burn \nthe mouth. \n\n\nTake some into your mouth and hold it \nthere for about 2 minutes. Then spit it \n\nout and repeat. Do this every hour you \n\nare awake. \n\n\nUse hydrogen peroxide for only 3 days. \nThen change and start rinsing with salt \nwater (page 7). \n\n\nif you take care, you can keep your teeth for a lifetime. \n\n\nCHAPTER 2 \n\n\nTeaching Family and Friends \nIn Your Community \n\n\nOld people can remember when there were fewer problems with teeth \nand gums. Children’s teeth were stronger and adults kept their teeth \n\n\nlonger. \n\nTimes are changing. Today there are more tooth and gum problems than \never before. In many countries, tooth decay and gum disease are two of \nthe fastest growing health problems. \n\n\nThis unhealthy situation is getting worse, for two reasons: changes in \nthe kind of food people now are eating, and not enough cleaning after \nthey eat. \n\n\nBEFORE, the food people ate was NOW, more people are buying \ntheir own, grown and prepared by softer and sweeter food from the \nthemselves. store. This kind of food sticks to \n\n\nthe teeth more easily so it has \nmore time to attack the teeth \nand gums. \n\n\nEven sugar cane was not as bad as Everyone must be more careful \nthe sticky candy children eat today. to clean away soft, sweet food. \nThe sugar was bad for the teeth, but But many people do not know \nthe fiber in the cane helped rub how. Some, especially children, \n\n\nthem clean. do not even try. \n\n\n10 \n\n\nMany people do not understand that tooth and gum problems are \ncaused by certain kinds of food, and poor cleaning of the teeth. In fact, \nsome have a completely different belief. \n\n\nTHERE MAY BE ANOTHER \nREASON. EATING SWEET FOOD \nAND NOT CLEANING YouR \n\nM \n\n\nTEETH CAN HURT o \nA iy \n\n\nUNCLE. \nHIM ANGRY \n\n\nDo not attack a belief because it is traditional. Many traditions are more \nhealthy than ‘modern’ things. Often, instead of telling people that their \nbelief is wrong, you can remind them of a different tradition that is \n\n\nhealthy. \n\n\nHelp your family and friends to recognize their healthy \ntraditions. Then help them find new ways to use these \n\n\nsame traditions for better health. \n\n\nBUT WE CAN MAKE \nFOR OURSELVES MANY \nOF THE THINGS THE \nSTORE SELLS. \n\n\nYES, AND WE CAN \nMAKE OUR OWN \nTOOTHBRUSHES FROM \n\n\nOUR PEOPLE DO Not \nUSE TOOTHBRUSHES. \nWE DO NOT HAVE MONEY \nTO BUY SUCH THINGS \nAT THE STORE. \n\n\nBE A GOOD EXAMPLE \n\n\nOther people like to watch what you do before they try something \ndifferent. First show members of your family and then they wil! be an \nexample to others in your community. For example: \n\n\n1. Instead of buying all your foods from the store, buy fresh fruits and \nvegetables from the market. It is even \nbetter to grow food in your own \ngarden. \n\n\nLearn to use several different kinds of \nfoods in each meal. Mixing foods is a \nhealthy idea. Invite friends to share \nyour meals and see the number of \ndifferent foods you have at each meal. \n\n\n2. Do not buy fizzy drinks like Coca-Cola or Fanta. \nThey have a lot of added sugar which quickly \nmakes children’s teeth rotten. \n\n\nAlso, do not sweeten your child’s milk or tea. \n\n\nWhen she is young she can learn to enjoy drinks \nthat are not sweet. \n\n\nClean, cool water, tea with little sugar, milk, or \nwater from a young coconut are best to drink. \nFresh fruits are delicious when you are thirsty. \n\n\nSs \n\n\nMost important: do not give your child a feeding bottle, especially \none with a sweet drink inside. (See page 3.) \n\n\n& 3. Keep your children’s teeth clean. \niF Your friends will notice clean \nSTN teeth or teeth that are dirty or \n\noe have cavities. Remember, clean \nteeth are healthy teeth. \n\n\nAn older child can clean his own \nteeth if you show him how. \n\n\nA younger child cannot. He needs \nhelp. Each day someone older \nshould clean his teeth for him \n(page 16). \n\n\nWhen you teach, remember that as others learn, \n\n\nthey too become teachers. Each person can teach another. \n\n\nEncourage people to pass along what you have taught. Mothers can \nteach family and friends. Students can talk at home with brothers, sisters, \nand older family members. \n\n\nFROM THE HEALTH CLINIC... ... TO THE HOME \n\n\nKEEP YOUR TEETH \nAND YOUR \nCHILDREN’S TEETH \nWEALTHY BY \n\n\n; CLEANING THEM, \n\n\nMARIE, PLEASE HELP \nME CLEAN BABY’S \nTEETH AND THEN \n\nBROTHER’S TEETH. \nWE WILL DO IT \nEVERY DAY. \n\n\nFIRST, I \nMUST CLEAN \nMY OWN \nTEETH PROPERLY, \n\n\nTHEN MAYBE MY \nTEETH WON'T HURT \nLIKE VINCENT’S, \n\n\n... TO THE SCHOOL... ... TO THE HOME \n\n\nBROTHER, TRY To BRUSH \nYOUR BACK TEETH BETTER. \nIF YOU DO, THEN THEY \n\nWILL STAY STRONG UNTIL \nYOU GROW OLD. \n\n\nUSE A SOFT TOOTHBRUSH. \nA SOFT BRUSH IS BEST \nBECAUSE IT WON'T \nHURT YOUR GUMS. \nTELL YOUR \nFAMILY THAT. \n\n\nWHAT SHOULD \nT 0O IF MY \nGUMS BLEED? \n\n\nWISH [ HAD \nKNOWN ABOUT \nTHAT BEFORE. \n\n\nIf all learners become teachers, a simple message can begin in the health clinic or school \nand reach many more people at home. \n\n\n13 \n\n\nFINDING THE BEST WAY TO TEACH \n\n\nDeciding what to teach is important, but just as important is how to \nteach. \n\n\nIMPROVING ORAL HYGIENE CAN \nSIGNIFICANTLY REDUCE. THE \n\n\nINCIDENCE OF DENTAL “<& \nBi \n\n\nLearning cannot take place when \nyou use words that people do not \nunderstand. They will learn \nsomething only when they see how \nit is related to their lives. \n\n\nRemember this when you teach about eating good food and keeping \nteeth clean. Design your own health messages, but be ready to change \nthem if people are not understanding or accepting what you say. \n\n\nHere are five suggestions for teaching well. \n\n\n1. Learn First From the People \n\n\nGet involved in your community's activities. Learn about people’s \nproblems, and then offer to help solve them. People will listen to you \nwhen they know that you care about them and want to help. \n\n\nSit and talk with people. Learn \nabout their customs, traditions \nand beliefs. Respect them. \n\n\nLearn about their health habits. \nImproving health may require \nchanging some habits and \nstrengthening others. \n\n\nLearn also about tooth decay \nand gum disease in your community. \n\n\nMake people smile—then look into their mouths. \n\n\nFind out how many children and adults are having \nproblems with their teeth and gums. Do a survey such \nas the one on p. 176. \n\n\n14 \n\n\n2. Build New Ideas Onto Old Ones \n\n\nPeople find their own ways to stay healthy. Many traditions are good, \nhelpful, and worth keeping. But some are not. \n\n\nWhen you teach, start with what people already understand and are \ndoing themselves. Then add new ideas. \n\n\nThis method of teaching is called ‘association of ideas’. It helps people \nto understand new ideas because they can compare them with what they \nalready are doing. \n\n\nin this way people can more easily accept, remember, and do what \nyou suggest. \n\n\nA HEALTHY TRADITION \n\n\nbuilds ———> NEW iDEAS AND WAYS \n\n\nJust as sweeping the in the Brushing the teeth and gums \ncompound makes it a clean same way keeps them clean and \n\n\nand healthy place to live. \n\n\naed Aa? \n\n\nAsmall child cannot find his in the A small child cannot see the \n\n\nown fice. Mother knows she same way food on his teeth. He needs \nmust help him. help with that also. \n\n\nEating different kinds of \nfood helps people to grow. \n\n\nDifferent vegetables when in the Eating them several times a \nplanted together—like maize same way day makes your teeth and \nand yams—help each other gums, as well as your whole \n\n\nto grow. body, grow stronger. \n\n\n15 \n\n\n3. Keep Your Messages Short and Simple \n\n\nInstead of partially teaching too many things, it is better to discuss a \nfew things well. After learning what health problems the people feel are \ngreatest, decide what information will help them solve these problems. \nThen think of how to share the information. Try to: \n\n\ne Use simple words (see page 13). If you must use a big word, take the \ntime to explain it. \n\n\ne Teach people when they are ready to learn. A sick person, for \nexample, usually wants to know how to prevent his sickness from \nreturning. He will remember what you tell him. \n\n\ne Repeat the most important message many times. Whenever you teach \nabout staying healthy, remember to emphasize eating good food and \nkeeping teeth clean. Repetition helps people remember. \n\n\ne Let people see what you mean. See pages 24 to 32 for ways to use \npictures, puppets, and plays. \n\n\n4. Teach Wherever People Get Together \n\n\nKnowing where to teach is sometimes as important as how you teach. \nInstead of asking people to come to a class you have organized, go to \nthem. Look for ways to fit into their way of living. You both will gain \nfrom the experience. They will ask more questions, and you will learn how \nto work with people to solve problems. \n\n\nTalk with people where they \ngather near their homes. \n\n\nTalk to men as they \nsit together and \ndiscuss important \nissues, Also go to \ntheir business and \nfarming meetings. \n\n\nTalk to women at \nhealth clinics, in the \nmarket, and at their \nchurch meetings. \n\n\nTeach men and women \nat reading groups. \n\n\n16 \n\n\n5. Teach Something People Can Do Right Away \n\n\nIt is good to tell a mother to keep her child’s teeth clean, but it is better \nto show her how to do it. She will remember how if she actually watches \nyou clean her child's teeth. \n\n\nAn even better way for a mother to Jearn is to let her clean her child’s \nteeth while you watch. A person discovers something for herself when she \ndoes it herself. \n\n\nPick out a child and clean his teeth yourself. Let \nhis mother watch. \n\n\nUse a soft brush (or for a baby, a clean cloth). \nGently but quickly brush or wipe his teeth. Do the \nbest you can even if he cries. \n\n\nIf mothers make this into a habit, the child will \nexpect to have his teeth cleaned and will soon \ncooperate—just the way he does to have lice - \nremoved from his hair. \n\n\nNow let each mother clean her own Ask her to do the same at home \n\nchild’s teeth. Teach her to clean on each day. At the next clinic, look at \n\ntop and on both sides of every the children’s teeth and see how \n\ntooth. : well the mothers are doing. Give \nfurther help when needed. Always \npraise and encourage those who are \ndoing well. \n\n\n17 \n\n\nCHAPTER 3 \n\n\nTeaching Children \nAt School \n\n\nChildren want to learn. They want to Know more about things that are \nreal to them. Family, friends, and teachers are all important sources of \nnew knowledge for the children. : \n\n\nIt is important to keep alive their desire to learn, so \nthat children can continue to ask questions, discover, \nand learn more for themselves. \n\n\nWhen children are interested in something, they will work \nhard to learn afl they can about it. \n\n\nIf you relate your teaching to children’s interests and needs, they will \nlearn more easily. New information added to what they already know \nhelps children to understand your lesson better. As a result, they will want \nto learn more because the information is both interesting and worthwhile. \n\n\nTeaching about teeth and gums is important. You must do it well if \nyou want children to pay attention, learn, and finally act to take care of \ntheir own teeth and gums. \n\n\nAs school children continue to learn, they can share their new ideas and \ninformation at home with brothers, sisters, mothers, fathers, and grand- \nparents. In this way, the circle of teaching and learning described on page \n12 comes back into the family and is complete. \n\n\nThis chapter has two parts. Part 1 gives seven guidelines for assuring \nthat learning takes place. Part 2 suggests ways to have fun while learning— \nwith stories, games, and pictures. |n Chapter 4 there are nine questions on \nteeth and gums with specific activities for learning how to answer them. \n\n\n18 \n\n\nPART 1: TEACHING SO THAT \nLEARNING CAN TAKE PLACE \n\n\nMore children than ever before are \nhaving problems with their teeth and their \ngums. \n\n\nWHAT 15 THE MATTER, LI? \nYOU ARE NOT \nKEEPING UP WITH \nTHE OTHERS. \nA tooth that hurts or gums that are sore \ncan affect a student’s ability to pay \nattention in school and learn. \n\n\nTreating the problem makes the child \nfeel better, and that is important. It is \nequally important to prevent the same \nproblem from returning later. \n\n\nWorking together, teachers and school children \n‘can do much to prevent both tooth decay \nand gum disease. \n\n\nKeeping the mouth healthy involves learning about eating good food \nand keeping teeth clean. Just giving information is not enough, though. To \ntruly learn, children need a chance to find out things for themselves. \n\n\nForcing a person simply to accept what you say does not work very well. \n\n\n“7LEARN THIS AND DON?T ASK ; \nWHY | — BLA, BLA, BLA... A student learns not to question. What you \nm™, teach may have no relation to his own \nI ws he We experiences and needs. \nis j \nSe \n\n\nAs a result, he may.end up not doing what \nyou teach—not eating good foods, and \nnot cleaning his teeth. \n\n\nWHAT DO YOU THINK \nABOUT THAT? \n\n\nRIGHT SIR, \n\n\nWELL, I WOULD LIKE TO \nLOOK AT MY BROTHER'S \nTEETH FIRST. \n\n\nLearning happens when a student with a \nquestion or an idea is able to discover more \nabout it himself. \n\n\nIt also happens when he has a chance to do \nwhatever is necessary to take better care of \nhimself and his family. \n\n\nHe can learn by doing. Give him a chance to \neat good food and clean his teeth at school. \n\n\n19 \n\n\nLearning about teeth and gums can be fun. When the teaching is real \nand practical, students love to learn. Here are some ideas: \n\n\nTeaching so that learning can take place \n\n\n1. Teach and learn together with your school children. \n2. Start with what the students already know. \n3. Let students see and then do. \n4, Let children help each other. \n5, Teach about teeth and gums together with other subjects. \n6. Beagood example. \n7. Make the community part of your classroom. \n\n\n1. Teach and Learn Together with School Children. \n\n\nShare ideas \ninstead of always \ngiving information. \nChildren learn more \nwhen they are \ninvolved. \n\nA lecture transfers \nyour own notes to \nthe children’s \nnotebooks without \never passing through \ntheir minds. \n\n\nA PERMANENT SUCCESSOR LIES \n\n\nAPICAL TO... PAY ATTENTION ! \nYOU NEED TO KNOW THIS FOR \n\n\nYouR TEST!... EACH PRIMARY \n\n\nA discussion draws \nout information and \nopinions. \n\n\nA LOOSE TOOTH \nMAY BE \nROTTEN. \n\n\nIt helps you to learn \nmore about the \nschool children, \nwhat they already \nknow and believe to \nbe true. \n\n\nBut it also allows \nyou to introduce \nimportant \ninformation that is \nrelated to the discussion. \n\n\n20 \n\n\n2. Start with What the Students Already Know. \n\n\nTo have meaning, learning should be a part of daily living. Talk with \nyour students. Find out what they know about teeth and gums, and what \nquestions they might have. \n\n\nAdd information by building upon \nwhat a person already knows. \n\n\nDo not use big words. Scientific names and textbook explanations are \nconfusing, and you usually do not need them. Talk about teeth and gums \nusing words that a school child can understand and use later at home. \n\n\nDEGLUTITION \n\n\na Tm \n\n\nThis way makes students feel stupid. \n\n\nel \\ \nBINNe—EsoRHAQUS \n\n\nWHAT pe \nPARTS HE \n\nyou To CHEW \nAND SWALLOW! ? \n\n\nThis way lets the students feel good, \nbecause it makes sense and they know \n\n\nRE. something about it. \n\n\nWhen you can understand new information, you gain confidence and \nyou look forward to learning more. \n\n\n21 \n3. Let Students See and Do. \n\n\nStudents learn best when they can take part and find out for themselves \nabout something new. \n\n\nAN OLD CHINESE SAYING : You \n\n\nCAN MAKE A \nTOOTHBRUSH \n\n\nPLHGART. CROOKED PERMANENT TEETH \n\n\ni} \n\n\nMOVING INTO NOT ENOUGH \nTHE CAVITY SPACE \n\n\n10 years \n\n\nadult \n\n\nTell mothers why baby teeth are important. Good food and regular \ncleaning keeps them healthy. They should know that new teeth coming \nin do not cause diarrhea and fever, but that a child may have diarrhea or \nfever at the same time. \n\n\nIf there is a cavity, fix it so the tooth can be kept in the mouth to do \nits important work (see Chapter 10). \n\n\n64 \n\n\nTAKING CARE OF MOLAR TEETH \n\n\nWe often notice front teeth growing in, but not the back ones. Back \nteeth—molars—are not so obvious. Swelling on the face can be either a \nnew molar growing in or an abscess. So, to help you to decide, look at \nthe tooth for a cavity and at the gums beside it for a gum bubble. \n\n\nCAVITY \n\n\nGUM BUBBLE \n\n\nWhen you see a swollen face, look for the two signs of an abscess. \n\n\nBut if the person is young (16-22 years), it often is not an abscess. The \nthird permanent molar tooth may be growing in at the back of her mouth. \nAs the tooth grows, it cuts through the skin. Just as a dirty cut ona \nperson’s hand can get infected, the cut gum around her new tooth also \ncan get infected, causing a swollen face. \n\n\nSee the red swollen skin on | \nLook behind her back teeth. top of the new tooth. \n\n\nIf there is enough space for the tooth, it will grow in by itself It only \nneeds time. Before acting, decide how serious the problem is. \n\n\n\\f there is no swelling and she can open her mouth, explain to her \nwhat is happening and what she can do herself to reduce infection and \ntoughen the gums. The best medicine is to rinse warm salt water over the \nsore area. A good home remedy is to rinse until the tooth grows all the \nway into the mouth. \n\n\n\\f it does appear serious (severe pain, swelling, not able to open the \nmouth), see page 88 for further treatment. \n\n\n65 \n\n\nTAKING CARE OF ALL YOUR TEETH \n\n\nThis book often repeats an important message: eat good food and clean \nyour teeth. |t is repeated because this is the most important thing you \ncan learn from this book. Later chapters will discuss what to do when \nproblems occur, but if you follow these two suggestions, you wil! almost \nnever have problems with your teeth and gums. This is true because good \nfood keeps your whole body healthy, including your teeth. Also, with no \n‘colonies’ of germs (page 48) or harmful factory sugar (p. 53) on your \nteeth, your mouth cannot make the acids that cause both tooth and gum \n\n\nproblems. So, rermember: \n\n\n1. Eat Good Food \n\n\nAn easy-to-remember rule is the same foods that are good for the body \nare good for the teeth. A healthy body is the best protection against \n\n\ninfection. \n\n\nGood nutrition (eating well) means two things: \n\n\nOne, eat a mixture of different kinds of foods \nevery time you eat. Look at the pictures on page \n53. There are several groups of foods. Every time \nyou eat, try to eat one or two foods from each of \nthe groups. This way, you will get three important \nkinds of food: GROW FOOD (body-building food) \nto give you the protein you need; GLOW FOOD \n\n\nThe MAIN FOOD is (protective food) to give you vitamins and \nat the center of minerals; and GO FOOD (concentrated energy \nevery meal. food) to give you calories to be active all day. \n\n\nTwo, be sure you eat enough food \nto give your body the energy it needs. \nThis is even more important than the \nfirst suggestion. We get half or more \nof our energy from our MAIN FOOD. \nIn most parts of the world, people eat \none low-cost energy food with almost \nevery meal. Depending on the area, \nthis MAIN FOOD may be rice, maize, \nmillet, wheat, cassava, potato, bread- \nfruit, or banana. The MAIN FOOD is \nthe central or ‘super’ food in the local \ndiet. \n\n\nA spoonful of cooking oil added to a \nchild’s food means he only has to eat \nabout 3% as much of the local main food \nin order to meet his energy needs. The \nadded oil helps make sure he gets enough \ncalories by the time his belly is full. \n\n\n66 \n\n\nGROW FOODS \n\n\ncD \no \noOo \n\nBe sure THE MAIN \nalways to eat oops AND \nGROW FOODS ‘GO FOODS’ \nand GLOW GIVE US THE \nFOODS to get ENERGY TO \nthe vitamins RUN, WORK \nand protein \nyou need. \n\n\nYour energy \nfoods give \n\nyou the most \nimportant \npart of your \ndiet—calories. \nHalf or more \nof our \n\ncalories come \nfrom the MAIN \nFOOD, and \nmost of the \nother calories \ncome from GO \nFOODS. \n\n\nWARNING ABOUT ‘GO FOODS’: Although GO FOOD gives us the energy \nwe need, some GO FOODS are worse than others. Honey, molasses and \nespecially white sugar can be very bad for the teeth, even though they \n\nhave the calories we need. Fruits, nuts, and oils all give us energy (calories) \nwithout attacking the teeth. \n\n\n2. Clean Your Teeth \n\n\nCleaning teeth requires time and care. If you hurry, you will leave food \nand germs behind, and they continue to make cavities and sore gums. \n\n\nYou may find that different dental workers recommend different ways \nof brushing teeth. Some ways are definitely better, but often they are \nharder to learn. \n\n\nTeach a method of cleaning that a person can learn and will do at \nhome. Let him start by scrubbing his teeth (and his children’s teeth) back \nand forth, or round and round. Encourage him to improve his method \nonly when you think he is ready. \n\n\nToothpaste is not necessary. Some people use charcoal or salt instead, \nBut it is the brush hairs that do the cleaning, so water on the brush is \nenough. \n\n\nScrub the outside, inside, and top of each tooth carefully. \n\n\nWhen you finish, feel the tooth with your tongue to make sure it is \nsmooth and clean. \n\n\nFinally, push the hairs of the brush \nbetween the teeth and sweep away any bits \nof food caught there. Do this for both upper \nand lower teeth. \n\n\n- Sweep away in the direction the tooth \ngrows: sweep upper teeth down and lower \nteeth up. \n\n\n67 \n\n\n68 \n\n\nExplain how important it is to use a brush with soft hairs. A brush that \nis stiff and hard will hurt the gums, not help them. \n\n\nNO \n\n\nYou can make a hard brush softer by ee ee mee ee \nputting the hairs into hot water for a y \n\n\nfew minutes. 9 \n\n\nDo not put the plastic handle into the \nhot water, or it will melt. \n\n\n\\f your store has only hard brushes, tell the storekeeper that hard \ntoothbrushes do not help the people in the community. Ask him to order \nand sell only soft toothbrushes. \n\n\nNote: Another important way to reduce cavities is by adding \nfluoride to teeth. Fluoride is a substance which, like calcium, \nmakes teeth harder and stronger. \n\n\nFluoride in drinking water, toothpaste, vitamins, and mouth rinses, \nhelps to prevent cavities. These methods are sometimes expensive. \nPerhaps the most effective and inexpensive method is the weekly \nrinse at school, described on page 167. \n\n\nFluoride can also be found naturally in food and water. For \nexample, tea leaves and most foods from the sea contain a large \namount of fluoride. \n\n\nSo, your source of fluoride can be either: \n\n\n69 \nCLEANING BETWEEN THE TEETH IS VERY IMPORTANT \nHere are three ways to clean between the teeth: . \n\n\n1, Push the hairs of a toothbrush between the teeth, and sweep the bits \nof food away. \n\n\n2, Remove the stem from a palm leaf. Use the thinner end and move it \ngently in and out between the teeth. \n\n\nRub the stem \nZz y against one tooth \n=— and then the other. \nThis way, you clean \nthe sides of both \nteeth. \n\n\n3. Use some thin but strong thread or string. String can be the best \nmethod of all—but you must be careful with it. \n\n\nBuy and use Dental Floss. \n\n\nGet some thin cotton rope This is a special kind of \nused for fishing nets. Unwind OR | string for cleaning \nand use one strand of it. between the teeth. \n\n\nBe careful! The string can hurt your gums if you do not use it correctly. \nThe next page shows how to use the string, but the best way to learn how \nto ‘floss’ your teeth is to have someone show you. Ask a dental worker \nwho has experience. \n\n\n70 \nWrap the ends of the string around the middle finger of each hand. \n\n\n0, \n\n\nes \n\n\nUse the thumb and finger to guide the string. Go back and forth to \nslide the string between two teeth. Be careful not to let it snap down and \n\n\nhurt the gums. \nUpper teeth \n\n\nLower teeth \n\n\nWith your fingers pull the string against the side of one tooth. Now \nmove the string up and down. Do not pull the string back and forth or \nit will cut the gum. \n\n\niw \n\n\nLift the string over the pointed gum and clean the other tooth. \n\n\nWhen you have cleaned both teeth, release the string from one finger \nand pull it out from between the teeth. Then wrap it around your two \nmiddle fingers once again, and clean between the next two teeth. \n\n\nRemember: clean teeth and good food \n\n\nwill prevent almost all dental problems. \n\n\n71 \n\n\nCHAPTER 6 \nExamination \nand Diagnosis \n\n\nCARE THE TEETH HEALTHY? Oo \n\nise \n\nfous 7“ \n\nWhenever you do an examination, Gee Tie ums wenerae DO\" \\ \n\nremember to examine the mouth. ewe S \n

\n\n\nA TOOTHACHE \n\n\nAND YOU FIND OUT \nTHAT \n\n\nPpeee \nIt hurts only after eating ae \nor drinking. There is a ~{RY a as \n: wan \ncavity, but the tooth does \nAD a \n\n\nnot hurt when you tap it. \n\n\nPart of the filling has fallen \nout, or is cracked and ready > vs) ( \nto fall out. Eating and yyy \ndrinking make the tooth hurt. \n\nThe tooth hurts when chewing \n\nfood. it may hurt when tapped, \n\nbut there is no cavity and \n\nthe tooth looks healthy. \n\n\nIt hurts all the time—even \nwhen person tries to sleep. \nThe tooth hurts when you tap \nit and it feels a bit loose. \n\n\nit hurts when person breathes \nin cold air. The tooth was \nhit recently. \n\n\nHe cannot open his mouth \nproperly. Steady pain and \n\na bad taste are coming from \nthe back of the mouth. \n\n\nSeveral top teeth hurt, even \nwhen you tap them. She had \na head cold and can only \nbreathe through her mouth. \n\n\nHE/SHE MAY | SEE \nHAVE PAGE \na cavity 86 \n\n\na cavity under \nan old filling \n\n\ntartar between \nthe teeth \n\n\na cracked or \nbroken tooth \n\n\na new tooth \ngrowing in \n\n\nan infected \nsinus \n\n\n78 \n\n\nIF THE PERSON \n\n\nHAS \n\n\n—— \n\n\nA \nSWOLLEN FACE \n\n\nA \nLOOSE TOOTH \n\n\nAND YOU FIND OUT \nTHAT \n\n\nHe had a toothache recently. \nThe bad tooth hurts when you \ntap it. \n\n\nShe is young, about 18 years \nold, and has trouble opening \nher mouth. \n\n\nHe was hit on the face or \njaw. The bone hurts when \nyou touch it. The teeth \n\ndo not fit together properly. \n\n\nThe swelling is under or \nbehind the jaw. It gets \nworse when he is hungry \nand smells food. \n\n\nThe swelling has been there \nfor a long time. It does \nnot seem to get better. \n\n\nFood and tartar are \nattached to the tooth, \nThe gums around it are \nloose and swollen, \n\n\nThere was pain in the tooth \nbefore, but it does not hurt \nso much anymore. It has a \ncavity, and there may be \n\na sore on the gums near it, \n\n\nThe tooth was hit some \ntime ago. \n\n\nWhen the loose tooth moves, \nthe bone around it and the \ntooth beside it also move. \n\n\nBONE BROKEN ‘ ; \nUNDER THE GUM _s\" \n\n\nWhen you ask the person to \nslowly close his teeth, one \ntooth hits another, before \n\nthe other teeth come together. \n\n\nHE/SHE MAY \nHAVE \n= \n\n\na tooth abscess \n\n\na new tooth \ngrowing in \n\n\na broken bone \n\n\nan infection \ninside the spit \ngland \n\n\na tumor \n\n\ninfection inside \nthe root fibers— \nfrom gum disease \n\n\ninfection in the \nbone—from an \nold tooth abscess \n\n\na root broken \nunder the gum \n\n\na broken bone \naround the \ntooth’s roots \n\n\nOR \n\n\ninfection inside \nthe bone from \nVincent's \nInfection \n\n\na tooth is out of \nposition and \nbiting too hard \nagainst another \n\n\nIF THE PERSON \nHAS \n————— \n\n\nA SORE MOUTH \nfrom \nINFECTED GUMS \n\n\nor \nA SORE MOUTH \nfroma \nSMALL SORE \nin another \nplace \n\n\nAND YOU FIND OUT \nTHAT \n\n\nThe gums are red and swollen. \nThey bleed when the teeth are \ncleaned. \n\n\nBetween two teeth the gums \nare sore and swollen, like \na small tumor, \n\n\nThe gums between the teeth \nhave died and are no longer \npointed. Pus and blood \naround the teeth make the \nmouth smelt! bad. \n\n\nThe gums are bright red and \nsore, but between the teeth \nthey are stil! pointed. \n\n\nA sore on the inside of the \ncheek, lips, or under the \ntongue, is yellow with the \nskin around it bright red. \nFood touching it makes the \nsore hurt more. \n\n\nA sore spot around or \nunder a denture hurts \nwhen you touch it. \n\n\nA kind of white cloth seems \nto be stuck to the top of \n\nthe mouth or tongue. It \n\nmay stop a baby from sucking. \n\n\nThe sore is near the root \nof a bad tooth. \n\n\nThe corners of the mouth \nare dry. The lips crack \nand are sore. \n\n\nSmall painful blisters on \nthe lips soon break and \nform dry scabs. \n\n\nHE/SHE MAY \nHAVE \n—— \n\n\ngum disease \nstarting \n\n\nsomething \ncaught under \nthe gum \n\n\nVincent's \nInfection \n{a more serious \ngum infection) \n\n\nfever blisters on \nthe gums—from \nHerpes Virus \n\n\na canker sore \n\n\na sharp place on \na denture, or an . \nold denture that \nneeds to be \nrefitted \n\n\nthrush \n\n\ngum bubble \nenone [oe \n\n\nfever blisters \n—from Herpes \nVirus \n\n\nA SORE THAT DOES NOT HEAL PROPERLY MAY BE CANCER (See page 119). \n\n\n79 \n\n\n80 \n\n\n\\F THE PERSON \nHAS \n$= — \n\n\nA SORE \nON THE FACE \n\n\nTROUBLE \nOPENING THE \n\n\n| CAN NOT \n\nOPEN ANY \n\nMORE THAN \nTHIS, \n\n\nTROUBLE \nCLOSING THE \n\n\nAND YOU FIND OUT \nTHAT \n\n\n- Inside his mouth, he has \na tooth abscess or a \nbroken tooth near the sore. \n\n\nA dark sore is eating through \nthe cheek. Her gums are badly \ninfected. A bad smell is coming \nfrom the dying skin on the face, \nand from inside the mouth. \n\n\nA 1-month-old sore \non the lips is not healing \nwith medicine. \n\n\nHe is young, between 16-24 \nyears, with some swelling \nbehind his jaw. \n\n\nHe recently had an accident. \n\n\nHe had a toothache before \nin a back tooth with some \nswelling. \n\n\nWhen she tries to open her \nmouth, there is a clicking \nsound from in front of her \near. It also hurts in that \n\npiace whenever she tries to \nopen her mouth or chew food. \n\n\nSwallowing is difficult, and %> OR BLP \nthe jaw grows stiff. Germs \n\nhave gone into the body from \n\ndirty instruments or an \n\ninfected wound. \n\n\nAfter opening wide to eat or \nyawn, his mouth became stuck \nthere. He has many missing \nback. teeth, \n\n\nHe had an accident, and now \nsomething is stopping the \nteeth from coming together. \n\n\nHE/SHE MAY \nHAVE \n——_ \n\n\nabscessed tooth \ndraining pus to \nthe outside of \nthe face \n\n\na condition called \nNoma-starting \nfrom Vincent's \nInfection of the \ngums \n\n\ncancer \n\n\na new tooth \ngrowing in \n\n\na broken jaw— \nprobably in front \nof the ear \n\n\nan abscess in a \nback tooth \n\n\npain in the joint \n—where the \njawbone joins \nthe head \n\n\n81 \n\n\nCHAPTER 7 \n\n\nTreating Some \nCommon Problems \n\n\nYou must make a good diagnosis to treat a problem so it finishes and \ndoes not return. Why treat a sore on the face by cleaning it when the sore \nis from pus draining from a tooth with an abscess? You need to know \nthe cause of the sore to give the best kind of treatment. \n\n\nAfter you make the diagnosis, you must decide whether you or a more \nexperienced dental worker should provide the treatment. \n\n\nKnow your limits. Do only \n\n\nwhat you know how to do. \n\n\nIn the following pages, we describe the kinds of problems you as a \nhealth worker may see, and we also give the treatment for each problem. \nUse the table below to help you find the right page. \n\n\nBefore you touch the inside of anyone’s mouth, learn how to keep \nclean. See the next 4 pages. \n\n\nPART 1: PROBLEMS YOU WILL SEE MOST OFTEN \n\n\nCavities: sic bho seen Ye aes Sore gums \n\n\nlost filling... ......004. page 86 gum disease starting ..... page 95 \nbroken filling... 2.0.2.0. page 86 something caught under \n\nAbscess... . ee ee page 87 _ the gums fepulis) -- page 95, 127 \n\n; Vincent's Infection... ... page 96 \n\nInfected sinus ........... page 89 fever blusters (from \n\nTooth injury Herpes virus)........ page 98 \n1. broken tooth ,........ page 90 GT HIPIGSFit dscns face tey Ne needa page 99 \n2. tooth Knocked out. .... page 91 \n\n\nOther sores in the mouth \n\n\nLoose tooth .........--. page 93 Canker SOreS ik 6 ee ek a page 100 \nNew tooth growingin....... page 94 fromadenture......... page 100 \nbabies’ teething ........ page 95 at the corners of the mouth . page 101 \n\n\nBroken bone...........-. page 102 PMROTAAUUS: oie: cece ibe aaa See aaa page 112 \nDistocated jaw. .......... page 107 Infection in the spit gland . . . . page 113 \nPaininthejoint.......... page 108 Sores on the face \n\nSwollen gums and epilepsy . . . . page 109 from atooth abscess ..... page 114 \n\n\nNoma \\cancrum oris), a \n\n\nBleeding from the mouth. .... page 110 complication of Vincent's \n\nAfter you take out a tooth (NIBSTLON: SS. aa Be page 115 \nswelling of the face ...... page 170 STOR dt CASh nor ete page 119 \npain from the socket ..... page 111 \n\n\nbleeding from the socket . . . page 112 Cancer»... see eee eee page 119 \n\n\n82 \n\n\nTHE FIRST RULE FOR TREATMENT: STAY CLEAN! \n\n\nNo matter what problem you are treating, be sure that your workplace, \nyour instruments, and you are always clean. For example, prevent \ninfection by always washing your hands before you examine or treat \nsomeone. ; \n\n\nWash your hands in front of the \nperson, in the same room. You \nwill show that you are a careful \nand caring health worker. Also, \nyou will demonstrate just how \nimportant cleanliness really is. \n\n\nThe mouth is a natural home for germs, They usually do not cause \nproblems because the body is used to them. In fact, many germs are \nhelpful. For example, when we eat, some germs break down chewed food \ninto parts small enough for the body to use. \n\n\nThere are problems when the number of these ordinary germs increases \ngreatly, or when strange, harmful germs come into a healthy body from \noutside. Fever and swelling follow. {t is an infection. \n\n\nWhen we regularly clean the mouth, the number of germs stays normal. \nYou can teach others to clean teeth and gums, but cleaning is each \nperson's responsibility. \n\n\nHowever, dental workers have one serious responsibility. You must \nnot spread germs from a sick person to a healthy person. You must do \neverything you can to make sure your instruments are clean. \n\n\n83 \n\n\nGerms hide inside bits of old food, cement, or \nblood on an instrument. There they can continue \nto live, even in boiling water. \n\n\nThis is why you must be sure to scrub the working \nend of each instrument carefully with soap and \nwater. Rinse, and then look carefully to see that \n\nit is clean and shiny. \n\n\nRemember that ‘clean looking’ is not necessarily ‘clean’. Truly ‘clean’ \nmeans free of germs. Unless you sterilize, that instrument may still have \ngerms, the kind that cause infection in the next person that it touches. \n\n\nSterilizing means killing germs. The best way to sterilize is with heat. \nHigh heat kills almost all harmful germs—especially those that cause \nhepatitis, tetanus, and mouth infections. Wet heat (steam) is always more \neffective than dry heat from an oven. \n\n\nHere is a simple rule to use in deciding \nwhen to sterilize: \n\n\nBoil any instrument that \nhas touched blood. \n\n\nThat means always sterilize with \nsteam all syringes, needles, and \ninstruments you use when scaling \n\n\nteeth (Chapter 8) or when taking \nout a tooth (Chapter 11). Be safe: When in doubt, sterilize! \n\n\nInstruments left in boiling water need 30 minutes to become sterile. A \npot with a cover to trap the steam can act faster. The inside becomes \nhotter and 20 minutes is enough. But remember that water can rust metal \ninstruments. To prevent rust: \n\n\ne Add 5 spoonfuls (20 ml.) of oil to every liter of water you boil. \n« Then lay the hot instruments on a dry, clean (sterile, if possible) \ncloth, so the water can evaporate. \n\n\nNever put an instrument away while it is wet. \n\n\nSterilizing with steam under pressure is the fastest and surest method. \nIt kills harmful germs in 15 minutes. You need a strong pot with a tight \nfitting lid. But be sure to make a small hole in the lid so steam can escape \nwhen the pressure becomes too great. \n\n\nA special pot called a pressure cooker is perfect for this. It even has a \nsafety hole on it to release extra steam. \n\n\n1. Put 2 cups of water and \n\n\n2 spoonfuls of oil . \ninto the pot. cree ie \n\n\nese ee _ - = \n22 ee \n° @ \n\n\n2. Place the handles together. \nPut on high heat until a \nloud hissing noise begins. % \n\n\n3. Put on lower heat. Begin \ntiming now. Leave the hissing \npot on the low flame for 15 \nminutes. \n\n\nDO NOT LET \n\n\nTHE COOKER oy) \nBOIL DRY! \n\n\n4, Cool the pot under water, \nopen, and lay the instruments \non a clean towel to dry. \n\n\nThe next time you use the pot, \nyou can use the same water that \nwas left inside it. \n\n\n85 \n\n\nSterilizing with heat is not necessary for instruments that do not touch \nblood. For example, after you examine a person or place a temporary \nfilling, you can clean your instruments and then soak them in a solution \nof alcohol or bleach, \n\n\nAlcohol solution tight fitting \nED lid \n\n\n1. Mix in a large container each week: #1 ——S \n\n\n7 parts alcohol (95%) js \nand 3 parts clean water. water \nKeep the container tightly covered CATT \nto prevent evaporation. \n\n\n2. Keep a covered pan half filled with alcohol \n\n\nthis mixture. You will have to add \nsome more of the mixture from the \nlarge container (#1) to the pan each \nday. \n\n\n#2 \n3. Leave your clean instruments in the QV \n\n\npan, completely covered with the \nliquid, for 30 minutes. \n\n\nBleach (sodium hypochlorite) solution \n\n\nFind the cheapest brand name in your area for \nbleach. Examples are Javex, Clorox, Purex, and \nCidex. Make 1 liter of solution with a mixture of \n1/2 cup (100 ml) of bleach and 3 1/2 cups (900 ml) \nof clean water. \n\n\nP esvorsnoe» DBDDD \n\n\naud 3 + % Cups \nUnfortunately, bleach rusts \nmetal instruments. To reduce \nrust, add 1 large spoonful of \nbaking soda (sodium \nbicarbonate) to the solution, \nand leave your instruments in \nthe solution for only 30 minutes. \n\n\nWipe each instrument with \nalcohol to remove the film of \nbleach, Then store it dry \ninside a clean cloth or in \nanother covered pan. \n\n\nChange the solution each week. \n\n\n86 \n\n\nPART 1: PROBLEMS YOU WILL SEE MOST OFTEN \nCAVITIES AND LOST.OR BROKEN FILLINGS \n\n\nA cavity can occur in any tooth. A cavity can also start around an old \nfilling, especially if it is dirty. The deeper a cavity gets inside the tooth \nwhere the nerve lives, the more the tooth hurts. \n\n\nSIGNS: \n\n\n@ pain when drinking water or eating \nsomething sweet \n\ne ahole (or black spot) on the tooth, or \nbetween two teeth \n\ne pain if food gets caught inside the hole \n\n® no pain when you tap the tooth \n\n\nTREATMENT (when there is no abscess): \n\n\nTry to remove any loose piece of filling with a probe. Then, following \nthe steps in Chapter 10, put in a temporary filling. \n\n\nNow: \n\n\n1. Fill the hole with cement. If you have no cement, put some cotton \ninto the hole to keep food out. \n\n2. Look for cavities or broken fillings in the other teeth. Fill each one \nwith cement before it gets worse and starts to hurt. \n\n\nSoon (within a few months): \n\n\n3. Arrange for someone to replace the temporary filling with a \npermanent one. You will need a person who has experience using \na dental drill (see p. 145). \n\n\nA groove on the neck of a tooth is a more \ndifficult cavity to fill. For the temporary \ncement to hold properly, you need to shape \nthe groove with a drill. To help temporarily, \nyou can paint the groove with fluoride water (page 167). Do this once \neach week until the inside part of the groove is stronger and the tooth \nhurts less. Or, you can paint the inside of the groove with oil of cloves \n(eugenol) to reduce the pain. \n\n\nTo avoid making the problem worse, {1) do not use a hard toothbrush; \n(2) do not brush back and forth along the gums; and (3) do not chew \nbetel nut and do not hold it against the teeth. \n\n\nTOOTH ABSCESS \n\n\nA cavity that is not filled grows bigger and deeper until it touches the \nnerve. Germs travel inside the tooth’s root and start an infection called \nan abscess. \n\n\nPus forms at the end of the root, inside the bone. As the pus increases, \nit causes great pressure. This is why an abscess causes severe pain. \n\n\nSIGNS: \n\n\n@ pain all the time, even when trying \nto sleep \n\ne tooth often feels longer, and even a \nbit loose \n\ne tooth hurts when it is tapped \n\n¢ asore on the gums near where the \nroot ends (gum bubble) \n\ne swelling of the gums around the \ntooth, or swelling of the face on the \nsame side as the bad tooth \n\n\nTREATMENT: \n\n\nIf there is no swelling, take out the tooth immediately (unless you are \nable to give root canal treatment). This allows the pus to escape and \nrelieves the pain. See Chapter 11. \n\n\nIf there is swelling, treat the swelling first. Take out the tooth only — \nafter the swelling goes down. This is necessary because an anesthetic (see \nChapter 9) will not work if there is swelling. If the anesthetic works, then \nit is safe to take out the tooth. \n\n\nTo treat the swelling, give an antibiotic. Penicillin by mouth is best. \nUse an injection only when the person is in immediate danger. For \nexample, inject penicillin when the person has a fever or if the swelling \nis pressing against the throat. But remember you can treat most serious \ninfections with simple penicillin by mouth. For the doses for serious \ninfections, look below the box on the next page. If you still think an \ninjection is necessary, look at the section on ‘aqueous procaine penicillin’ \non page 166. \n\n\nAdults and children over 25 kg. (60 pounds) of weight should take the \nsame amount of oral penicillin. Children under 25 kg. should take 1/2 as \nmuch. For most infections, penicillin by mouth is taken 13 times: a very \nlarge first dose and 12 smaller doses every 6 hours for 3 days. The person \nshould take all of the penicillin, even if the pain or swelling goes down. \nFor the correct doses, see the next page. \n\n\n87 \n\n\n88 \n\n\n-— \n\n\nTHE BEST CHOICE \n\n\nPenicillin G or V: \n1 tablet = 250 mg. \nGive enough tablets for 3 days \n\n\nFirst Dose (take all at once) \n\n\nAdults 8 tablets \nand children over 25 kg. (2000 ma.) \nChildren under 25 kg. 4 tablets \n{1000 mg.) \n\nThen every 6 hours for 3 days (12 doses) \nAdults 2 tablets \nand children over 25 kg. (500 ma.) \nChildren under 25 kg, 1 tablet \n(250 mg.) \n\n\nIMPORTANT: to allow it to best fight \n\n\nSECOND CHOICE \n(for those allergic to penicillin) \n\n\nErythromycin: \n1 tablet (or capsule) = 250 mg. \nGive enough tablets for 3 days \n\n\nFirst Dose (take all at once) \n\n\nAdults 4 tablets \nand children over 25 kg. (1000 mg.} \nChildren under 25 kg. 2 tablets \n(500 mg.) \n\nThen every 6 hours for 3 days (12 doses) \nAdults 2 tablets \nand children over 25 kg. (500 mg.) \nChijdren under 25 kg. 1 tablet \n(250 ma.) \n\n\nIMPORTANT: to avoid upset stomach, \ntake erythromycin with meals. \n\n\ninfection, take penicillin before eating. \n\n\nFor serious infections, it may be necessary to take the antibiotics for a \nlonger time. Take the same first dose as above, then take 1/2 the first \ndose every 6 hours until the condition begins to improve. Then take the \nsecond, smaller dose every 6 hours until the end of five days, or seven \ndays if it is very serious.* Usually you can take out the tooth 1 or 2 days \nbefore the end of the antibiotic treatment, but the person must continue \nto take all of the tablets, even after you have taken out the tooth. \n\n\nIf the swelling is ‘pointing’, open it with a sharp sterile knife to release \nthe pus. Cover the wound with a sterile dressing to keep it clean. If you \nare not able to do that, explain how to reduce the swelling-with heat. \n\nAs often as possible until the swelling goes away: \n\n\ne soak a cloth in warm water and hold it against the face. \ne hold warm water inside the mouth near the swelling. It is not \nnecessary to add salt to the water. \n\n\nFinally, give the person medicine for pain. A two-day supply will be \nenough, because the penicillin and the heat will reduce the pressure and \nthat will reduce the pain. The best medicines for pain are aspirin, which \ncomes in 300 mg. tablets, and acetaminophen (paracetamol), which \ncomes in 500 mg. tablets. Aspirin is usually cheaper, but acetaminophen \ndoes not cause stomach pain and it is safer than aspirin for children. (To \navoid stomach pain, take aspirin with food, milk, or water.) \n\n\nTake aspirin or acetaminophen 4 times a day. Every 6 hours, adults \ncan take 2 tablets, children 8 to 12 years take 1 tablet, and children 3 to \n7 take 1/2 tablet. Children 1 to 2 years should only take acetaminophen, \n1/4 tablet 4 times a day. See page 165. \n\n\n*|f the infection does not heal, penicillin may not be the best antibiotic. Take some pus from the \ninfection and have it tested, to see which antibiotic is best. \n\n\n89 \n\n\nINFECTED SINUS \n\n\nA sinus is a hollow place inside the bone. There is a sinus under the \neyes, on each side of the nose. Because the sinus is very close to the roots \nof the top teeth, these teeth may hurt if the sinus becomes infected. \n\n\nSIGNS: \n\n\n® toothache in several top teeth. The \nteeth look healthy, but hurt when \nyou tap them. \n\n\n®@ ahead cold, and plugged nose. She \ncan only breathe through her mouth. \n\n\n® hurts when you press against the bone \nunder her eyes. \n\n\nTREATMENT: \n\n\nDo not take out any teeth. They will feel better after you treat the sinus \ninfection. \n\n\n1, Give penicillin for 3 days (page 88). \n\n\n2, Explain to the person that she should: \n\n\n® drink lots of water. \n\n\n* breathe steam from boiling water— \nto clear her nose. \n\n\n@ hold awarm wet cloth against her \nface, as often as possible. \n\n\n® not try to blow her nose, or else her \nears will hurt. Wiping the nose is \nbetter. \n3. See the person again after 3 days, and \n\n\n* examine her teeth closely, tapping them to be sure they are strong \nand healthy. \n\n\n« if she is not better, get help from a more experienced health worker. \n\n\n90 \n\n\nTOOTH INJURIES \n1. Broken tooth \n\n\nIt is possible to save a broken tooth. It depends on where the tooth \nis broken and whether its nerve is still covered. \nSIGNS: \n\n\ne pain when breathing air or drinking \nwater \n\n\ne blood from the gums around the tooth \n\n\ne tooth moves when you touch it \n\n\nTREATMENT: \n\n\nTake out the broken tooth if: \n\n\ne its nerve is not covered. If no one can give special root canal \ntreatment, the tooth must come out. Germs from the spit have \nalready gone inside the tooth and started a small infection. \n\n\ne its root is broken. To see if it is broken, push gently against the \ntooth as you feel the bone around its roots. The tooth’s root \nprobably is broken if the tooth moves but the bone does not. The \nroot probably is not broken if both the tooth and bone move. \nHowever, the bone around the roots may be broken (page 103). \n\n\nYou can save a broken tooth if the nerve is still covered and the root \nis not broken. To do this, use a file on the sharp edges around the break. \nThis makes them smooth so they do not cut the tongue. Later, an \nexperienced dental worker who has the equipment can cover the broken \npart with a cap or a filling. Until this is possible, tell the person how to’ \nprotect the tooth: \n\n\ne Give the tooth a rest. Use other teeth to eat. \n\n\ne Do not drink things that are very hot or cold, and do not eat spicy \nfood. \n\n\ne Watch the tooth. See if it changes color (gets darker). Also watch \nthe gums near the root. See if a sore (gum bubble) develops. \n\n\nA dark tooth and gum bubble are signs that the tooth is dying. Take it \nout, unless you can give special nerve treatment. \n\n\n91 \n\n\n2. Tooth knocked out \n\n\nWhen a tooth is knocked out of the mouth, you should ask two \nquestions: (1.) Was it a baby tooth? and (2.) How long ago did it happen? \n\n\nBaby tooth. There is no reason to try to put a baby tooth back into \nthe socket. Tell the child to bite on some cotton to stop the bleeding. \nThen wait for the permanent tooth to replace it. Warn the mother that \nthe permanent tooth may take more time than usual to grow into the \nmouth, \n\n\nSimilarly, there is no need for \ntreatment if the baby tooth is pushed \nup under the gum. \n\n\nThe tooth may grow back into the \nright place later, or it may turn dark \nand die. If you see a darkened tooth or \na gum bubble (p. (72), take out the \nbaby tooth before it hurts the permanent \ntooth that is growing under it. \n\n\nPermanent tooth. A permanent tooth is worth saving. How long ago \nwas It knocked out? If it was less than 12 hours ago, you can put a \npermanent tooth back into the socket. The sooner you do this the better, \nso do not wait. If you replace the tooth in the first hour, it has a much \nbetter chance of joining with the gum and bone. |n order to heal and to \njoin the bone, the tooth must be held firmly. \n\n\n1, Wash the tooth gently \nwith clean water. There \nshould not be any bits of \ndirt on the root of the \ntooth. \n\n\nKeep the tooth damp \nwith wet cotton gauze. \n\n\nDo not scrape away any \nskin from the root or from \nthe inside of the socket. \n\n\n92 \n\n\n3, Soften some beeswax and form it \n\n\n2. Gently push the tooth up into the \nsocket. As you push it up, use a slight \nturning movement back and forth. \n\n\nThe biting edge of the loose tooth \nshould be at the same level as the \nteeth beside it. \n\n\nHold it in place with your fingers for \nabout 5 minutes. \n\n\ninto 2 thin rolls. Place-1 roll near the \ngums on the front side of five teeth: \nthe loose tooth and the two teeth on \neach side of it. Press the wax firmly, \nbut carefully, against these teeth. \n\n\nDo the same with the second roll of \nwax on the back side of the same \nteeth, again near the gums. \n\n\nIt is good if the wax on the back side \nis touching the wax on the front \n\nside. This helps the wax hold the \nteeth more firmly. To do this, you \ncan push the wax between the teeth \nwith the end of your cotton tweezers. \n\n\nKeep the wax in its position for at \nleast 3 weeks. \n\n\nTell the person with the injured tooth to return to see you several \ntimes. The tooth may die several months or even several years later (see \npage 45). If that happens, you must take out the tooth, unless you can \n\n\n. do root canal treatment. \n\n\nIf it is possible, take an X-ray of the tooth 6 months later and then \nagain each year. Look at the X-ray picture of the root to be sure an \ninfection is not eating it away. To do this, compare the root with the \nroots of the teeth beside it. \n\n\nLOOSE TOOTH \n\n\nA tooth may be loose for one of several reasons. Decide the reason \nbefore giving the treatment. \n\n\n-——— \n\n\nIF THE TOOTH IS LOOSE BECAUSE THE BEST TREATMENT: \nanew permanent tooth is 1. tell the mother and child what is \ngrowing under it. happening. \n\n\n2. pull out the loose baby tooth, if it is \nhurting the child. \n\n\ngum disease or an old abscess . take out the tooth, especially if it \n\nhas eaten the bone around its also hurts. \n\nroots. . explain to the person what to do to \nprevent this problem in other teeth, \n(See Chapter 5). \n\n\nits root has been broken. take out both parts of the tooth. If you \n\n\nhave trouble taking out the broken root, \nleave it and try again a week later. \n\n\nthe bone around its root is Do not take out the tooth. If you do, \ncracked, (The bone moves when the bone will come out with it. Instead, \nyou push against the tooth.) hojd the tooth with wires (page 104), \n\n\nA tooth may also be loose because \nanother tooth is biting too \nhard against it. \n\n\nSIGNS: \n\n\n@ you can feel the tooth move \nwhen the upper and lower teeth \nmeet. \n\ne that tooth hurts. \n\n\nTREATMENT: \n\n\nYou need to remove a bit of each of the teeth that are biting too hard. \nUse either a dental worker’s drill, a small file, or a hard stone. \n\n\n1. Smooth the inside edge of the upper tooth. \n2. Smooth the outside edge of the lower tooth. \n\n\n94 \n\n\nNEW TOOTH GROWING IN \n\n\nA new tooth cuts through the gums when it grows into the mouth. \nGerms can easily go under the gums in that place and cause an infection. \nWhen the opposite tooth bites against the sore gum it can make an \ninfection worse. \n\n\nSIGNS: \n\n\ne toothache at the back of the jaw \n© mouth cannot open properly \n\n\ne abad taste coming from the back of \nthe mouth \n\n\ne sore throat \n\n\ne skin over the new tooth is sore and \nhurts when you touch it Infection in the gums and \n\n\ne the age of the person is the right age pressure from the new tooth are \n\n\nfor growing a new molar tooth painful. Notice the ‘flap’ \n(page 64). of skin over the new tooth. \nTREATMENT: \n\n\nDo not take out a new tooth while there is still infection and pain. Wait \nfor the infection to finish. Then decide if there is room for the tooth to \ngrow in. A dental X-ray can help you make that decision. New molar \nteeth are often difficult to take out. Ask an experienced dental worker to \ntake out the tooth, if it must be done. \n\n\nWhat you can do \n\n\nFirst, treat the infection. Then wait for the new tooth to grow more \ninto the mouth, Tell the person what is happening. Tell him what he can \ndo to keep the gums healthy while the tooth grows in: \n\n\ne Rinse the area with warm salt water (page 7). Make 4 cups each day \nuntil the mouth opens normally again. Then make 1 cup each day \nto prevent the problem from returning. Keep rinsing this way until \nthe tooth grows all the way in. \n\n\ne Hold a warm wet cloth against the jaw as often as possible each day. \ne Take aspirin for pain (page 88). \n\n\nGive penicillin (page 87) if there is fever, a swelling, or if he is only able \nto open his mouth a little. \n\n\n95 \n\n\nTEETHING \n\n\nWhen babies and small children first get their teeth, it is called teething. \nThis can make the child unhappy, because his gums are sore. \n\n\nTeething does not cause fever, head \ncolds, or cough. \n\n\nBut a child can have any of these \nproblems at the same time as he gets a \nnew tooth. \n\n\nTREATMENT: \n\n\nIf the child has another sickness, do not blame it on teething. Look for \nanother cause and treat it separately. Also, do not cut the gum over the \nnew tooth. Let the tooth grow through the gum by itself. \n\n\n1, Give acetaminophen or aspirin for pain and fever (page 88). \n\n\n2. Give the child something hard to bite against. This will help the tooth \nto grow through the gums faster. For example, let him chew on a dry \nhard biscuit. \n\n\nGUM DISEASE STARTING \n\n\nInfection can start in the gums whenever the teeth near them are not \nclean. For example, there may be swelling (called an epulis) between \nonly 2 teeth or between many teeth. tn addition, gums that are weak \nfrom poor nutrition are not able to resist the infection. This is why a \npregnant woman must take special care to eat well and clean her teeth \ncarefully. \n\n\nSIGNS: \n\n\ne Gums are red instead of pink. \n\ne Gums are loose instead of \ntight against the tooth. \n\ne Between the teeth, gums are \nround instead of pointed. \n\ne Gums bleed when you press \nagainst them, or when you \nscrape away food from under \n\n\nFeel for tartar under the gum— \n\n\nthem. or even a piece of fishbone. \ne The person has bad breath \n\n\nand a bad taste inside the mouth. \n\n\n96 \n\n\nTREATMENT: \n\n\nExplain to the person the cause of her gum problem and what she can do \nto help herself. \n\n\n1, Show her how to clean her teeth better near the gums (page 67). \n\n\n2. Tell her to rinse her mouth with warm salt water (page 7). Make 4 \ncups each day until the bleeding stops. Then make 1 cup each day to \nkeep the gums strong and tough. \n\n\n3. Tell her to eat fresh fruits and vegetables. Guavas, oranges, pineapples, \npapayas, tomatoes, peas, and green leaves give strength to gums. \n\n\n4. Gently reach under the gums and remove tartar (or loose piece of \nfishbone) that is caught there (see Chapter 8). \n\n\nMORE SERIOUS GUM DISEASE \n\n\nVincent’s Infection of the gums, also called trench mouth, affects both \nadults and children. In its worst form, it can eat a hole through the cheek \nof a weak child (page 115). \n\n\nA person with Vincent's Infection may not want to eat because his \nteeth hurt when he chews food. That can make a child’s malnutrition \nworse, \n\n\nYou must prevent this problem from starting, especially in a child who \nis weak from sickness. Teach mothers toclean their children’s teeth and \nto get their children to rinse their mouths with warm salt water. \n\n\nSIGNS: \n\n\n*® gums between the teeth are dying \nand turning gray. \n® pus and old blood collect \naround the teeth. \n® burning pain from the gums. \nbleeding from the gums. \n# the mouth smells bad. \n\n\nTREATMENT: \n\n\nYou will need to see the person over a two-week period. Start some \ntreatment NOW: \n\n\n1. If the person is already sick, give penicillin for 3 days (page 88). \n\n\n97 \n\n\n2. Clean away the pus, old food, and big pieces of tartar. Then: \n® Tell the person to rinse his mouth with warm water. \n\n\ne Wipe his gums with cotton soaked in a 5% solution of hydrogen \nperoxide. Rinse with warm water. For a child, use a weaker solution. \nMix 1 part hydrogen peroxide with 5 parts water and wipe the \nchild’s gums with it. \n\n\ne Scrape away the bigger pieces of tartar. Do not try to remove ail of \nit. You can do that later. Put topical anesthetic on the gums if you \nhave some (first dry the area with cotton so the topical anesthetic \nwill stay longer). Rinse away any loose bits of tartar with warm water. \n\n\n3. Give Vitamin C (ascorbic acid), 2 tablets a day for 7 days. \n(1 tablet = 500 mg.) \n\n\n4, Teach the person how to care for the gums at home: \n\n\ne Rinse at home for 3 days with a weak solution of hydrogen peroxide \n(page 8). Try to hold the solution in the mouth for several minutes. \nThe longer the solution touches the gums, the better it is for the \ngums. Rinse once every hour. After 3 days, change to salt water, \n\n4 cups a day. If you have no hydrogen peroxide, rinse with salt \nwater from the beginning. \n\n\nFor a young child who is not able to rinse, Mother or \nFather can wipe his gums with the weak solution of \nhydrogen peroxide 4 times a day. \n\n\nShow parents how to do this. Give them some cotton \ngauze and hydrogen peroxide to take home. \n\n\ne Clean the teeth with a soft brush. Parents can clean children’s teeth. \nShow them how (page 16), and ask them to do it even if the gums \nbleed, \n\n\ne Cook food that is soft (like pounded yam) and not spicy (no pepper). \nEat fresh fruits and vegetables that give strength to the gums (page \n96). \n\n\ne Stop smoking and stop chewing betel nut. \nOne week later, scrape away the rest of the tartar from the teeth. Then \n\n\nuse the person’s own brush and show him how to do a better job of \ncleaning his teeth. \n\n\n98 \n\n\nFEVER BLISTERS \n\n\nHerpes virus causes fever blisters. Herpes virus is a kind of germ. Fever \nblisters are sores that can form either inside the mouth on the gums, or \noutside on the lips. \n\n\nWhen the sores are inside the mouth, it is a serious problem. It usually \naffects children between 1 and 5 years old. A child with fever blisters in \nhis mouth can become very sick. He will not be able to eat properly. If \nhe does not drink enough fluids, he can become dehydrated (lose his body \nwater). This is dangerous! \n\n\nSIGNS: \n\n\n© sore throat \n\ne fever \n\ne crying, stops sucking 2-3 \ndays before sores appear \n\ne spit spills from the mouth \nbecause it hurts to swallow \n\ne painful swelling under the jaw. \n\ne bright red blisters on the gums, \nbut not between the teeth. \nBlisters also may be on the roof \nof the mouth. \n\n\nTREATMENT: \n\n\nMedicine cannot kill the Herpes virus. The sores will go away by them- \nselves in about 10 days. The treatment is to help the person feel more \ncomfortable and to be sure he gets enough to eat and drink. \n\n\nInside the mouth \n\n\n1. Give aspirin or acetaminophen for fever (page 88). \n\n2, Wipe milk or yogurt over the sores to protect them before eating. Wash \nyour hands before touching the inside of someone’s mouth! (See page \n82.) Then give food that is soft and not spicy. If he cannot eat, prepare \na special milk-oil drink for him, as on page 105. \n\n3. Give lots of fluids to drink. \n\n\nSores on the lips usually occur after the age Co a) \nof 5. They often appear when the person is { \nweak and sick (for example, with diarrhea or s— \npneumonia.) Usually there is no fever. The \nblisters soon break open and release water. \nWhen they dry, a crust forms. The blisters often \n\n\nPanui. On the lips \n\n\nThese sores go away in about 1 week. To prevent them from becoming \ninfected, paint the sores with gentian violet, tincture of benzoin, or \npetroleum jelly. !f you hold ice against the sores for several minutes each \nday, it may help them heal faster. \n\n\n99 \n\n\nTHRUSH \n\n\nThrush is a kind of infection. It often appears when a person is weak \nand poorly nourished, or sick and taking medicine like tetracycline or \nampicillin. In a baby, thrush usually appears on the tongue or top of the \nmouth. It can stop the baby from sucking. In an adult, thrush often occurs \nunder a denture. \n\n\nSIGNS: \n\n\ne White patches on the tongue, \ncheek, or top of the mouth. \n\n\nWipe the white area: \n\nIf there is no bleeding it \nis old milk. \n\nIf there is bleeding, it \n\nis thrush. \n\n\ne the child may not want to suck or eat. \n\n\nTREATMENT: \n\n\nThere is usually something else present which is helping thrush to grow. \nTry to find what it is and deal with it. For example, treat the malnutrition, \nchange or stop the antibiotic medicine, or leave the denture out of the \nmouth for a while. Then: \n\n\n1. Put some nystatin creme on top of the white patch with a bit of cotton. \n\n\nadults: put some on 4 times a day \nchildren 5-12 years: put some on 3 times a day \nchildren up to 5 years old: put some on 2 times a day \n\n\nShow the mother how she can do this in her child’s mouth at home. If \nyou have no nystatin creme, paint gentian violet on the white area. The \nmother should paint the child’s mouth 2 times a day. \n\n\nDo not use penicillin or any other antibiotic unless you need to treat \nsomething different. Thrush can get worse when a person uses an \nantibiotic for a long time. \n\n\n2. Continue breast feeding. For older persons, make their food soft and \neasy to chew. \n\n\nIMPORTANT: Sometimes white lines appear on the inside of an adult’s \ncheek or on the roof of the mouth. If these lines become sore, they can \nchange into a cancer (page 119). To prevent this cancer, ask the person to \nstop smoking (especially pipes), stop chewing betel nut, and get dentures \nadjusted if they do not fit properly. \n\n\n100 \nCANKER SORES \n\n\nA virus can cause canker sores, as with fever blisters. Unlike fever \nblisters, canker sores usually affect adults rather than children. \n\n\nOne or more sores can appear at any time. These sores hurt, especially \nwhen pieces of food touch them. \n\n\nSIGNS: \n\n\ne Asore can appear on the tongue, \nroof of the mouth, or below the \ngums on the smooth skin. \n\n\ne The sore is white or yellow with the \nskin around it bright red. \n\ne The person may have had a similar \nkind of sore before. It tends to \ncome back. \n\n\nNote: a sharp edge of a denture rubbing against the gums can make \na similar kind of sore. \n\n\nTREATMENT: \n\n\nA canker sore goes away by itself in about 10 days. Medicine does not \nmake that happen any faster. (However, smoothing a denture does help.) \nThe treatment is simple. Tell the person how to feel more comfortable \nwhile waiting for the 10 days to pass: \n\n\nEat foods that are soft and not likely to hurt the sore. Do not eat food \nwith a lot of pepper. Drink lots of water. Chew food on the other side of \nthe mouth, away from the sore. \n\n\nA denture which does not \nfit should be remade. \n\n\nIn the meantime, leave \nthe denture out of the \nmouth for 2-3 days. \n\n\nAsk the person to rinse \nwith warm salt water, \n4 cups each day until \nthe sore is better. \n\n\nIf the sore continues after 10 days, it may be infected. Give penicillin \n(page 87). \n\n\nA sore that does not heal after antibiotic treatment may be cancer. \nSee a doctor immediately. \n\n\n101 \nSORES AT THE CORNERS OF THE MOUTH \n\n\nTeeth support the lips. When they come together for chewing, the teeth \nstop the person’s chin from moving any closer to the nose. \n\n\nA person without many teeth looks old. A person with a poor fitting \ndenture also looks old. \n\n\nThe distance from his chin to \nhis nose is shorter than \n\n\nnormal. eo a } |4/ \nHe must close his jaw further \n\n\nto eat. That causes lines to \\ y, \n\n\nform at the corners of his “a \nmouth, \n\n\nPoor health can make lines at \nthe corners of the mouth crack \nand become sore. \n\n\nA person with missing teeth needs dentures. Dentures will help him \nchew more food and make him look younger. They support his lips and \nopen his mouth more. \n\n\nNote: Making dentures is not easy. We hope to write a book \nin the future that will tell more about dentures. \n\n\nA child who has had a fever or measles often has pl lips. The corners \nof her mouth can crack and become sore. = \n\n\nCracks and sores appearing \n\nat the corners of a child’s \nmouth are signs of dehydration \nand malnutrition. \n\n\nThe child needs to eat the kind of foods that give strength, energy, and \nprotection. Feed her beans, milk, eggs, fish, oils, fruits, and green leafy \nvegetables (see page 65). \n\n\nTREATMENT (when sores occur}: \n\n\n1. Wash the sores with soap and hot water. \n2. Mix 1 part sulfur with 10 parts of petroleum jelly (Vaseline). \n3. Smear some on the sores 3-4 times a day. \n\n\n102 \n\n\nPART 2: SOME SPECIAL PROBLEMS \n\n\nYou will find some problems that are too serious for you to treat. If \n\n\nyou can, send the sick person to a more experienced dental worker as soon \nas possible. \n\n\nSometimes, however, it is better to start some of the treatment yourself. \n\n\nEarly treatment can prevent some problems from becoming more serious. \nAlso, if you know what to do when someone returns from the hospital, \nyou can help that person to get well faster, \n\n\nSometimes, you will find it impossible to get help. Therefore, we will \n\n\ndiscuss each of these more serious problems in detail, so you can give as \nmuch help as necessary. \n\n\nBROKEN BONE \n\n\nThree main bones form the face and lower jaw. \n\n\n1. cheek bone \n\n\n2. upper jaw bone \n\n\n(lower jaw joins \nthe head here) \n\n\n3. lower jaw bone \n\n\nA bone can break completely, or part of it can crack. In either case, the \n\n\nteeth are usually pushed out of position. Look for this as a sign of a \nbroken bone. \n\n\nSIGNS of a broken bone: \n\n\ne The person has had an injury. \ne When teeth are closed, some upper \nteeth do not meet lower teeth. \ne The person cannot open or close \nthe mouth properly, . \ne There is bleeding from between 4} ) \n2 teeth. \ne There is swelling or a bruise on \nthe face or jaw. \ne There is bleeding into the eye. \n\n\n103 \n\n\nSIGNS of a cracked bone around \nthe tooth’s roots: @ AND THE OTHER \n\n\ne When you move one tooth, the f TOOTH ALSO MOVES \n\n\ntooth beside it also moves. \ne When you move the loose tooth, \n\n\nthe bone moves with them. ge @) BECAUSE THE \ne Blood is coming from under BONE AROUND \nthe gums. @ PUSH GENTLY THEIR, ROOTS \nAGAINST ONE IS CRACKED. \nTREATMENT: TOOTH \n\n\nWhen a bone is broken or cracked, the treatment is to hold the broken \nparts together so that the parts can rejoin. The usual way to do this is to \nout wires around the teeth. An experienced dental worker should do this. \nThere are two things you can do. First, provide emergency care. Later, \nshow the person how to eat and how to keep his mouth clean. \n\n\nEmergency care (pages 103-104): \n\n\n1. Be sure the person can breathe. \n2. Stop the bleeding. \n\n\n3. Put a bandage on the person‘s head. \n4. Give penicillin to stop infection. \n5. Give aspirin for pain. \n\n\n1. Be sure the person can breathe. \n\n\nLie him on his side \nso that his tongue and \njaw fall forward. \n\n\n> \n\n\nLater, carry him to the hospital in that position. If he goes in a car, be \nsure he sits with his head forward. His jaw and tongue will be forward and \nhe will breathe more easily. \n\n\nLook inside the mouth to see if any tooth is broken and very loose. A \nbroken piece of tooth can fall out and block the person’s airway, so take \nout the broken part now. You can leave in the root, but if you do, tell \nthe dental workers at the hospital (p. 175). They will remove the root \nwhen they put on the final wires. \n\n\n2. Stop the bleeding. \n\n\nWipe away the dried blood from his face and from inside his mouth, \nLook for the place that is bleeding. Sew any deep cuts on his face (see \nWhere There Is No Doctor, p. 86). If you gently press cotton gauze against \nthe bleeding gums, it will usually control the bleeding. \n\n\n104 \n\n\nBleeding inside the mouth, from between the broken parts of the bone, \nis more difficult to stop. You must pull the two sides together and hold \nthem in that position. To do this, you need wire that is thin, strong, and \nbends easily. ‘Ligature wire’ (0.20 gauge) is best. \n\n\nPlace a piece of wire around two teeth, one on \neach side of the break. Choose the strongest \ntooth on each side—the ones with the longest \nor the most roots. \n\n\nTighten the wire around the two strong teeth \n\n\nwith pliers or a hem : \nP he ostat BLEEDING FROM THE BONE \n\n\nAsk the person to close his teeth. Lift up the broken part of the jaw \nand hold it so the lower teeth meet the upper teeth properly. This is the \nnormal way the jawbone holds the teeth. \n\n\nNow join the wires. Twist and tighten them \ntogether. This may be painful. You can inject \nlocal anesthetic—see Chapter 8. You must twist \nthe wire tight enough to hold the broken parts \ntogether. \n\n\nBend the end of the twisted wire toward the teeth. Now it cannot poke \nthe person's lips or cheek. \n\n\n3. Put on a head bandage. \n\n\nGently close the person's jaw so that his teeth come together. Support \nit in this position with a head-and-chin bandage. \n\n\nTie the bandage to support the jaw, not to pull it. Do not make it \ntoo tight. It is all right if his mouth stays partly open with the \nteeth slightly apart. \n\n\nBe sure not to let the bandage choke the person. \n\n\n4. Give penicillin by injection (page 166) for 5 days to stop infection \ninside the bone. \n\n\n5. Give something for pain. Aspirin (o. 88) may be enough. If there is a \nlot of pain and the person cannot sleep, give codeine. The dose for an \nadult is 30 mg. \n\n\n105 \n\n\nSend the person to the hospital as soon as possible. The person must \nhave wires placed on his teeth within a week of the accident. The wires \nmust remain there for 4 to 6 weeks. Every week, the person must return \nto the hospital to have the wires tightened. During this time he cannot \nopen his mouth to chew food or brush his teeth. \n\n\nCaring for a person who cannot eat properly (see below): \n\n\n1. Give him liquids containing food for both strength and energy. \n2, Show him how to keep his teeth clean and his gums tough. \n\n\n1. Give liquid foods for strength and energy. \n\n\nPrepare food in two ways: (1) First, a milk-oil drink to build strength; \nand then (2) a special soup to keep him strong and give him energy. \n\n\nTo build strength: Milk-oil drink \nMix for him each day at your clinic: \n\n\n© 9 cups of water \ne 3 cups of milk powder \n@ 150 ml of peanut oil or coconut milk \ne 1/2 cup of honey or 1 cup of sugar \nLeave some near his bed, and keep the rest in a cool place. \n\n\nTo keep strength and give energy: Special vegetable soup \n\n\nCut into small pieces and cook together in a pot of water: \n\ne 1/2 tin of fish, or a handful of dried fish \n\ne 4small spoonfuls of peanut oil or palm oil \n> @ 6 sweet potatoes or small yams \n\ne 1 large handful of green leaves \n\n# 1 small spoonful of Salt is : \n\n\nPour the soup into an empty tin with small holes made in the bottom. \nUse the back of a spoon to press as much of the cooked food as you can \nthrough the holes. The person can suck the soup between the teeth to \nthe throat and then swallow it. Clean the tin and set it in boiling water, \nso you Can use it again the next day. \n\n\n2. Keep the teeth clean and the gums tough. \nThe person must learn to clean teeth and gums or the gums can quickly \nbecome infected and the mouth will feel sore. So: \n\n\ne Scrub both the wires and the teeth with a soft brush after drinking \nsoup, \n* Rinse with warm salt water (page 7), 2 cups every day. \n\n\n106 \n\n\nIf the bone around the roots of the teeth is cracked, those teeth will \nbe loose. Do not take the teeth out until the bone is healed. Otherwise, \nbone will come out with the teeth and there will be a big hole in the jaw. \nInstead, support the teeth, in order to hold both sides of the bone steady. \n\n\n1. With your thumb and finger, gently move the \nloose teeth and bone back into normal \nposition. \n\n\n2, Cut a hypodermic needle and use it as a BEND THE NEEDLE \nsplint. Make it long enough to fit around two AROUND THE TOOTH \nstrong teeth on each side of the loose teeth. $0 IT DOES NOT \n\n\nCurve the needle so it fits the curve of the Pa OUT \nteeth. To make the sharp ends smooth, use a \n\n\nfile or rub the ends against a stone. Chpesy \n\n\n3. Tie each tooth to the needle. Use short pieces \nof 0.20 gauge ligature wire (page 104). \n\n\nPut one end of the wire under the needle. \nBring it around the back of one tooth and \nout to the front again over the needle. \n\n\nUse the end of asmall instrument to hold USE A STRONG \ndown the wire at the back of the teeth. Then HEMOSTAT OR \n\ntwist the ends together. Tighten the wire NEEDLE HOLDER \naround each one of the 6 teeth. \n\n\n4. Cut the ends of the ligature wire. Turn them \ntoward the teeth, so they will not cut the lip. \n\n\n5. Tighten the wires the next day, and then once each week. But be \ncareful. Only 1/2 a turn usually is needed. More, and the wire will \nbreak. Always twist in the direction a clock moves. With this habit, you \nwill remember which way tightens the wire and which way loosens it. \n\n\n6. Explain to the person that it takes 4 weeks for the bone to heal. The \nwires must remain on the teeth for this time. To help the teeth to \nheal, ask the person to: \n\n\ngive these teeth a rest. Use other teeth for chewing. \nclean both the teeth and the wires with a soft brush. \nrinse with warm salt water, 2 cups every day (p. 8). \nreturn to have the wires tightened every week. \n\n\n7. After 4 weeks, cut and remove the wires. Ask the person to watch \nthose teeth. A dark tooth and gum bubble are signs that the tooth is \ndying. Take it out, unless you can give special nerve treatment. \n\n\nDISLOCATED JAW \n\n\n107 \n\n\nIf a person opens her mouth wide and then is unable to close it, we say \nher jaw is dislocated. |t is stuck in the open position. This problem often \nhappens to a person who does not have several of her back teeth. When \nshe opens wide to yawn or shout, the part of her jaw that joins her head \nmoves too far forward inside the joint. It is then unable to return to its \n\n\nnormal position. \n\n\nSIGNS: \n\n\nNORMAL DISLOCATED \nTREATMENT: \n\n\nShe is unable to close her teeth \ntogether. \n\nShe cannot close her tips easily. \nHer lower jaw looks long and \npointed. \n\nIt hurts when you press on the \njoint in front of her ear. \n\nShe cannot speak clearly. \n\n\nThe treatment is to try to move the lower jaw back where it belongs. \nThen hold it in that position until the muscles can relax. \n\n\n1. Find a way to support the person’s head. For example, have the \n* person sit on the floor with her head against a wall. \n\n\n2. Kneel in front of her. Put your fingers under her jaw, outside the \nmouth. Put your thumbs beside her last molar tooth on each side. \n\n\nDo not put your thumbs on the molars. The person may bite them! \n\n\nPress down hard with the ends of \nyour thumbs. Force the jaw to move \nquickly down and back into position. \nBe sure to press down before you \npress back. \n\nIf the jaw will not move, perhaps the \nmuscles are too tight. A doctor or \ndentist can put the person to sleep, \nwhich will relax the muscles. \n\n\n3. Support the jaw with a head-and- \nchin bandage for 3 to 4 days \n(page 104), \n\n\n4. Give aspirin for pain (page 88). \n\n\n5. Explain the problem to the person and tell her how to care for her \njaw: (1) eat mostly soft foods for 2 weeks; (2) hold a warm wet \ncloth against the jaw; (3) remember not to open the mouth wide \nanymore. If possible, replace the missing back teeth with dentures \n\n\n(page 101). \n\n\n108 \nPAIN IN THE JOINT \n\n\nA joint is the place where one bone joins another. The jawbone has \ntwo joints, for it joins the head in front of each ear. \n\n\nThe mouth opens and closes because: \ne muscles pull the jawbone; and \n\n\ne the jawbone slides against the head \nbone, inside the joints. \n\nPain in these joints may be because: \n\n(1) The muscles are tight because the \nthe person is tense or nervous. \n\n(2) The jawbone is fractured in the area \nof the joint. \n\n(3} The teeth do not fit together \nproperly. \n\n\nTREATMENT: \n\n\nBefore you treat, decide what is causing the pain. We will discuss the \nthree causes mentioned above. \n\n\n1. Tension. \n\n\nTalk with the person and help, if you can, to find a solution to her \npersonal problems. This can do much to help her and her muscles relax. \nIn addition, explain how to care for the sore joint: \n\n\n(a) Eat only soft foods until it no longer hurts to chew. \n\n(b) Hold a hot, wet cloth against the jaw, to help relax the muscle. Do \nthis as often as possible, but be careful not to burn the skin. \n\n(c) Take aspirin (page 88) to reduce the pain. \n\n\n2. Fracture. \n\n\nIf an X-ray shows a fracture, the person needs expert help. A dentist \ncan wire the teeth in a way that will allow the bone to heal. \n\n\n3. Teeth do not fit together properly. \n\n\nImagine a line that passes between the two middle upper teeth and the \ntwo middle lower teeth in the person’s closed mouth (see the next page). \nWhen the person opens the mouth, this line becomes longer, but it is still \na straight line. If it is not, this condition can, after a long time, cause pain \nin the joint. \n\n\n109 \n\n\n; 1 \nThese teeth are normal. The line formed between the two middle teeth does not shift \nwhen the mouth opens. \n\n\nWhen you see teeth that do \nnot fit properly: \n\n\n(a) Warn the person not to open \nhis mouth wide. Suggest, \nfor example, that he take \nhis food in small bites. \n\n\n| (b) Tell the person what can \nbe done to help. Often \n\n\na dentist can grind the teeth These teeth do not fit properly. \nin aspecial way and this Because the line shifts, this means \ncan end the pain. the jaw is also shifting. This \n\n\nshift can cause pain in the joint. \n\n\nSWOLLEN GUMS AND EPILEPSY \n\n\nMany persons who suffer from epilepsy \n(see Where There Is No Doctor, page \n78) have a problem with swollen gums. \nIn severe cases, the gums are so \nswollen that they cover the teeth. This \nproblem is caused not by epilepsy but by \ndiphenylhydantoin (Dilantin), a drug \n\nused to control epilepsy. \n\n\nWhen you see swollen gums, find out what medicines the person \nis taking. If possible, change to a different drug. If the person must \ncontinue using diphenylhydantoin, explain how to prevent this swelling \nof the gums. Show the person this book, especially pages 67 to 70. \nPersons who take this drug may be able to prevent the swelling by \nbrushing the teeth carefully after each meal, and taking special \ncare to clean between the teeth. (page 69). \n\n\n110 \n\n\nBLOOD IN THE MOUTH \n\n\nUse wet cotton gauze to wipe away the old blood from inside the \nmouth. Then you can see where it is coming from. Treat the cause of the \n\n\nbleeding. \n\n\nIF YOU SEE: \nSESE Ene \na large red clot growing \nout of a socket where you \nhave taken out a tooth \n\n\nsore and bleeding gums \nand the mouth smells bad \n(Vincent's infection) \n\n\na red, bleeding growth inside \nthe cavity in a tooth \n\n\na loose tooth with bleeding \n\n\ngums around it \n\n\ntorn gums with broken bone \nand bleeding \n\n\nTO STOP THE BLEEDING: \n\n\n. Remove the clot with cotton \n\n\ntweezers. \n\n\n. Ask the person to bite on a \n\n\npiece of cotton. \n\n\n, Rinse with a mixture of \n\n\nhydrogen peroxide and water. \n\n\n. Remove as much tartar as you can, \n\n\nTake out the tooth; it has an \nabscess. \n\n\nHold the tooth with wires, \nor if the root is broken, \ntake out the tooth. \n\n\n. With wire, hold the broken \n\n\nparts of the bone together. \n\n\n. Send the person to an \n\n\nexperienced dental worker. \n\n\nPROBLEMS AFTER YOU TAKE OUT A TOOTH \n\n\nProblems like swelling, severe pain, and bleeding can occur after you \ntake out a tooth. Tetanus (p. 112), a more serious problem, can also occur, \n\n\nespecially if your instruments were not clean. \n\n\nSwelling of the face \n\n\nYou can expect some swelling after you \ntake out a tooth. But if the swelling \ncontinues to grow, and it is painful, this \nis not normal. Probably an infection has \nstarted. The treatment is the same as for \na.tooth abscess: penicillin for 3 days to \nfight infection, heat to reduce the swelling, \nand aspirin for pain. See page 88 for the \n\n\nproper doses, \n\n\n111 \n\n\nPain from the Socket \n\n\nThere is always some pain after a tooth is taken out. Aspirin is usually \nenough to help. \n\n\nHowever, sometimes a severe kind of pain starts inside the tooth’s \n‘socket’ (the wound) 2 to 3 days after you take out the tooth. This \nproblem is called dry socket and it needs special care. \n\n\nTREATMENT: \n\n\n1. Place a dressing inside the socket. Change it each day until the pain \nstops. \n\n\nFirst, clean out the socket. \n\n\nSquirt warm water inside the socket with \na clean syringe. After the person spits out \nthe water, squirt water inside once more. \nUse a blunt needle so that it does not hurt \nthe gums or bone if it touches them. \n\n\nThird, place the dressing gently \ninside the socket. \n\n\nSecond, prepare the dressing. Place one piece of dressing into \n\n\neach root space. Push it down into \nthe root space gently. \n\n\nSoak 1-2 small pieces of cotton \nin eugenol (oil of cloves). \nSqueeze each piece so that it \n\n\n; i i n \nis damp but not wet. Cover the socket with plain cotto \n\n\ngauze, and send the person home \nbiting against it. He can remove \nthe plain cotton in an hour. The \ndressing should remain inside the \nsocket. \n\n\nNote: There may be a local \nmedicine in your area that \nrelieves pain. Use it instead of \neugenol. \n\n\n2. Give aspirin for pain (page 88). \n\n\n112 \n\n\nBleeding from the socket \n\n\nWhen you take out a tooth it leaves a wound, so you can expect some \nblood. However, if the person bites firmly against a piece of cotton, it \nusually controls the bleeding. To help the wound heal (from a clot), tell \nthe person not to rinse with salt water or spit for 1 or 2 days after you \ntake out the tooth. \n\n\nWhen the first bleeding occurs, put a new piece of cotton on top of \nthe wound and ask the person to close her teeth against it for an hour. \nKeep her there with you, to be sure she continues to bite on the cotton. \n({f it is too painful, you may want to inject anesthetic. See Chapter 9.) \nChange the cotton if it becomes soaked with blood. \n\n\nTREATMENT (if the bleeding continues): \n\n\n1. Take her blood pressure (see Helping Health \nWorkers Learn, page 19-13). If it is high, \nyou may need medicine to bring it down. \nThat can help slow the bleeding. \n\n\n2. Look carefully at the wound. If the gum \nis torn or loose, put in a suture (pages 155- \n157). \n\n\n. 3. Wrap tea leaves in cotton gauze. Soak the \nbundle in water and then put it on the socket. Have the person bite \nagainst it. Or, have her bite against cotton gauze soaked with cactus juice. \n\n\nLet the person go home only when the bleeding stops. Give her some \nclean cotton to use in case the bleeding starts again later (see page 157). \n\n\nTETANUS \n\n\nThis is a very serious infection. Tetanus germs enter the body when a \nwound, like a wound on the bottom of the foot, gets dirty. Germs can \nalso be carried to the socket when you use a dirty instrument to take out \na tooth. To avoid this, carefully read pages 82 to 85. \n\n\nSIGNS: = OLD, DRY BLOOD \not \n\n\ne the jaw becomes stiff and tight cleaning \ne itis hard to swallow property, \ne the whole body becomes tight, with sudden \nspasms ON \n\n\nTREATMENT: \n\n\nA person with signs of tetanus requires immediate medical help. See \nWhere There Is No Doctor, page 182, if you cannot get help immediately. \n\n\n113 \n\n\nINFECTION INSIDE THE SPIT GLAND \n\n\nSpit glands are places where the spit is made. They are located in front \nof the ear and under the jaw, on each side of the head. If there is an \ninfection inside a spit gland, the face will become swollen and the area \nwill hurt. \n\n\nSpit is sent from the gland to the mouth through a thin pipe called a \nduct. Ducts open into the mouth in two places: on the inside of each \ncheek, and under the tongue. \n\n\nA small stone can often block a duct and cause an infection in the spit \ngland and swelling of the face. You may be able to feel the stone near \nwhere the duct enters the mouth. \n\n\nSIGNS: \n\n\ne swelling in the area of the spit gland. \n\n\ne pain which gets worse when the person is hungry, and when he sees \nor smells food. \n\n\ne the opening of the duct is red, swollen, and hurts when you touch it. \n\n\nspit from \nthis gland \nenters on \nthe inside \nof the cheek \n\n\nTONGUE \n\n\nspit from \nthis gland \nenters under \nthe tongue \n\n\nTREATMENT: \nReduce the infection and swelling first. Later try to remove the \nstone. \n1. Give penicillin for 3 days (page 88). If the swelling is large and the \ninfection serious, start with short-acting crystalline penicillin (see \np. 166). \n2. Give aspirin for pain (page 88). \n. Apply a wet hot cloth to the swelling as often as possible. \n4. Give enough soft food to prevent the person from feeling hungry. \nThe pain will be less then. \n5, When the person feels better, a dentist or doctor can remove the \nstone that is blocking the duct. \n\n\nOO \n\n\n114 \n\n\nSORES ON THE FACE \n\n\nWhenever you see a sore on a person’s cheek or under his chin, \nremember there may be a tooth or gum problem. If it is agum problem, \nit may be Noma. See p. 115. \n\n\nA bad tooth: \nAsk him to open his mouth. \nLook for an infected tooth in \n\n\nthe area of the sore. \n\n\nThere may be a large cavity and \nthe tooth may be loose. \n\n\nOr the tooth may be darker \nin color than the others. This \nis because it is dead. \n\n\nThe pus is draining onto the \nskin, so the pressure is reduced \nand the person does not \ncomplain of pain. \n\n\nTREATMENT: \n\n\n1. Take out the tooth (see Chapter 11). \n\n2. Give penicillin for 5 days (see page 88). \n\n3. After the penicillin treatment, check the sore. If it has healed, there \nis no longer infection inside. The treatment is finished. \n\n\nBut if the sore is still open and you can squeeze out pus, you will need \nthe help of experienced health workers who can: \n\n\ne test the pus to see if it is resistant to penicillin. The person may \nneed to take a different antibiotic, \n\n\ne take an X-ray to see if there are dead pieces of bone which are \nkeeping the infection alive. If there are, they must be removed. \n\n\nlf infected gums (and not a bad tooth) are the cause of a sore on the \ncheek or chin, the problem is more serious. See the next 4 pages. \n\n\n115 \nNOMA \n\n\nWhen a child is sick, a simple gum infection can get out of control and \nspread through the cheek to the face. When that happens the condition is \ncalled Noma or Cancrum Oris. Noma is a complication of Vincent's \nInfection of the gums (page 96). \n\n\nYou will usually see noma in children. It will only develop if these 3 \nthings are true: \n\n\n(1) The child’s general resistance is low. Usually, he \nis undernourished and anemic (lacks iron). He \nmay have tuberculosis. \n\n\n(2) The child has Vincent's Infection. \n\n\n(3) The child has recently had a serious illness like \nmeasles or malaria. \n\n\n~_— \n\n\nSIGNS: \nThe infection starts in the mouth. \n\n\nThen it passes to the gums. \n\n\n1, Sore mouth with itching gums. \n\n2. Swollen, sore gums. \n\n3. Gums bleed when eating or when \nteeth are cleaned. \n\n4, Bad breath, spits a lot. \n\n\nThen it reaches the jaw. \n\n\n5, Loose teeth. \n6. Loose pieces of bone around the \nteeth. \n\n\nFinally, it affects the cheek. \n\n\n7, Skin is tight with dark red swelling. \n\n8. Black spot on the cheek breaks open, \nleaving a hole into the mouth. \n\n9. A line separates dead tissue from \nhealthy tissue. \n\n\n116 \nTREATMENT: \n\n\nYou must start treatment for noma immediately in order to prevent the \nhole from getting bigger. The bigger the hole, the tighter the scar that \nforms after you close the hole. A tight scar will prevent the child from \nopening his mouth and chewing the food he needs to grow stronger. \n\n\n1. Give fluids. \n\n\nThe child needs to overcome \nboth the lack of body water \n\n(dehydration) and his lack of \nresistance to disease. \n\n\nStart giving the Milk-oil drink \ndescribed on p. 105. \n\n\nIf he cannot drink by himself, \nhelo him. Use a spoon or \nsyringe. \n\n\nPlace the fluid on the inside \nof the healthy cheek and ask \nthe child to swallow. \n\n\n2. Treat the anemia. \n\n\nStart giving iron now. The child should continue taking the tablets or \nmixture for 3 months. \n\n\nFerric Ammonium OR Ferrous Sulfate \nCitrate Mixture Tablets (200 mg.) \n\n\nover 6 years: 11/2 ml. (30 drops) daily 200 mg. (1 tab) 3 times a day \n3-6 years: 1 ml. (20 drops) daily 100 mg. (1/2 tab) 3 times a day \nunder 3 years: 1/2 ml. (10 drops) daily 50 mg. (1/4 tab) 3 times a day \n\n\nAlso give food rich in iron: meat, fish, eggs, dark green leafy vegetables, \npeas and beans. \n\n\nNote: a child may have anemia because he has hookworm. It is wise not \nto wait for a test for hookworm. Begin now giving hookworm medicine such \nas thiabendazole and folic acid (see Where There /s No Doctor, pages 142, \n363, and 376). \n\n\n117 \n\n\n3. Start antibiotics. \n\n\nPenicillin is the best antibiotic to use. As the child may not be able to \nswallow pills easily, it is best to start with penicillin injections (page 166). \n\n\nIf you do not have penicillin, you can give sulfadimidine 4 times a day. \nit comes in 500 mg. tablets or in syrup that has 500 mg. in 5 ml. To \ndecide how much to give, weigh the child. \n\n\nWeight Dose (give 4 times a day) \n\n\n5 to 10 kg. \n10 to 17 kg. \n17 to 25 kg. \nover 25 kg. \n\n\n1/2 tablet or 1/2 teaspoon of syrup \n1 tablet or 1 teaspoon of syrup \n\n1 1/2 tablet or 1 1/2 teaspoon of syrup \n2 tablets or 2 teaspoons of syrup \n\n\n4. Treat the other illness that helped noma to develop. \n\n\nIt is wise to assure that the child has malaria and to begin treating \nwith antimatarial drugs (see Where There Is No Doctor, pages 357 and \n358). \n\n\nLook for any other illnesses and treat them, too. \n\n\n5. Clean the sore. \n\n\nGently pull away any dead skin with tweezers. Wash the inside of the \nsore with hydrogen peroxide. (Be sure you measure the hydrogen peroxide \ncarefully. See page 8.} Then put in a wet dressing. \n\n\nThe dressing: \n\n\ne Soak cotton gauze in salt water. Squeeze out the extra water so that \nit is damp but not wet. \n\ne Put it in the hole and cover it with a dry bandage. \n\ne Every day, remove the bandage, wash the hole with hydrogen \nperoxide, and put in a new dressing. Do this until the hole does not \nsmell anymore and there is no more dark dead skin. \n\n\n6. Remove the loose teeth and dead bone. \n\n\nYou can use a local anesthetic (Chapter 9). Usually there is not much — \nbleeding. If gums are loose, join them with a suture (see pages 155-157). \n\n\n118 \n\n\n7. Keep the mouth clean. \n\n\n# Use asoft brush gently to clean the remaining teeth. Do this 3 times \na day for the child. \n\ne Wipe the gums with a weak solution of hydrogen peroxide. Use \ncotton gauze that is damp with the solution. Do this every 2 hours \nfor 5 days. \n\n« Then after 5 days, start rinsing with warm salt water 3 cups a day. \n\n\n8. Get advice on whether surgery is needed. \n\n\nUnfortunately, the child will probably need surgery, to release the scar. \nWithout this surgery, the child will not be able to open his mouth \nproperly. \n\n\nSend the child for medical help when the \ninfection is finished and the wound starts to \nclose. \n\n\nYou may also need a dentist’s help at this time. \nThe child's jaws may need to be wired. The \nwires are put on the healthy teeth in a way that \nholds the mouth open while the tight scar is \nforming. When the wires are removed, the child \nwill be able to open and close his mouth to \nchew food. \n\n\nPREVENTION of Noma: \n\n\nNoma need not occur. We can prevent it. Always give special attention \nto the mouth of a sick child, to be sure to keep his teeth clean. \n\n\nWhenever someone is nursing or caring for asick child, that person \nshould clean the child’s teeth as a normal activity. This is especially true \nfor a child who is weak, undernourished, and with little body water \n(dehydration). \n\n\nSuch a child should always: \n\n\n(1) have his teeth carefully cleaned each \nday with a soft brush. \n\n\n(2) rinse his mouth with a warm salt \nwater solution (page 7), 2 times a \nday. \n\n\n(3) eat fresh fruits and vegetables, \nespecially the kind that have Vitamin \nC—guavas, oranges, pineapples, \npapayas, tomatoes, peas, and dark \ngreen leaves. \n\n\n119 \n\n\nTUMOR \n\n\nA tumor is a lump that grows under the skin or inside the bone. \ngrows slowly but steadily, usually without any pain. \n\n\nt \n\n\nIf the swelling does not get better after 5 days of antibiotics and \nheat treatment (page 88), it may be a tumor. \n\n\nTREATMENT: \n\n\nDo not waste any more medicine or any more time. A tumor may be \ncancer. Send for medical help. Surgery is needed to remove a tumor. \n\n\nCANCER \nY \nY Any sore that does not heal may be \n\ncancer. The lips and tongue are the \n\ntwo places in the mouth where \ncancer starts most often. \n\n\nCancer is deadly. \n\n\nMedicine cannot help. \nIt wastes time to use it. \n\n\nCancer can spread quickly to the inside of the person’s body where \nyou cannot see it. This can lead to the person's death. \n\n\nTREATMENT: \n\n\nWhenever you treat a sore and it does not get better, send the person \nfor medical help immediately. A doctor can cut out a piece from the sore, \nlook at it under a microscope, and decide if it is cancer. \n\n\n121 \n\n\nCHAPTER 8 \n\n\nScaling Teeth \n\n\nScaling means ‘scraping away . You can scale old food, tartar, or even a \nfish bone caught under the gum. You usually scale teeth to remove tartar. \n\n\nWe get tartar when the coating \nof germs on our teeth (p. 48) \nbecomes hard. \n\n\nGums that press against \ntartar become sore and infected. \n\n\nClean teeth keep our gums healthy. Scaling a person’s teeth gives \ninfected gums a chance to become normal again. \n\n\nHowever, gums remain healthy only when we keep the teeth beside \nthem clean. |f we are not careful about cleaning our teeth after they are \nscaled, tartar will soon return. Instead of being healthy, the gums will \nbecome sore and infected again. \n\n\nScale a person’s teeth, but \n\n\nalso teach how to keer ceeth clean. \n\n\nYou must remove something caught under the gums (page 127) before \nit causes more pain and swelling. Remove a piece of fish bone or piece of \nmango string now. \n\n\nIf the person has a mild gum problem (gums that bleed), wait a week or \nso before scaling. |f the person uses this time to clean his teeth better and \nto rinse with warm salt water (page 7), the gums will improve. The \nperson's teeth will be easier for you to scale, and he will learn that he can \ndo much by himself to care for the gums. \n\n\nUse a mirror to show the person gum infection inside his own mouth. \nLater he can see the improvement he has made. He can learn about how \nto keep gums healthy as he follows his own progress. \n\n\nScale a person’s teeth only when he really wants to try to keep them \nclean. |f he does not want to clean his teeth, the tartar will soon return. \nDo not waste your time scaling the teeth of a person who does not want \nto learn. \n\n\n122 \n\n\nTHE INSTRUMENTS YOU NEED FOR SCALING \n\n\nWe scale teeth with special instruments called sealers. There are many \ndifferent kinds of scalers for different teeth, to make scaling easier. It can \nbe a problem to know which ones to buy. \n\n\nScalers are expensive instruments. For that reason, it is better to order \nonly a few instruments that you can use to clean most teeth. \n\n\nYou need only 2 double-ended scalers, or 4 single-ended scalers. \nFor instance: \n\n\n1. One with two pointed tips—to remove tartar from the part of the tooth \nnear the gum. \n\n\nSores ae Its proper name is \n\\\\ f/ a SS Ivory C-1 scaler, \n2. Another with two blunt, rounded ends—to remove tartar from the part \nof the tooth under the gum. \n\n\nIts proper name is \nG-11 and 12 curette. \n\n\nThe ends of the scaler are the important parts. One end is bent to the \nleft and the other end is bent to the right, so you can reach more easily \naround all sides of the tooth. \n\n\nThe blade at each end of the scaler is sharp. You must keep the blade \nsharp. A sharp blade can break more of the tartar away than a blunt blade. \n\n\nYou also need these: \n\n\nProbe Tweezers Sharpening stone \nMirror (explorer) (cotton pliers) (Arkansas stone) \n\n\nNote: When you order an instrument, use both its common and proper \nname. Then you have a better chance of receiving the instrument \nyou want. You can also make some of your own instruments. See \npages 170-172. \n\n\nKeep everything in a Scaling Kit. \n\n\n123 \n\n\nHOW TO SCALE TEETH \n\n\nTartar starts to form inside the gum pocket. There it builds up, because \nthe gums protect it. So you often must feel rather than see the tartar when \nyou scale a tooth. \n\n\nYou must remove all of the tartar so the gums can heal. New tartar \ngrows faster when there is old tartar left behind for it to build upon. \n\n\nLay out what you need ahead of time. \n\n\nJf your instruments: scalers, mirror, probe, tweezers \n\n\n/_ sharpening stone \n\n\nvA \n\n\ncotton gauze \n\n\nYour light must be good enough to see the tooth and gums around it \nclearly. Scaling teeth requires time and practice. Make yourself and the \nperson comfortable. You can sit next to a special chair that lets the person \nlean back (see page 73). \n\n\nThe steps in scaling teeth are these (pages 123-127): \n\n\n. Explain to the person what you are going to do, \n\n. Feel under the gum for rough spots (tartar). \n\n. Place the scaler under the tartar. \n\n. Pull the scaler against the side of the tooth. \n\n. Check to be sure the tooth is smooth. \n\n. Explain what you have done and what the \nperson should now do. \n\n\nOarwWwNn— \n\n\n1. Explain what you are going to do. Tell the person what to expect. There \nwill be some bleeding and possibly some pain. However, you can stop \n\nand rest, or inject local anesthetic, if it is painful. Remember: first wash \nyour hands and your instruments! (See pages 82-85.) \n\n\n2. Feel under the gum for tartar. Tartar feels like a rough spot on the root \nof the tooth. Since tartar can form anywhere inside the gum pocket, feel \nfor it on all sides of the tooth. \n\n\nYou can check for tartar two ways. \n\n\n1. Use your probe. Slide the point up.and down along the \nroot surface under the gum. Feel for places that are \nrough. Teeth without tartar are smooth. \n\n\n2. Use cotton gauze. Twist a corner and press it between \nthe teeth. The gauze lowers the gum and soaks up the \nspit. You can then see more tartar. \n\n\n124 \n\n\n3. Place the scaler under the tartar. You must learn two important things: \nhow to hold the scaler and how to slide the scaler into the gum pocket. \n\n\nHold the scaler \nalmost as you would \nhold a pen, You can \nthen pull it against \nthe tartar with both \npower and control. \n\n\nControl is very important. The \nends of the scalers are sharp. \n\nIf you are not careful, the blades \ncan cut the gums. Be gently and do \nnot hurry. Always hold the tip of \nthe scaler on the tooth to avoid \npoking the gums. \n\n\nRest your 3rd finger against a \ntooth. This will steady your hand \nand let you slide the sharp scaler \nunder the gum with care. \n\n\n125 \n\n\nThe edge of the gum, near the tooth, folds under to form a pocket. This \ngum pocket goes completely around each tooth. The gum pocket can be \nshallow or deep. A deep pocket means there has been an infection for a \n\n\nwhile. \n\n\nGUM POCKET \n\n\nROOT FIBERS \n\n\n9, \n\n\n— BONE \n\n\nROOT \n\n\nFirst, use the pointed-tip \nscaler to remove the tartar \nthat you can see. \n\n\nBe careful when you place the rounded end of the scaler in \n\n\npocket. \n\n\n1. Put the sharp face of the \nblade against the tooth. \nSlide it along the tooth \ndown into the gum pocket. \n\n\nTartar starts forming deep \ninside the gum pocket. If \nyou remove tartar that you \ncan see above the gum, it \nis helpful, but not good \nenough. You must remove \nthe rest of the tartar, or \nthe infection will continue. \nIf part of the tartar \n\nstays on the tooth, the \ninfection will continue. \n\n\nThen, go back with your rounded- \ntip scaler and scrape away the \nremaining tartar. Ae \n\n\nside the gum \n\n\n: \\ \nan \nat \n\n\n2. You can feel the edge as it \ngoes over the rough tartar. \nStop when you feel the \nbottom of the gum pocket. \n\n\n126 \n\n\n4. Hold the end tight against the side of the tooth and pull the scaler. Try \nto break free as much tartar as possible at once. It is a bad idea to remove \nthe tartar a bit at a time, because the remaining tartar becomes smooth \nand harder to scrape away. \n\n\n1. Tighten your fingers 2. Pull the scaler with \non the scaler. a firm short stroke. \n\n\nALWAYS KEEP THE TIP \nOF THE SCALER ON THE \nTOOTH—NOT POKING THE GUM. \n\n\n3, Wipe the end of the 4. Press against the gums \nscaler with cotton gauze. to stop the bleeding. \n\n\n5. Check to be sure the tooth is smooth. \n\n\nWith your probe, feel under the gum for \nany place that is still rough. \n\n\nWhen all the sides of the tooth feel \nsmooth, move to the next tooth. \n\n\nDo not hurry. {t is more important to take your time and carefully \nremove all the tartar. If the person has a lot of tartar, scale only half the \nmouth now. Do the other half on another day, as soon as the person can \nreturn, \n\n\nFinally, make the tooth look clean. Use the sharp edge of either scaler. \nScrape away the dark material on the front and back sides of the tooth. \n\n\nThe tooth itself has not turned dark. It \nis just a stain. People most often get \nthese stains when they eat meat, drink \ntea or smoke tobacco. \n\n\nYou can scrape away this old food and \nuncover the white tooth. But remember: \nthe teeth will turn dark again if not \ncleaned carefully every day. \n\n\n127 \n\n\n6. Talk to the person about what you have done and what to expect. The \ngums will be sore for the next few days. That is normal. \n\n\nThen explain to the person what to do to make the gums strong and \ntough again. \nA. Clean your teeth better with a soft brush. Reach with the brush into \nthe gum pocket, and behind your front teeth. That is where tartar \ncollects most often (page 67). \n\n\nB. Clean between your teeth. Use your brush, the stem from a palm \nleaf, or a piece of strong, thin thread (page 69). \n\n\nC. Rinse your mouth with warm salt water. Start with 4 cups a day, \nto make the gums strong. Then use 1 cup a day to keep them strong \n(page 7). \n\nD, Eat local foods that give strength to gums. Fresh fruits like guava \n\n\nand oranges, and fresh vegetables with dark green leaves are good \nfor the gums. , \n\n\nREMOVING SOMETHING FROM UNDER THE GUM \n\n\nlf the gum between two teeth is red and swollen, something may be \ncaught inside the gum pocket. Ask what the person has been eating. The \nobject may be a fish bone, mango string, or a sharp piece of tartar. \n\n\nFirst try to feel the object with your probe. Then remove it using a \nscaler or a piece of strong thread. \n\n\nUse the rounded-tip \nscaler in the same way \nas you would to remove \ntartar. ——s \n\n\nFeel the object, go \n\n\nunder it gently, and \nthen lift it out. \n\n\n— ce Tie a knot in a piece of \nthread. Then slide the thread \nbetween 2 teeth (page 69). \n\n\nHowever, do not move the \nthread up and down. Instead, \npull it and the knot out \n\nthe side. The knot can pull \nthe object out with it.* \n\n\n*|f the gum has grown into a kind of tumor fepulis), an experienced dental worker should cut \nit away. \n\n\n128 \n\n\nKEEP YOUR SCALING INSTRUMENTS \nSHARP AND CLEAN \n\n\nA sharp scaler bites into tartar better than a blunt one. Sharpen the \nedge whenever you feel it sliding over the tartar. \n\n\nFrom time to time, fee! the cutting edge to be sure \nit is sharp. \n\n\nScrape it against your fingernail. If the cutting edge \nis not able to cut your nail, it will not be sharp \nenough to break the tartar free. \n\n\nSharpen the cutting edge of the scaler on a fine-grain stone (Arkansas \nstone). Put a few drops of oil or water on the stone first, so the scaler can \nslide against it more easily. \n\n\nRest your 2nd or 3rd finger against the side of the \nstone. This is for control. \n\n\nRub the cutting edge against the stone. Move it back \nand forth. \n\n\nTurn the round scaler as you sharpen it. This helps \nto keep the scaler’s round shape. \n\n\nScalers must be more than clean—they must be sterile. This is because \nthere may be spots of blood on them. Hepatitis (Where There /s No \nDoctor, page 172) can pass from the blood of one person to the blood of \nanother person. To learn how to sterilize, see pages 83 and 84. \n\n\nYour mirror, probe, and cotton tweezers do not need sterilization. A \ndisinfectant (see page 85) will clean them. Dry all the instruments with a \ntowel. Then wrap them inside a clean cloth and put them in your scaling \nkit. They are now ready for use whenever you need them again. \n\n\nI HAVE TAKEN OFF ALL \nTHE HARD STUFF. NEVER \nLET IT COME BACK/ g \n\n\nRemind each person: scaling is not \n\na cure. Rather it is a way of giving \nher a new start. Only she can give \nherself the care she needs to keep her \ngums healthy. You have removed the \nhard material from her teeth, and if \nshe brushes carefully, the tartar will \nnot return! \n\n\nInjecting Inside \nthe Mouth \n\n\n129 \n\n\nCHAPTER 9 \n\n\nIt is possible to treat a tooth without pain. You do this with an \ninjection of local anesthetic. You must inject near the nerve, so to give \ngood injections, you must know where the nerves are. \n\n\nInjecting is a skill that develops with experience. The best way to learn \nis not from a book, but from a person who has experience giving injections. \n\n\nWatch an experienced dental worker give injections. That person \n\n\ncan then watch you and show you how to inject carefully and safely. \n\n\nLocal anesthetic is an injectable medicine. When it touches a nerve, the \ntooth joined to that nerve feels numb or dead for about an hour. This \nusually gives you enough time to take out a strong tooth or to puta \n\n\ncement filling into a deep cavity. \n\n\nWHAT YOU NEED TO INJECT \n\n\nThere are two kinds of syringes for injecting local anesthetic inside the \nmouth. One is made of metal and the other is made of glass. The metal \nsyringe uses local anesthetic in a cartridge. The glass syringe uses local \n\n\nanesthetic from a bottle. \n\n\nMETAL SYRINGE \n\n\nThis is a dental syringe. It uses special needles, \n\n\nand the local anesthetic is sealed inside a \nglass cartridge. You must throw away both \nneedle and cartridge after. injecting. % \n\n\n; \n\n\nbefore you inject, \n\nbe sure the local \nanesthetic is able to \ncome out of the needle. \n\n\nUse a new needle and a new cartridge of local \nanesthetic for each person. \n\n\nGLASS SYRINGE \n\n\nThis kind of syringe is for injections of \nmedicine like penicillin, but you can use it in \nthe mouth. Boil the syringe and needles (p. 84) \nbefore and after each use. When sterile, the \nneedles are ready for another person. \n\n\nBe careful! Do not touch the needle. \n\n\n130 \n\n\nYour choice of which syringe to use depends on the local anesthetic you \ncan get. Order needies to fit your particular kind of syringe. \n\n\n————$—_ \nMETAL SYRINGE GLASS SY RINGE \nOrder: Order: \n1. syringe: aspirating dental cartridge syringe, 1. syringe: standard glass syringe that holds \n1.8 ml. (Iml=1cc) around 3 ml! (1ml=1cc) \n2. needles: disposable needles for dental 2. needles: 24 gauge, long (40 mm x.56 mm \ncartridge syringe (27 gauge, long) or similar) \nOne box contains 100 needles, each one | 3. local anesthetic: 20 ml! bottle of lidocaine \ninside a plastic cover (lignocaine) 2% \n3. local anesthetic: local anesthetic cartridges Or, if not available: order 2 ml ampules \nfor a dental syringe of procaine nydrochloride 1% \n\n\nOne sealed tin contains 50 cartridges \n\n\nof lidocaine (lignocaine) 2% : \n\n\nNOTE: Lidocaine will keep the teeth numb longer if there is epinephrine \nin it. But this is more expensive, and you should not use it on \npersons with heart problems (see the bottom of the next page). \n\n\nWHERE TO INJECT \n\n\nYou\n…[truncated]", "summary": "Where There Is No Dentist by Murray Dickson with an Introduction by David Werner, author of Where There Is No Doctor Compiled by noonya Library of Congress Cataloging in Publication Data Catalog card No. 82-84067 Dickson, Murray Where there is no dentist. Includes index. Palo Alto, CA: Hesperian Foundation ISBN: 0-942364-05-8 First edition, November 1983 Seventh Printing, July 1996 PUBLISHED BY: The Hesperian Foundation P.O. Box 1692 Palo Alto, California…", "source_url": "https://archive.org/details/where-there-is-no-dentist-murray-dickson", "pdf_url": "https://archive.org/details/where-there-is-no-dentist-murray-dickson", "doc_date": "2024-12-23", "case": "hesperian", "sub_case": "Copyright © 1983, 2006, 2010 by the Hesperian Foundation", "tags": ["hesperian", "DENTIST", "DENTISTAS DENTES", "CARIES", "RESTAURATRIONS OF TEETH"], "page_count": 0} {"title": " Where There Is No Doctor A Village Health Care Handbook d Werner", "content": "Where There Is No Doctor \n\na viCCaat heeded cart handbook \n\n\n-revised edition \n\n\n% \n\nVavld Werner \n\nmcfi \n\nCarol Thuman and Jane MaxwdC \n\n\nmtfv drawings hy David Werner \n\n\nCompiled by noonya \n\n\nLibrary of Congress Cataloging-in-Publication Data \nWerner, David, 1934- \n\nWhere there is no doctor: a village health care \nhandbook / by David Werner; with Caro! Thuman and \nJane Maxwell. — Rev. ed. \n\nIncludes Index. \n\nISBN 0-942364-15-5 \n\n1. Medicine, Popular. 2. Rural health. I. Thuman, Carol, \n1959- . II. Maxwell, Jane, 1941- . III. Title. \n\n[DNLM: 1. Community Health Aides — handbooks. \n\n2. Medicine — popular works. 3. Rural Health — handbooks. \nWA 39 W492w] \n\nRC81.W4813 1992 610— dc20 \n\nDNLM/DLC 92-1539 \n\nfor Library of Congress CIP \n\n\nPublished by: \n\nThe Hesperian Foundation \n1919 Addison St., #304 \nBerkeley, California 94704 \nUnited States of America \n\nCopyright© 1992 by the Hesperian Foundation \nFirst English edition: October 1977 \n\n\nRevised English edition: May 1992 \n\nSeventh printing, June 2003 \n\n\nThe original English version of this book was produced in 1977 as a revised \ntranslation of the Spanish edition, Donde no hay doctor. \n\nThe Hesperian Foundation encourages others to copy, reproduce, or adapt \nto meet local needs, any or all parts of this book, including the illustrations, \n\nprovided the parts reproduced are distributed free or at cost — not for profit. \n\nAny organization or person who wishes to copy, reproduce, or adapt any or \nall parts of this book for commercial purposes, must first obtain permission to \ndo so from the Hesperian Foundation. \n\nPlease contact the Hesperian Foundation before beginning any translation \nor adaptation to avoid duplication of efforts, and for suggestions about \nadapting the information in this book. The Foundation would appreciate receiving \na copy of any materials in which text or illustrations from this book have been used. \n\n\nTHIS REVISED EDITION CAN BE IMPROVED WITH YOUR HELP. \n\nIf you are a village health worker, doctor, mother, or anyone with \nideas or suggestions for ways this book could be changed to better \nmeet the needs of your people, please write to the Hesperian \nFoundation at the above address. Thank you for your help. \n\n\nOTHER BOOKS FROM THE HESPERIAN FOUNDATION \n\n\nWhere Women Have No Doctor, by A. August Burns, Ronnie Lovich, Jane \nMaxwell and Katharine Shapiro, combines self-help medical information with \nan understanding of the ways poverty, discrimination, and cultural beliefs limit \nwomen's health and access to care. Clearly written and with over 1000 \ndrawings, this book is an essential resource for any woman who wants to \nimprove her health, and for health workers who want more information about \nthe problems that affect only women, or that affect women differently from \nmen. 584 pages. \n\nA Book for Midwives, by Susan Klein, is written for midwives, traditional birth \nattendants, community health workers and anyone concerned about the health \nof pregnant women and their babies. The book is an invaluable tool for \nmidwives facilitating education and training sessions as well as an essential \nreference for practice. The author emphasizes helping pregnant women stay \nhealthy; giving good care and dealing with complications during labor, \nchildbirth and after birth; family planning; breastfeeding; and homemade, low- \ncost equipment. 528 pages. \n\nWhere There Is No Dentist, by Murray Dickson, shows people how to care for \ntheir own teeth and gums, and how to prevent tooth and gum problems. \nEmphasis is placed on sharing this knowledge in the home, community, and \nschool. The author also gives detailed and well-illustrated information on using \ndental equipment, placing fillings, taking out teeth, and suggests ways to teach \ndental hygiene and nutrition. 208 pages. \n\nDisabled Village Children, by David Werner, contains a wealth of information \n\nabout most common- disabilities of children, including, polio, xerebral palsy, \n\njuvenile arthritis, blindness, and deafness. The author gives suggestions for \nsimplified rehabilitation at the village level and explains how to make a variety \nof appropriate low-cost aids. Emphasis is placed on how to help disabled \nchildren find a role and be accepted in the community. 672 pages. \n\nHelping Health Workers Learn, by David Werner and Bill Bower, is an \nindispensable resource for anyone involved in teaching about health. This \nheavily illustrated book shows how to make health education fun and effective. \nIncludes activities for mothers and children; pointers for using theater, flannel- \nboards, and other techniques; and many ideas for producing low-cost teaching \naids. Emphasizing a people-centered approach to health care, it presents \nstrategies for effective community involvement through participatory education. \n640 pages. \n\nHelping Children Who Are Blind, by Sandy Niemann and Namita Jacob, aids \nparents and other caregivers in helping blind children from birth through age 5 \ndevelop all their capabilities. Topics include: assessing how much a child can \nsee, preventing blindness, moving around safely, teaching common activities, \nand many others. 192 pages. \n\n\nAll titles are available from Hesperian in both English and Spanish. For information regarding other \nlanguage editions, prices and ordering information, or for a brochure describing the Foundation's work, \nplease write to us: \n\nThe Hesperian Foundation \n\n1919 Addison, St., #304 \nBerkeley, California 94704 USA \nTelephone: (510) 845-4507 \nFax: (510) 845-0539 \ne-mail: bookorders@hesperian.org \nVisit our website: www.hesperian.org \n\n\nWhere l~here Is No Docfor \n\nis more than a book on first aid. It covers a wide range of things that affect the \nhealth of the villager — from diarrhea to tuberculosis, from helpful and harmful \nhome remedies to the cautious use of certain modern medicines. Special \nimportance is placed on cleanliness, a healthy diet, and vaccinations. The book \nalso covers in detail both childbirth and family planning. Not only does it help \nreaders realize what they can do for themselves, but it helps them recognize \nwhich problems need the attention of an experienced health worker. This new \nrevised edition includes information about some additional health problems — \nAIDS, dengue, complications from abortion, drug addiction, among many \nothers — and updated advice on topics covered in the first edition. \n\n\nTHIS BOOK IS FOR . . . \n\nTHE VILLAGER who lives far from medical \n^ centers. It explains in simple words and \n\ndrawings what he can do to prevent, recognize, \nand treat many common sicknesses. \n\n\nTHE VILLAGE STOREKEEPER OR PHARMACIST \nwho sells medicines and health-care supplies. The \nbook explains which medicines are most useful for \nspecific sicknesses and warns against ones that are \nuseless or dangerous. Risks and precautions are \ncarefully explained. Guidelines are given for the \nsensible use of both traditional and modern medicines. \n\nTHE TEACHER in a rural school. The book will help \nhim give practical advice and care to the sick \nand injured. It also gives guidelines for teaching \nchildren and adults in his community about the \nproblems of health, cleanliness, and nutrition. \n\n\nTHE VILLAGE HEALTH WORKER, or anyone who \nis concerned about the health and well-being \nof those in her community. An introductory \nsection for the village health worker \ndiscusses ways to determine needs, share \nknowledge, and involve the community in \nactivities that can better people’s health. \n\nMOTHERS AND MIDWIVES will find useful \nthe clear, easy-to-understand information \n\nfor home birth, care of the mother, and child health. ISBN □ TM23L4 15 5 \n\n\nTHANKS \n\n\nThis revision of Where There Is No Doctor has been a cooperative effort. We thank the \nmany users of the book around the world who have written us over the years with \ncomments and suggestions — these have guided us in updating this information. \n\nDavid Werner is the author of the original Spanish and English versions of the book. \n\nHis vision, caring, and commitment are present on every page. Carol Thuman and Jane \nMaxwell, share credit for most of the research, 'writing, and preparation of this revised \nversion. We are deeply grateful for their excellent and very careful work. \n\nThanks also to others who researched portions of this revised edition: Suellen Miller, \nSusan Klein, Ronnie Lovich, Mary Ellen Guroy, Shelley Kahane, Paula Elster, and George \nKent. For information taken from the African edition, our thanks to Andrew Pearson and \nthe other authors at Macmillan Publishers. \n\nMany doctors and health care specialists from around the world generously reviewed \nportions of the book. We cannot list them all here, but the help of the following was \nexceptional: David Sanders, Richard Laing, Bill Bower, Greg Troll, Deborah Bickel, Tom \nFrieden, Jane Zucker, David Morley, Frank Catchpool, Lonny Shavelson, Rudolph Bock, \nJoseph Cook, Sadja Greenwood, Victoria Sheffield, Sherry Hilaski, Pam Zinkin, Fernando \nViteri, Jordan Tapero, Robert Gelber, Ted Greiner, Stephen Gloyd, Barbara Mintzes, \n\nRainer Arnhold, Michael Tan, Brian Linde, Davida Coady, and Alejandro de Avila. Their \nexpert advice and help have been of great value. \n\nWe warmly thank the dedicated members of the Hesperian Foundation for their help \nin preparing the manuscript: Kyle Craven for computer graphic arts and layout, Stephen \nBabb and Cynthia Roat for computer graphics, and Lisa de Avila for editorial assistance. \nWe are also grateful to many others who helped in this book’s preparation: Kathy \nAlberts, Mary Klein, Evan Winslow-Smith, Jane Bavelas, Kim Gannon, Heidi Park, Laura \nGibney, Nancy Ogaz, Martin Bustos, Karen Woodbury, and Trude Bock. Our special \nthanks to Keith and Luella McFarland for being there when we needed them most. \n\nFor help updating this book, we thank Manisha Aryal, Marcos Burgos, Todd Jailer, Erika \nLeemann, Malcolm Lowe, Jane Maxwell, Susan McCallister, Gail McSweeney, Elena Metcalf, \nChristine Sienkiewicz, Lora Santiago, Peter Small, Melissa Smith, Fred Strauss, Fiona Thomson, \nKathleen Vickery, and Sarah Wallis. \n\nArtwork for the new edition was created by David Werner, Kyle Craven, Susan Klein, \nRegina Faul-Jansen, and Sandy Frank. We also thank the following persons and groups \nfor permission to use their artwork: Dale Crosby, Carl Werner, Macmillan Publishers (for \nsome of Felicity Shepherd’s drawings in the African edition of this book), the “New \nInternationalist” (for the picture of the VIP latrine), James Ogwang (for the drawings on \npage 417) and McGraw-Hill Book Company (for drawings appearing on pages 85 and \n104 taken from Emergency Medical Guide by John Henderson, illustrated by Niel Hardy). \n\nThe fine work of those who helped in the creation of the original version is still \nreflected on nearly every page. Our thanks to Val Price, Al Hotti, Rodney Kendall, Max \nCapestany, Rudolf Bock, Kent Benedict, Alfonzo Darricades, Carlos Felipe Soto Miller, \n\nPaul Quintana, David Morley, Bill Bower, Allison Orozco, Susan Klein, Greg Troll, Carol \nWestburg, Lynn Gordon, Myra Polinger, Trude Bock, Roger Bunch, Lynne Coen, George \nKent, Jack May, Oliver Bock, Bill Gonda, Ray Bleicher, and Jesds Manjarrez. \n\nFor this new edition, we are grateful for financial support from the Carnegie \nCorporation, Gladys and Merrill Muttart Foundation, Myra Polinger, the Public Welfare \nFoundation, Misereor, the W.K. Kellogg Foundation, the Sunflower Foundation, and the \nEdna McConnell Clark Foundation. \n\nFinally, our warm thanks to the village health workers of Project Piaxtla in rural Mexico \n— especially Martin Reyes, Miguel Angel Manjarrez, Miguel Angel Alvarez, and Roberto \nFajardo— whose experience and commitment have provided the foundation for this book. \n\n\nCONTENTS \n\n\nA list of what is discussed in each chapter \n\n\nINTRODUCTION \n\nNOTE ABOUT THIS NEW EDITION \n\n\nHealth Needs and Human Needs w2 \nMany Things Relate to Health Care w7 \nTake a Good Look at Your Community w8 \nUsing Local Resources to Meet Needs w12 \nDeciding What to Do and Where to \nBegin w13 \n\nTrying a New Idea w15 \nA Balance Between People and Land w16 \n\n\nwl \n\nA Balance Between Prevention and \nTreatment w17 \n\nSensible and Limited Use of Medicines w18 \nFinding Out What Progress Has Been \nMade w20 \n\nTeaching and Learning Together w21 \n\nTools for Teaching w22 \n\nMaking the Best Use of This Book w28 \n\n\nWORDS TO THE VILLAGE HEALTH WORKER (Brown Pages) \n\n\nChapter 1 \n\nHOME CURES AND POPULAR BELIEFS \n\nHome Cures That Help 1 \nBeliefs That Can Make People Well 2 \nBeliefs That Can Make People Sick 4 \nWitchcraft — Black Magic — and the Evil Eye 5 \n_Questions_and Answers 6 \nSunken Fontanel or Soft Spot 9 \n\n\n_L \n\nWays to Tell Whether a Home Remedy \nWorks or Not 10 \nMedicinal Plants 12 \n\nHomemade Casts — for Broken Bones 14 \nEnemas, Laxatives, and Purges 15 \n\n\nChapter 2 \n\nSICKNESSES THAT ARE OFTEN CONFUSED 17 \n\nExamples of Local Names for Sicknesses 22 \nMisunderstandings Due to Confusion of \nNames 25 \n\nConfusion between Different Illnesses That \nCause Fever 26 \n\nChapter 3 \n\nHOW TO EXAMINE A SICK PERSON 29 \n\n\nQuestions 29 \n\nEyes 33 \n\nGeneral Condition of Health \n\n30 \n\nEars 34 \n\nTemperature 30 \n\nSkin 34 \n\nHow to Use a Thermometer \n\n31 \n\nThe Belly (Abdomen) \n\n35 \n\nBreathing (Respiration) 32 \n\nMuscles and Nerves \n\n37 \n\nPulse (Heartbeat) 32 \n\n\nWhat Causes Sickness? 17 \nDifferent Kinds of Sicknesses and Their \nCauses 18 \n\nNon-infectious Diseases 18 \n\nInfectious Diseases 19 \n\nSicknesses That Are Hard to Tell Apart 20 \n\n\nChapter 4 \n\nHOW TO TAKE CARE OF A SICK PERSON \n\n\n39 \n\n\nThe Comfort of the Sick Person 39 \nSpecial Care for a Person Who Is Very ill 40 \nLiquids 40 \nFood 41 \n\nCleanliness and Changing Position in Bed 41 \n\nChapter 5 \n\nHEALING WITHOUT MEDICINES . \n\nHealing with Water 46 \n\nWhen Water Is Better than Medicines 47 \n\n\nWatching for Changes 41 \n\nSigns of Dangerous Illness 42 \n\nWhen and How to Look for Medical Help 43 \n\nWhat to Tell the Health Worker 43 \n\nPatient Report 44 \n\n\n45 \n\n\nChapter 6 \n\nRIGHT AND WRONG USE OF MODERN MEDICINES 49 \n\nGuidelines for the Use of Medicine 49 When Should Medicine Not Be Taken? 54 \n\nThe Most Dangerous Misuse of Medicine 50 \n\n\nChapter 7 \n\nANTIBIOTICS: WHAT THEY ARE AND HOW TO USE THEM 55 \n\nGuidelines for the Use of Antibiotics 56 \n\nWhat to Do if an Antibiotic Does' Not Seem to Help 57 \n\nImportance of Limited Use of Antibiotics 58 \n\n\nChapter 8 \n\nHOW TO MEASURE AND GIVE MEDICINE \n\n\nMedicine in Liquid Form 61 \n\nHow to Give Medicines to Small Children 62 \n\nHow to Take Medicines 63 \n\nChapter 9 \n\n\nWhen to Inject and When Not To 65 \nEmergencies When It Is Important to Give \nInjections 66 \nMedicines Not to Inject 67 \nRisks and Precautions 68 \nDangerous Reactions From Injecting Certain \nMedicines 70 \n\n\n59. \n\nDosage Instructions for Persons Who \nCannot Read 63 \n\n\n65 \n\nAvoiding Serious Reactions to Penicillin 71 \nHow to Prepare a Syringe for Injection 72 \nHow to Inject 73 \n\nHow Injections Can Disable Children 74 \nHow to Sterilize Equipment 74 \n\n\nINSTRUCTIONS AND PRECAUTIONS FOR INJECTIONS \n\n\nChapter 10 \nFIRST AID \n\n\n75 \n\n\nFever 75 \nShock 77 \n\nLoss of Consciousness 78 \nWhen Something Gets Stuck in the \nThroat 79 \nDrowning 79 \n\nWhen Breathing Stops: Mouth-to-Mouth \nBreathing 80 \n\nEmergencies Caused by Heat 81 \n\nHow to Control Bleeding from a Wound 82 \n\nHow to Stop Nosebleeds 83 \n\nCuts, Scrapes, and Small Wounds 84 \n\nLarge Cuts: How to Close Them 85 \n\nBandages 87 \n\n\nInfected Wounds 88 \n\nBullet, Knife, and Other Serious Wounds 90 \nEmergency Problems of the Gut \n(Acute Abdomen) 93 \nAppendicitis, Peritonitis 94 \nBurns 96 \n\nBroken Bones (Fractures) 98 \n\nHow to Move a Badly Injured Person 100 \n\nDislocations \n\n(Bones out of Place at a Joint) 101 \nStrains and Sprains 102 \nPoisoning 103 \nSnakebite 104 \n\nOther Poisonous Bites and Stings 106 \n\n\nChapter 11 \n\nNUTRITION: WHAT TO EAT TO BE HEALTHY \n\n\nSicknesses Caused by Not Eating Well 107 \nWhy It Is Important to Eat Right 109 \nPreventing Malnutrition 109 \nMain Foods and Helper Foods 110 \nEating Right to Stay Healthy 111 \nHowTo Recognize Malnutrition 112 \nEating Better When You Do Not Have Much \nMoney or Land 115 \nWhere to Get Vitamins: In Pills or \nin Foods? 118 \n\nThings to Avoid in Our Diet 119 \nThe Best Diet for Small Children 120 \nHarmful Ideas about Diet 123 \n\n\nChapter 12 \n\n\nCleanliness— and Problems from Lack of \nCleanliness 131 \n\nBasic Guidelines of Cleanliness 133 \n\nSanitation and Latrines 137 \n\nWorms and Other Intestinal Parasites 140 \n\nRoundworm (Ascaris) 140 \n\nPinworm (Threadworm, Enterobius) 141 \n\nWhipworm (Trichuris) 142 \n\nHookworm 142 \n\nTapeworm 143 \n\n\n107 \n\nSpecial Diets for Specific Health \nProblems 124 \nAnemia 124 \nRickets 125 \nHigh Blood Pressure 125 \n\nFat People- J26 \n\nConstipation 126 \nDiabetes 127 \n\nAcid Indigestion, Heartburn, and Stomach \nUlcers 128 \nGoiter \n\n(A Swelling or Lump on the Throat) 1 30 \n\n\n131 \n\nTrichinosis 144 \nAmebas 144 \nGiardia 145 \nBlood Flukes \n\n(Schistosomiasis, Bilharzia) 146 \nVaccinations (Immunizations) — Simple, Sure \nProtection 147 \n\nOther Ways to Prevent Sickness and Injury 148 \nHabits That Affect Health 1 48 \n\n\nPREVENTION: HOW TO AVOID MANY SICKNESSES \n\n\nChapter 13 \n\nSOME VERY COMMON SICKNESSES \n\n\n151 \n\n\nDehydration 151 \n\nDiarrhea and Dysentery 153 \n\nThe Care of a Person with Acute Diarrhea 160 \n\nVomiting 161 \n\nHeadaches and Migraines 162 \nColds and the Flu 163 \nStuffy and Runny Noses 164 \nSinus Trouble (Sinusitis) 165 \nHay Fever (Allergic Rhinitis) 165 \nAllergic Reactions 166 \nAsthma 167 \nCough 168 \n\n\nBronchitis 170 \nPneumonia 171 \nHepatitis 172 \n\nArthritis (Painful, Inflamed Joints) 173 \nBack Pain 173 \nVaricose Veins 175 \nPiles (Hemorrhoids) 175 \nSwelling of the Feet and Other Parts of the \nBody 176 \n\nHernia (Rupture) 177 \nFits (Convulsions) 178 \n\n\nChapter 14 \n\nSERIOUS ILLNESSES THAT NEED SPECIAL MEDICAL ATTENTION \n\n\nTuberculosis (TB, Consumption) 179 \n\nRabies 181 \n\nTetanus (Lockjaw) 182 \n\nMeningitis 185 \n\nMalaria 186 \n\n\nChapter 15 \n\nSKIN PROBLEMS \n\nGeneral Rules for Treating Skin Problems 193 \nInstructions for Using Hot Compresses 195 \nIdentifying Skin Problems 196 \nScabies 199 \nLice 200 \nBedbugs 200 \nTicks and Chiggers 201 \nSmall Sores with Pus 201 \nImpetigo 202 \nBoils and Abscesses 202 \nItching Rash, Welts, or Hives 203 \nThings That Cause Itching or Burning of the \nSkin 204 \n\nShingles (Herpes Zoster) 204 \nRingworm, Tinea (Fungus Infections) 205 \nWhite Spots on the Face and Body 206 \nMask of Pregnancy 207 \nPellagra and Other Skin Problems Due to \nMalnutrition 208 \n\n\n- • ■ 179 \n\nDengue (Breakbone Fever, Dandy \nFever) 187 \n\nBrucellosis (Undulant Fever, Malta Fever) 188 \nTyphoid Fever 188 \nTyphus 190 \n\nLeprosy (Hansen's Disease) 191 \n\n\n193 \n\nWarts (Verrucae) 210 \nCorns 210 \n\nPimples and Blackheads (Acne) 211 \nCancer of the Skin 211 \nTuberculosis of the Skin or Lymph \nNodes 212 \n\nErysipelas and Cellulitis 212 \nGangrene (Gas Gangrene) 213 \nUlcers of the Skin Caused by Poor \nCirculation 213 \nBed Sores 214 \nSkin Problems of Babies 215 \nEczema \n\n(Red Patches with Little Blisters) 216 \nPsoriasis 216 \n\n\nChapter 16 \nTHE EYES \n\n\nDanger Signs 217 \nInjuries to the Eye 218 \nHow to Remove a Speck of Dirt from the \nEye 218 \n\nChemical Burns of the Eye 219 \nRed, Painful Eyes — Different Causes 219 \n'Pink Eye’ (Conjunctivitis) 219 \nTrachoma 220 \n\nInfected Eyes in Newborn Babies \n(Neonatal Conjunctivitis) 221 \nIritis (Inflammation of the Iris) 221 \nGlaucoma 222 \nInfection of the Tear Sac \n(Dacryocystitis) 223 \n\nChapter 17 \n\nTHE TEETH, GUMS, AND MOUTH \n\nCare of Teeth and Gums 229 \nIf You Do Not Have A Toothbrush 230 \nToothaches and Abscesses 231 \nPyorrhea, a Disease of the Gums 231 \n\n\n217 \n\nTrouble Seeing Clearly 223 \nCross-Eyes and Wandering Eyes 223 \nSty (Hordeolum) 224 \nPterygium 224 \n\nA Scrape, Ulcer, or Scar on the Cornea 224 \nBleeding in the White of the Eye 225 \nBleeding behind the Cornea (Hyphema) 225 \nPus behind the Cornea (Hypopyon) 225 \nCataract 225 \n\nNight Blindness and Xerophthalmia 226 \nSpots or 'Flies’ before the Eyes 227 \nDouble Vision 227 \n\nRiver Blindness (Onchocerciasis) 227 \n\n\n229 \n\nSores or Cracks at the Corners of the \nMouth 232 \n\nWhite Patches or Spots in the Mouth 232 \nCold Sores and Fever Blisters 232 \n\n\nChapter 18 \n\nTHE URINARY SYSTEM AND THE GENITALS 233 \n\n\nUrinary Tract Infections 234 \nKidney or Bladder Stones 235 \nEnlarged Prostate Gland 235 \nDiseases Spread by Sexual Contact \n\n(Sexually Transmitted Diseases) 236 \nGonorrhea (Clap, VD, the Drip) and \nChlamydia 236 \nSyphilis 237 \n\nBubos: Bursting Lymph Nodes in the \nGroin 238 \n\n\nUse of a Catheter to Drain Urine 239 \nProblems of Women 241 \nVaginal Discharge 241 \nHow a Woman Can Avoid Many \nInfections 242 \n\nPain or Discomfort in a Woman's Belly 243 \nMen and Women Who Cannot Have Children \n(Infertility) 244 \n\n\nChapter 19 \n\nINFORMATION FOR MOTHERS AND MIDWIVES \n\n\nThe Menstrual Period \n\n(Monthly Bleeding in Women) 245 \nThe Menopause \n\n(When Women Stop Having Periods) 246 \nPregnancy 247 \n\n\n245 \n\nHow to Stay Healthy during Pregnancy 247 \nMinor Problems during Pregnancy 248 \nDanger Signs in Pregnancy 249 \nCheck-ups during Pregnancy \n(Prenatal Care) 250 \n\n\nRecord of Prenatal Care 253 \n\nThings to Have Ready before the Birth 254 \n\nPreparing for Birth 256 \n\nSigns That Show Labor Is Near 258 \n\nThe Stages of Labor 259 \n\nCare of the Baby at Birth 262 \n\nCare of the Cut Cord (Navel) 263 \n\nThe Delivery of the Placenta (Afterbirth) 264 \n\nHemorrhaging (Heavy Bleeding) 264 \n\nThe Correct Use of Oxytocics: \n\nErgonovine, Oxytocin, Pitocin, etc. 266 \nDifficult Births 267 \n\n\nTearing of the Birth Opening 269 \nCare of the Newborn Baby 270 \nIllnesses of the Newborn 272 \nThe Mother's Health after Childbirth 276 \nChildbirth Fever \n\n(Infection after Giving Birth) 276 \nCare of the Breasts 277 \nLumps or Growths in the Lower Part of the \nBelly 280 \n\nMiscarriage (Spontaneous Abortion) 281 \nHigh Risk Mothers and Babies 282 \n\n\nChapter 20 \nFAMILY PLANNING- \n\nHAVING THE NUMBER OF CHILDREN YOU WANT \n\n\nChoosing a method of Family Planning 284 \nOral Contraceptives \n\n(Birth Control Pills) 286 \nOther Methods of Family Planning 290 \nCombined Methods 292 \n\n\n283 \n\nMethods for Those Who Never Want to Have \nMore Children 293 \nHome Methods for Preventing \nPregnancy 294 \n\n\nChapter 21 \n\n\nHEALTH AND SICKNESSES OF CHILDREN \n\n\nWhat to Do to Protect Children’s \nHealth 295 \nChildren's Growth — \n\nand the ‘Road to Health' 297 \nChild Health Chart 298 \nReview of Children’s Health Problems \nDiscussed in Other Chapters 305 \nHealth Problems of Children Not \n\nDiscussed in Other Chapters 309 \nEarache and Ear Infections 309 \nSore Throat and Inflamed Tonsils 309 \nRheumatic Fever 310 \nInfectious Diseases of Childhood 311 \nChickenpox 311 \nMeasles (Rubeola) 311 \nGerman Measles (Rubella) 312 \n\n\n295 \n\nMumps 312 \n\nWhooping Cough 313 \n\nDiphtheria 313 \n\nInfantile Paralysis (Polio) 314 \n\nHow to Make Simple Crutches 315 \n\nProblems Children Are Born With 316 \n\nDislocated Hip 316 \n\nUmbilical Hernia \n\n(Belly Button That Sticks Out) 31 7 \nA 'Swollen Testicle’ \n\n(Hydrocele or Hernia) 317 \nMentally Slow, Deaf, or Deformed \nChildren 318 \n\nThe Spastic Child (Cerebral Palsy) 320 \nRetardation in the First Months of Life 321 \nSickle Cell Disease 321 \nHelping Children Learn 322 \n\n\nChapter 22 \n\nHEALTH AND SICKNESSES OF OLDER PEOPLE \n\n\n323 \n\n\nSummary of Health Problems Discussed in \nOther Chapters 323 \n\nOther Important Illnesses of Old Age 325 \nHeart Trouble 325 \n\nWords to Younger Persons Who Want to \nStay Healthy When Older 326 \nStroke (Apoplexy, Cerebro-Vascular \nAccident, CVA) 327 \n\n\nDeafness 327 \n\nLoss of Sleep (Insomnia) 328 \nDiseases Found More Often in People over \nForty 328 \n\nCirrhosis of the Liver 328 \nGallbladder Problems 329 \nAccepting Death 330 \n\n\nChapter 23 \n\nTHE MEDICINE KIT \n\nHow to Care for Your Medicine Kit 332 \nBuying Supplies for the Medicine Kit 333 \nThe Home Medicine Kit 334 \n\n\n331 \n\nThe Village Medicine Kit 336 \nWords to the Village Storekeeper \n(or Pharmacist) 338 \n\n\nTHE GREEN PAGES — The Uses, Dosage, and Precautions for Medicines . 339 \n\n\nList of Medicines in the Green Pages 341 \n\nIndex of Medicines in the Green Pages 345 \n\nInformation on Medicines 351 \n\n\nTHE BLUE PAGES— New Information \n\nAIDS 399 \n\nSores on the Genitals 402 \nCircumcision and Excision 404 \nSpecial Care for Small, Early, \n\nand Underweight Babies 405 \nEar Wax 405 \nLeishmaniasis 406 \n\n\n399 \n\nGuinea Worm 406 \nEmergencies Caused by Cold 408 \nHow to Measure Blood Pressure 41 0 \nPoisoning from Pesticides 412 \nComplications from Abortion 414 \nDrug Abuse and Addiction 416 \n\n\nVOCABULARY— Explaining Difficult Words 419 \n\nADDRESSES FOR TEACHING MATERIALS 429 \n\nINDEX (Yellow Pages) 433 \n\n\nDosage Instructions for Persons Who Cannot Read \nMaking Medical Reports \nInformation About Vital Signs \n\n\nINTRODUCTION \n\n\nThis handbook has been written primarily for those who live far from medical \ncenters, in places where there is no doctor. But even where there are doctors, \npeople can and should take the lead in their own health care. So this book is \nfor everyone who cares. It has been written in the belief that: \n\n1. Health care is not only everyone’s right, but everyone’s responsibility. \n\n2. Informed self-care should be the main goal of any health program or \nactivity. \n\n3. Ordinary people provided with clear, simple information can prevent \nand treat most common health problems in their own homes — earlier, \ncheaper, and often better than can doctors. \n\n4. Medical knowledge should not be the guarded secret of a select few, \nbut should be freely shared by everyone. \n\n5. People with little formal education can be trusted as much as those \nwith a lot. And they are just as smart. \n\n6. Basic health care should not be delivered, but encouraged. \n\nClearly, a part of informed self-care is knowing one’s own limits. Therefore \nguidelines are included not only for what to do, but for when to seek help. \n\nThe book points out those cases when it is important to see or get advice from \na health worker or doctor. But because doctors or health workers are not \nalways nearby, the book also suggests what to do in the meantime — even for \nvery serious problems. \n\n\nThis book has been written in fairly basic English, so that persons without \nmuch formal education (or whose first language is not English) can understand \nit. The language used is simple but, I hope, not childish. A few more difficult \nwords have been used where they are appropriate or fit well. Usually they are \nused in ways that their meanings can be easily guessed. This way, those who \nread this book have a chance to increase their language skills as well as their \nmedical skills. \n\nImportant words the reader may not understand are explained in a word list \nor vocabulary at the end of the book. The first time a word listed in the \nvocabulary is mentioned in a chapter it is usually written in italics. \n\n\nWhere There Is No Doctor was first written in Spanish for farm people in the \nmountains of Mexico where, 27 years ago, the author helped form a health care \nnetwork now run by the villagers themselves. Where There Is No Doctor has \nbeen translated into more than 50 languages and is used by village health \nworkers in over 100 countries. \n\n\nThe first English edition was the result of many requests to adapt it for use in \nAfrica and Asia. I received help and suggestions from persons with \nexperience in many parts of the world. But the English edition seems to have \nlost much of the flavor and usefulness of the original Spanish edition, which \nwas written for a specific area, and for people who have for years been my \nneighbors and friends. In rewriting the book to serve people in many parts of \nthe world, it has in some ways become too general. \n\nTo be fully useful, this book should be adapted by persons familiar with \nthe health needs, customs, special ways of healing, and local language of \nspecific areas. \n\n\nPersons or programs who wish to use this book, or portions of it, in \npreparing their own manuals for villagers or health workers are encouraged to \ndo so. Permission from the author or publisher is not needed — provided the \nparts reproduced are distributed free or at cost— not for profit. It would be \nappreciated if you would (1) include a note of credit and (2) send a copy of \nyour production to the Hesperian Foundation, 1919 Addison St., #304, Berkeley, \nCalifornia 94704, U.S.A. \n\nFor local or regional health programs that do not have the resources for \nrevising this book or preparing their own manuals, it is strongly suggested that \nif the present edition is used, leaflets or inserts be supplied with the book to \nprovide additional information as needed. \n\nIn the Green Pages (the Uses, Dosage, and Precautions for Medicines) \nblank spaces have been left to write in common brand names and prices of \nmedicines. Once again, local -programs or -organizations- distributing the book \nwould do well to make up a list of generic or low-cost brand names and prices, \nto be included with each copy of the book. \n\n— —■ .. • — \n\nThis book was written for anyone who wants to do something about his or \nher own and other people’s health. However, it has been widely used as a \ntraining and work manual for community health workers. For this reason, an \nintroductory section has been added for the health worker, making clear that \n\nthe health worker’s first job is to share her knowledge and help educate \npeople. \n\nToday in over-developed as well as under-developed countries, existing \nhealth care systems are in a state of crisis. Often, human needs are not being \nwell met. There is too little fairness. Too much is in the hands of too few. \n\nLet us hope that through a more generous sharing of knowledge, and \nthrough learning to use what is best in both traditional and modern ways of \nhealing, people everywhere will develop a kinder, more sensible approach to \ncaring — for their own health, and for each other. \n\n\n— D.W. \n\n\nHow to Use This Book \n\n\nWhen you get this book: \n\nRead the list of CONTENTS at the beginning. This tells what each chapter is \nabout and gives the page numbers for the different subjects discussed. \n\nTo look up an illness or other health subject: \n\n1. Look in the YELLOW PAGES at the end of the book. This is an INDEX that \nlists, in the order of the alphabet, all the subjects in this book. Also, if you look \nup a particular problem, it refers you to the possible causes (for example, look \nup ‘itching’). If you cannot find what you want, look for it under another name. \nOr... \n\n2. Check the list of CONTENTS. When you find what you want, turn to the pages \nshown. \n\nIf you do not understand the meaning \nof some of the words in this book: \n\nLook for the word in the VOCABULARY right after the blue pages in the back of \nthe book. Words explained in the Vocabulary are written in italics the first time \nthey are used in a chapter. \n\nBefore using any medicine: \n\nAlways look at the GREEN PAGES for information on uses, dosage, risks, and \nprecautions. A LIST OF MEDICINES and an INDEX OF MEDICINES can be found \nnear the beginning of the GREEN PAGES. \n\nTo be ready for emergencies: \n\n1. Keep a Medicine Kit like the ones recommended in Chapter 23 handy in the \nhouse or in the village. \n\n2. Study this book before it is needed, especially Chapter 10, FIRST AID, and \nChapter 4, HOW TO CARE FOR A SICK PERSON. \n\nTo help keep your family in good health: \n\nCarefully study Chapter 11, on NUTRITION, and Chapter 12, on PREVENTION, and \npay attention to the guidelines and precautions. \n\nTo improve health in your community: \n\nOrganize a meeting of your neighbors, to study this book and discuss local health \nproblems. Or ask a teacher to give classes to the children and adults, using the \nbook. You will find many useful suggestions in the brown pages. WORDS TO THE \nVILLAGE HEALTH WORKER, in the first part of this book. \n\n\nThanks |y the Wrtrfc and \n\n■Jed i Lillian <.if nijiiy y.r : iU |JS 3 ltd \nin(i(vidii£t]i aroiind Lha world, \nWhere There f.f Nti line tttf \n1)3.3 teen translated imo \nnunc llian SO languages- \nThe following arc some \nof ih-c- translations and \nLhc addicsscK where \nyou can obtain (tiarn- \n\n\nSPANISH AND ENGLISH: \n\nThe /Hesperian Foundation \n1910 Addison SL.-kfJOd \ni SftrKeHey, OilAjiTia $4704 \nUmted Stales ol America \nwww. hesper l an rg \nbOflkonrasi sS^espei ian org \n\nFRENCH: \n\nEN0A \n\nPublicstinns Dept \nB P 3370 \nDakar. SENEGAL \n\nARABIC: \n\nArab Resource Collective \nPO Bc*73B0 \nNipeele. CYPRUS \n\nHINDI: \n\nvha] \n\n40, InalHullqnal Area \n(Hear Gulab Hotel S of l.l T.J \nNew Delhi, IIMlfc \nJNDIA \n\nINDONESIAN: \n\nYayysani Esse^a Medic® \n\nF.Q. Sox TQ5$ \n\nYogyakarla, INDONESIA 65010 \n\n\nSPANISH: \n\nEditorial Fax-M4xico \nAvc Cuauhtemoc 143* \n\nMexico. D.F. 03310 \nMEXICO \n\nNEPALI: \n\nHealth Learning Materials Ctr \nInstitute of Medtoine \nP.O. Bq:h. 2533 \nKalhmandu. NEPAL \n\nRUSSIAN: \n\nMercy Craps Internationa) \n\n3030 SW la! Avenue \nPorlland, Oregon 07201 \nUnited Slates &l America \n\nUZBEK: \n\nAntHijiXi Osvatflpmenl Center \n£h. Rainidov Kb'Chasi 1 A \nAndiibfl City, 7ia000 \nUZBEKISTAN \n\nITALIAN: \n\nakjq Eer,p0kei!i \n\nijmversiia Delia Pace Jc»orgit> La Pira- \nC so IV Nevembre, 2R \n13100 Ctmeo. ITALY \n\n\nPlease wote to i he Hesperian. Foundation for information on other editions, \nincluding! Aymara, Bengali. Chinese, Creole, Dari, German. Kannada, Korean, \nLao, Marathi. PortuguesH. Pushtu, Quochua, Shuar, Sindhi, Sshheia. Tamil, Thai, \nTigre, Tigrina, Tswana, and Urdu, as well as English editions adapted for \nspeciiic countries. \n\nWe are looking lor ways to get ihis book ig lhaee Mean serve beet — namely \npersons in soiated villages ard fringe oommunilies of poor countries. II you are \nable lo nelp or have sag goal ions, please contact the Hssparian Foundai on. \n\nWe oHIer this book al a lower price 10 persons pi low income living in poor \ncountries. \n\n\nWORDS TO THE VILLAGE HEALTH WORKER \n\n\nWho is the village health worker? \n\nA village health worker is a person who helps lead family and neighbors \ntoward better health. Often he or she has been selected by the other villagers \nas someone who is especially able and kind. \n\nSome village health workers receive training and help from an organized \nprogram, perhaps the Ministry of Health. Others have no official position, but \nare simply members of the community whom people respect as healers or \nleaders in matters of health. Often they learn by watching, helping, and \nstudying on their own. \n\nIn the larger sense, a village health worker is anyone who takes part in \nmaking his or her village a healthier place to live. \n\nThis means almost everyone can and should be a health worker: \n\n• Mothers and fathers can show their children how to keep clean; \n\n• Farm people can work together to help their land produce more food; \n\n• Teachers can teach schoolchildren how to prevent and treat many \ncommon sicknesses and injuries; \n\n• Schoolchildren can share what they learn with their parents; \n\n• Shopkeepers can find out about the correct use of medicines they sell \nand give sensible advice and warning to buyers (see p. 338V. \n\n• Midwives can counsel parents \nabout the importance of \neating well during pregnancy, \nbreast feeding, and family \nplanning. \n\nThis book was written for the \nhealth worker in the larger sense. \n\nIt is for anyone who wants to \nknow and do more for his own, \nhis family’s or his people’s well- \nbeing. \n\nIf you are a community health \nworker, an auxiliary nurse, or even \na doctor, remember: this book is \nnot just for you. It is for all the __ \npeople. Share it! \n\nUse this book to help explain \nwhat you know to others. Perhaps \nyou can get small groups together THg village health worker lives and \n\nto read a chapter at a time and works at the level of his people, his \n\ndiscuss it. FIRST JOB IS TO SHARE HIS KNOWLEDGE. \n\n\nwl \n\n\nDear Village Health Worker, \n\n\nThis book is mostly about people's health needs. But to help your village be \na healthy place to live, you must also be in touch with their human needs. Your \nunderstanding and concern for people are just as important as your knowledge \nof medicine and sanitation. \n\nHere are some suggestions that may \nhelp you serve your people’s human \nneeds as well as health needs: \n\n1 . BE KIND. A friendly word, a smile, \na hand on the shoulder, or some other \nsign of caring often means more than \nanything else you can do. Treat others \nas your equals. Even when you are \nhurried or worried, try to remember the \nfeelings and needs of others. Often it \nhelps to ask yourself, “What would I do \nif this were a member of my own family?” \n\nTreat the sick as people. Be have compassion. \n\nespecially kind to those who are very Kindness often helps more \n\nsick or dying. And be kind to their than medicine. Never be \n\nfamilies. Let them see that you care. afraid to show you care. \n\n2. SHARE YOUR KNOWLEDGE^ As a health worker; your first job is to teach. “ \n\nThis means helping people learn more about how to keep from getting sick. It \nalso means helping people learn how to recognize and manage their illnesses \n\n— including the sensible \nuse of home remedies \nand common medicines. \n\nThere is nothing you \nhave learned that, if \ncarefully explained, \nshould be of danger to \nanyone. Some doctors \ntalk about self-care as if \nit were dangerous, \nperhaps because they \nlike people to depend on \ntheir costly services. But \nin truth, most common \nhealth problems could \nbe handled earlier and \nbetter by people in \n\nlook for ways to share your knowledge. their own homes. \n\n\nw2 \n\n\n3. RESPECT YOUR PEOPLE'S TRADITIONS AND IDEAS, \n\n\nBecause you learn something about modern medicine does not mean you \nshould no longer appreciate the customs and ways of healing of your people. \nToo often the human touch in the art of healing is lost when medical science \nmoves in. This is too bad, because ... \n\nIf you can use what is best in modern medicine, together with what is best in \ntraditional healing, the combination may be better than either one alone. \n\nIn this way, you will be adding to your people’s culture, not taking away. \n\nOf course, if you see that some of the home cures or customs are harmful \n(for example, putting excrement on the freshly cut cord of a newborn baby), \nyou will want to do something to change this. But do so carefully, with respect \nfor those who believe in such things. Never just tell people they are wrong. Try \nto help them understand WHY they should do something differently. \n\nPeople are slow to change their attitudes and traditions, and with good \nreason. They are true to what they feel is right. And this we must respect. \n\nModern medicine does not have all the answers either. It has helped solve \nsome problems, yet has led to other, sometimes even bigger ones. People \nquickly come to depend too much on modern medicine and its experts, to \noveruse medicines, and to forget how to care for themselves and each other. \n\nSo go slow — and always keep a deep respect for your people, their \ntraditions, and their human dignity. Help them build on the knowledge and \nskills they already have. \n\n\nWORK WITH TRADITIONAL \nHEALERS AND MIDWIVES— \nNOT AGAINST THEM. \n\nLearn from them \nand encourage them \nto learn from you. \n\n\nw3 \n\n\n4. KNOW YOUR OWN LIMITS. \n\n\nf I KNOW ITS A LONG WAY TO THE \nj health center, but here we. \n\nI cannot give him THE TREATMEMT \n\\HE NEEDS, i'll Go WITH YOU. \n\n\nNo matter how great or small your \nknowledge and skills, you can do a good \njob as long as you know and work within \nyour limits. This means: Do what you \nknow how to do. Do not try things you \nhave not learned about or have not had \nenough experience doing, if they might \nharm or endanger someone. \n\nBut use your judgment. \n\nOften, what you decide to do or not \ndo will depend on how far you have \nto go to get more expert help. \n\n\nFor example, a mother has just given \nbirth and is bleeding more than you \nthink is normal. If you are only half an \nhour away from a medical center, it may \nbe wise to take her there right away. \n\nBut if the mother is bleeding very \n\nheavily and you are a long way from the health center, you may decide to \nmassage her womb (see p. 265) or inject an oxytocic (see p. 266) even if you \nwere not taught this. \n\n\nKNOW YOUR LIMITS. \n\n\nDo not take unnecessary chances. But when the danger is clearly greater if \nyou do nothing, do not be afraid to try something you feel reasonably sure will \nhelp. \n\n\nKnow your limits — but also use your head. Always do your best to protect \nthe sick person rather than yourself. \n\n\n5. KEEP LEARNING. Use every chance \nyou have to learn more. Study whatever \nbooks or information you can lay your \nhands on that will help you be a better \nworker, teacher, or person. \n\nAlways be ready to ask questions of \ndoctors, sanitation officers, agriculture \nexperts, or anyone else you can learn from. \n\nNever pass up the chance to take \nrefresher courses or get additional \ntraining. \n\n\nKEEP LEARNING-Do not let \nanyone tell you there are things \nyou should not learn or know. \n\n\nYour first job is to teach, and unless \nyou keep learning more, soon you will \nnot have anything new to teach others. \n\n\nw4 \n\n\n6. PRACTICE WHAT YOU TEACH. \n\nPeople. are more likely to pay attention to \nwhat you do than what you say. As a health \nworker, you want to take special care in your \npersonal life and habits, so as to set a good \nexample for your neighbors. \n\nBefore you ask people to make latrines, \nbe sure your own family has one. \n\nAlso, if you help organize a work group — \nfor example, to dig a common garbage hole — \nbe sure you work and sweat as hard as \neveryone else. \n\n\nGood leaders do not \ntell people what to do. \nThey set the example. \n\n\nPRACTICE WHAT YOU TEACH \n(or who will listen to you?) \n\n\n7. WORK FOR THE JOY OF IT. \n\nIf you want other people to take part in improving their village and caring for \ntheir health, you must enjoy such activity yourself. If not, who will want to follow \nyour example? \n\n\nTry to make community work projects fun. For example, fencing off the public \nwater hole to keep animals away from where people take water can be hard \nwork. But 'if the whole village helps do it as a ‘work festival’ — perhaps with \nrefreshments and music — the job will be done quickly and can be fun. \n\nChildren will work \n\n\nhard and enjoy it, if \nthey can turn work \ninto play. \n\n\nYou may or may \nnot be paid for your \nwork. But never \nrefuse to care, or \ncare less, for some- \none who is poor or \ncannot pay. \n\n\nThis way you will \nwin your people’s \nlove and respect. \nThese are worth far \nmore than money. \n\n\nWORK FIRST FOR THE PEOPLE-NOT THE MONEY. \n(People are worth more.) \n\n\nw5 \n\n\n8. LOOK AHEAD— AND HELP OTHERS TO LOOK AHEAD. \n\n\nA responsible health worker does not wait for people to get sick. She tries to \nstop sickness before it starts. She encourages people to take action now to \nprotect their health and well-being in the future. \n\nMany sicknesses can be prevented. Your job, then, is to help your people \nunderstand the causes of their health problems and do something about them. \n\nMost health problems have many causes, one leading to another. To correct \nthe problem in a lasting way, you must look for and deal with the underlying \ncauses. You must get to the root of the problem. \n\nFor example, in many villages diarrhea is the most common cause of death \nin small children. The spread of diarrhea is caused in part by lack of \ncleanliness (poor sanitation and hygiene). You can do something to correct this \nby digging latrines and teaching basic guidelines of cleanliness (p. 133). \n\nBut the children who suffer and die most often from diarrhea are those \nwho are poorly nourished. Their bodies do not have strength to fight the \ninfections. So to prevent death from diarrhea we must also prevent poor \nnutrition. \n\nAnd why do so many children suffer from poor nutrition? \n\n• Is it because mothers do not realize what foods are most important (for \nexample, breast milk)? \n\n• Is it because the family does not have enough money or land to produce \nthe food it needs? \n\n• Is it because a few rich persons control most of the land and the wealth? \n\n• Is it because the poor do \nnot make the best use of \n\n\n* Is it because people do \nnot look or plan ahead? \nBecause they do not \nrealize that by working \ntogether and sharing they \ncan change the conditions \nunder which they live \nand die? \n\n\n* Is it because fathers lose \nhope and spend the little \nmoney they have on drink? \n\n\n• Is it because parents \n\n\nthey or their land can \nprovide for, and keep \nhaving more? \n\n\nland they have? \n\n\nhave more children than \n\n\nHELP OTHERS TO LOOK AHEAD. \n\n\nw6 \n\n\nYou may find that many, if not all, of \nthese things lie behind infant deaths in \nyour area. You will, no doubt, find other \ncauses as well. As a health worker it is your \njob to help people understand and do \nsomething about as many of these causes \nas you can. \n\n\nBut remember: to prevent frequent \ndeaths from diarrhea will take far more \nthan latrines, pure water, and 'special \ndrink’ (oral rehydration). You may find \nthat child spacing, better land use, and \nfairer distribution of wealth, land, and \npower are more important in the long run \n\n\nThe causes that lie behind much sickness \nand human suffering are short-sightedness \nand greed. If your interest is your people's \nwell-being, you must help them learn to \nshare, to work together, and to look ahead. \n\n\nMANY THINGS \n\nRELATE TO HEALTH CARE \n\nWe have looked at some of the causes \nthat underlie diarrhea and poor nutrition. \nLikewise, you will find that such things as \n\nfood production, land distribution, \neducation, and the way people treat or \nmistreat each other lie behind many \ndifferent health problems. \n\n\nDEATH \n\n__1_ \n\n\nDIARRHEA \n\n\nSPREAD OF \nINFECTION \n\n\nPOOR HYGIENE \nAND LACK OF \nCLEANLINESS \n\n\nLARGE FAMILIES \n(MANY CHILDREN) \n\nUNFAIR DISTRIBUTION \nOF LAND AND WEALTH \n\n\nGREED AND FAILURE \nTO LOOK AHEAD \n\n\nThe chain of causes leading \nto death from diarrhea. \n\n\nIf you are interested in the long-term welfare of your whole community, you \nmust help your people look for answers to these larger questions. \n\n\nHealth is more than not being sick. It is well-being: in body, mind, and \ncommunity. People live best in healthy surroundings, in a place where they can \ntrust each other, work together to meet daily needs, share in times of difficulty \nand plenty, and help each other learn and grow and live, each as fully as he or \nshe can. \n\n\nDo your best to solve day-to-day problems. But remember that your greatest \njob is to help your community become a more healthy and more human place \nto live. \n\n\nYou as a health worker have a big responsibility. \nWhere should you begin? \\ \n\n\nw7 \n\n\nTAKE A GOOD LOOK AT YOUR COMMUNITY \n\n\nBecause you have grown up in your community and know your people well, \nyou are already familiar with many of their health problems. You have an inside \nview. But in order to see the whole picture, you will need to look carefully at \nyour community from many points of view. \n\nAs a village health worker, your concern is for the well-being of all the \npeople — not just those you know well or who come to you. Go to your people. \nVisit their homes, fields, gathering places, and schools. Understand their joys \nand concerns. Examine with them their habits, the things in their daily lives that \nbring about good health, and those that may lead to sickness or injury. \n\n\nBefore you and your community attempt any project or activity, carefully \nthink about what it will require and how likely it is to work. To do this, you must \nconsider all the following: \n\n1 . Felt needs — what people feel are their biggest problems. \n\n2. Real needs — steps people can take to correct these problems in a lasting \nway. \n\n3. Willingness — or readiness of people to plan and take the needed steps. \n\n4. Resources — the persons, skills, materials, and/or money needed to carry \nout the activities decided upon. \n\nAs a simple example of how each of these things can be important, let us \nsuppose that a man who smokes a lot comes to you complaining of a cough \n\n\nthat has steadily been getting worse. \n\n\n1. His felt need is to get rid of his cough. \n\n\n3. To get rid of his cough will require his \nwillingness to give up smoking. For this \nhe must understand how much it really \nmatters. \n\n\n2. His real need (to correct the problem) \nis to give up smoking. \n\n\n4. One resource that may help him give \nup smoking is information about the harm \nit can do him and his family (see p. 149). \nAnother is the support and encouragement \nof his^family, his friends, and you. \n\n\nFinding Out the Needs \n\n\nAs a health worker, you will first want to find out your people’s most \nimportant health problems and their biggest concerns. To gather the \ninformation necessary to decide what the greatest needs and concerns really \nare, it may help to make up a list of questions. \n\n\nOn the next 2 pages are samples of the kinds of things you may want to ask. \nBut think of questions that are important in your area. Ask questions that not \nonly help you get information, but that get others asking important questions \nthemselves. \n\n\nDo not make your list of questions too long or complicated — especially a list \nyou take from house to house. Remember, people are not numbers and do not \nlike to be looked at as numbers. As you gather information, be sure your first \ninterest is always in what individuals want and feel. It may be better not even to \ncarry a list of questions. But in considering the needs of your community, you \nshould keep certain basic questions in mind. \n\n\nW9 \n\n\nSample Lists of Questions \n\nTo Help Determine Community Health Needs \nAnd at the Same Time Get People Thinking \n\n\nFELT NEEDS \n\n\nWhat things in your people’s daily lives (living conditions, ways of doing things, \nbeliefs, etc.) do they feel help them to be healthy? \n\nWhat do people feel to be their major problems, concerns, and needs— not \nonly those related to health, but in general? \n\n\nWhat are different houses made of? Walls? Floors? Are the houses kept clean? \nIs cooking done on the floor or where? How does smoke get out? On what do \npeople sleep? \n\nAre flies, fleas, bedbugs, rats, or other pests a problem? In what way? What do \npeople do to control them? What else could be done? \n\nIs food protected? How could it be better protected? \n\nWhat animals (dogs, chickens, pigs, etc.), if any, are allowed in the house? \nWhat problems do they cause? \n\nWhat are the common diseases of animals? How do they affect people's \nhealth? What is being done about these diseases? \n\nWhere do families get their water? Is it safe to drink? What precautions are \ntaken? \n\nHow many families have latrines? How many use them properly? \n\nIs the village clean? Where do people put garbage? Whv? \n\n\nHow many people live in the community? How many are under 15 years old? \n\nHow many can read and write? What good is schooling? Does it teach children \nwhat they need to know? How else do children learn? \n\nHow many babies were born this year? How many people died? Of what? At \nwhat ages? Could their deaths have been prevented? How? \n\nIs the population (number of people) getting larger or smaller? Does this cause \nany problems? \n\nHow often were different persons sick in the past year? How many days was \neach sick? What sickness or injuries did each have? Why? \n\nHow many people have chronic (long-term) illnesses? What are they? \n\nHow many children do most parents have? How many children died? Of what? \nAt what ages? What were some of the underlying causes? \n\nHow many parents are interested in not having any more children or in not \nhaving them so often? For what reasons? (See Family Planning, p. 283.) \n\n\nHOUSING AND SANITATION \n\n\nPOPULATION \n\n\nwlO \n\n\nNUTRITION \n\n\nHow many mothers breast feed their babies? For how long? Are \nthese babies healthier than those who are not breast fed? Why? \n\nWhat are the main foods people eat? Where do they come from? \n\nDo people make good use of all foods available? \n\nHow many children are underweight (p. ,109) or show signs of poor nutrition? \nHow much do parents and schoolchildren know about nutritional needs? \n\nHow many people smoke a lot? How many drink alcoholic or soft drinks very \noften? What effect does this have on their own and their families’ health? (See \np. 148 to 150.) \n\nLAND AND FOOD \n\nDoes the land provide enough food for each family? \n\nHow long will it continue to produce enough food if families keep growing? \n\nHow is farm land distributed? How many people own their land? \n\nWhat efforts are being made to help the land produce more? \n\nHow are crops and food stored? Is there much damage or loss? Why? \n\nHEALING, HEALTH \n\nWhat role do local midwives and healers play in health care? \n\nWhat traditional ways of healing and medicines are used? \n\nWhich are of greatest value? Are any harmful or dangerous? \n\nWhat health services are nearby? How good are they? What do they cost? How \nmuch are they used? \n\nHow many children have been vaccinated? Against what sicknesses? \n\nWhat other preventive measures are being taken? What others might be taken? \nHow important are they? \n\nSELF-HELP \n\nWhat are the most important things that affect your \npeople's health and well-being — now and in the future? \n\nHow many of their common health problems can people care \nfor themselves? How much must they rely on outside help and medication? \n\nAre people interested in finding ways of making self-care safer, more effective, \nand more complete? Why? How can they learn more? What stands in the way? \n\nWhat are the rights of rich people? Of poor people? Of men? Of women? Of \nchildren? How is each of these groups treated? Why? Is this fair? What needs \nto be changed? By whom? How? \n\nDo people work together to meet common needs? Do they share or help each \nother when needs are great? \n\nWhat can be done to make your village a better, healthier place to live? Where \nmight you and your people begin? \n\n\nwl 1 \n\n\nUSING LOCAL RESOURCES TO MEET NEEDS \n\n\nHow you deal with a problem will depend upon what resources are available. \n\nSome activities require outside resources (materials, money, or people from \nsomewhere else). For example, a vaccination program is possible only if \nvaccines are brought in — often from another country. \n\nOther activities can be carried out completely with local resources. A family \nor a group of neighbors can fence off a water hole or build simple latrines \nusing materials close at hand. \n\nSome outside resources, such as vaccines and a few important medicines, \ncan make a big difference in people’s health. You should do your best to get \nthem. But as a general rule, it is in the best interest of your people to \n\n\nUse local resources whenever possible. \n\n\nThe more you and your \npeople can do for yourselves, \nand the less you have to \ndepend on outside assistance \nand supplies, the healthier and \nstronger your community will \nbecome. \n\nNot only can you count on \nlocal resources to be on hand \nwhen you need them, but \noften they do the best job at \nthe lowest cost. For example, \nif you can encourage mothers \nto breast feed rather than \nbottle feed their babies, this \nwill build self-reliance through \na top quality local resource — \nbreast milk! It will also prevent \nneedless sickness and death \nof many babies. \n\nIn your health work \nalways remember: \n\n\nEncourage people to make \nthe most of local resources. \n\n\nBREAST MILK— A TOP QUALITY \nLOCAL RESOURCE— BETTER THAN \nANYTHING MONEY CAN BUY! \n\n\nThe most valuable resource for the health of the people \nis the people themselves. \n\n\nw12 \n\n\nDECIDING WHAT TO DO AND WHERE TO BEGIN \n\nAfter taking a careful look at needs and resources, you and your people \nmust decide which things are more important and which to do first. You can do \nmany different things to help people be healthy. Some are important \nimmediately. Others will help determine the future well-being of individuals or \nthe whole community. \n\nIn a lot of villages, poor nutrition plays a part in other health problems. \n\nPeople cannot be healthy unless there is enough to eat. Whatever other \nproblems you decide to work with, if people are hungry or children are poorly \nnourished, better nutrition must be your first concern. \n\nThere are many different ways to approach the problem of poor nutrition, for \nmany different things join to cause it. You and your community must consider \nthe possible actions you might take and decide which are most likely to work. \n\nHere are a few examples of ways some people have helped meet their \nneeds for better nutrition. Some actions bring quick results. Others work over a \nlonger time. You and your people must decide what is most likely to work in \nyour area. \n\nPOSSIBLE WAYS TO WORK TOWARD BETTER NUTRITION \n\n\nFAMILY GARDENS \n\n\nCONTOUR DITCHES \nto prevent soil from \nwashing away \n\n\nROTATION OF CROPS \n\nEvery other planting season plant a crop that returns strength to the soil — like beans, peas, \nlentils, alfalfa, peanuts or some other plant with seed in pods (legumes). \n\n\nThis year maize \n\n\nNext year beans \n\n\nw13 \n\n\nMORE WAYS TO WORK TOWARD BETTER NUTRITION \n\n\nIRRIGATION OF LAND FISH BREEDING \n\n\nCompost pile \n\n\nw14 \n\n\nTRYING ANEW IDEA \n\n\nNot all the suggestions on the last pages are \nlikely to work in your area. Perhaps some will \nwork if changed for your particular situation and \nresources at hand. Often you can only know \nwhether something will work or not by trying it. \nThat is, by experiment. \n\nWhen you try out a new idea, always start \nsmall. If you start small and the experiment \nfails, or something has to be done differently, \nyou will not lose much. If it works, people will see \nto apply it in a bigger way. \n\n\nthat it works and can begin \n\n\nDo not be discouraged if an experiment does not work. Perhaps you can try \nagain with certain changes. You can learn as much from your failures as your \nsuccesses. But start small. \n\n\nHere is an example of experimenting with a new idea. \n\nYou learn that a certain kind of bean, such as soya, is an excellent body-building \nfood. But will it grow in your area? And if it grows, will people eat it? \n\nStart by planting a small patch — or 2 or 3 small patches in different conditions of \nsoil or water. If the beans do well, try preparing them in different ways, and see if \npeople will eat them. If so, try planting more beans in the conditions where you \nfound they grew best. But try out still other conditions in more small patches to see \nif you can get an even better crop. \n\nThere may be several conditions you want to try changing. For example, \ntype of soil, addition of fertilizer, amount of water, or different varieties of seed. \nTo best understand what helps and what does not, be sure to change only one \ncondition at a time and keep all the rest the same. \n\nFor example, to find out if animal fertilizer (manure) helps the beans grow, and how \nmuch to use, plant several small bean patches side by side, under the same \nconditions of water and sunlight, and using the same seed. But before you plant, mix \neach patch with a different amount of manure, something like this: \n\n\n5 shovels \nmanure \n\n\nThis experiment shows that a certain amount of manure helps, but that too \nmuch can harm the plants. This is only an example. Your experiments may \ngive different results. Try for yourself! \n\n\nwl 5 \n\n\nWORKING TOWARD A BALANCE BETWEEN \nPEOPLE AND LAND \n\n\nHealth depends on many things, but above all it depends on whether people \nhave enough to eat. \n\nMost food comes from the land. Land that is used well can produce more \nfood. A health worker needs to know ways to help the land better feed the \npeople — now and in the future. But even the best used piece of land can only \nfeed a certain number of people. And today, many of the people who farm \ndo not have enough land to meet their needs or to stay healthy. \n\nIn many parts of the world, the situation is getting worse, not better. Parents \noften have many children, so year by year there are more mouths to feed on the \nlimited land that the poor are permitted to use. \n\nMany health programs try to work toward a balance between people and \nland through 'family planning’, or helping people have only the number of \nchildren they want. Smaller families, they reason, will mean more land and \nfood to go around. But family planning by itself has little effect. As long as \npeople are very poor, they often want many children. Children help with work \nwithout having to be paid, and as they get bigger may even bring home a little \nmoney. When the parents grow old, some of their children — or grandchildren— \nwill perhaps be able to help care for them. \n\nFor a poor country to have many children may be an economic disaster. But \nfor a poor family to have many children is often an economic necessity — \nespecially when many die young. In the world today, for most people, having \nmany children is the surest form of social security they can hope for. \n\nSome groups and programs take a different approach. They recognize that \nhunger exists not because there is too little land to feed everyone, but because \nmost of the land is in the hands of a few selfish persons. The balance they \nseek is a fairer distribution of land and wealth. They work to help people gain \ngreater control over their health, land, and lives. \n\nIt has been shown that, where land and wealth are shared more fairly and \npeople gain greater economic security, they usually choose to have smaller \nfamilies. Family planning helps when it is truly the people’s choice. A balance \nbetween people and land can more likely be gained through helping people \nwork toward fairer distribution and social justice than through family planning \nalone. \n\nIt has been said that the social meaning of love is justice. The health worker \nwho loves her people should help them work toward a balance based on a \nmore just distribution of land and wealth. \n\n\nA LIMITED AMOUNT \nOF LAND CAN \nONLY SUPPORT A \nLIMITED NUMBER \nOF PEOPLE. \n\n\nA LASTING \nBALANCE BETWEEN \nPEOPLE AND LAND \nMUST BE BASED ON \nFAIR DISTRIBUTION. \n\n\nw16 \n\n\nWORKING TOWARD A \nBALANCE BETWEEN \n\n\nA balance between treatment and prevention often comes down to a balance \nbetween immediate needs and long-term needs. \n\nAs a health worker you must go to your people, work with them on their \nterms, and help them find answers to the needs they feel most. People’s first \nconcern is often to find relief for the sick and suffering. Therefore, one of your \nfirst concerns must be to help with healing. \n\nBut also look ahead. While caring for people’s immediate felt needs, also \nhelp them look to the future. Help them realize that much sickness and \nsuffering can be prevented and that they themselves can take preventive \nactions. \n\nBut be careful! Sometimes health planners and workers go too far. In their \neagerness to prevent future ills, they may show too little concern for the \nsickness and suffering that already exist. By failing to respond to people's \npresent needs, they may fail to gain their cooperation. And so they fail in much \nof their preventive work as well. \n\nTreatment and prevention go hand in hand. Early treatment often prevents \nmild illness from becoming serious. If you help people to recognize many of \ntheir common health problems and to treat them early, in their own homes, \nmuch needless suffering can be prevented. \n\n\nIf you want their cooperation, start where your people are. Work toward a \nbalance between prevention and treatment that is acceptable to them. Such a \nbalance will be largely determined by people’s present attitudes toward \nsickness, healing, and health. As you help them look farther ahead, as their \nattitudes change, and as more diseases are controlled, you may find that the \nbalance shifts naturally in favor of prevention. \n\nYou cannot tell the mother whose child is ill that prevention is more important \nthan cure. Not if you want her to listen. But you can tell her, while you help her \ncare for her child, that prevention is equally important. \n\n\nUse treatment as a doorway to prevention. One of the best times to talk \nto people about prevention is when they come for treatment. For example, if a \nmother brings a child with worms, carefully explain to her how to treat him. But \nalso take time to explain to both the mother and child how the worms are \nspread and the different things they can do to prevent this from happening \n(see Chapter 12). Visit their home from time to time, not to find fault, but to \nhelp the family toward more effective self-care. \n\n\nEarly treatment is a form of preventive medicine. \n\n\nWork toward prevention— do not force it. \n\n\nUse treatment as a chance to teach prevention. \n\n\nSENSIBLE AND LIMITED USE OF MEDICINES \n\nOne of the most difficult and important parts of preventive care is to educate \nyour people in the sensible and limited use of medicines. A few modern \nmedicines are very important and can save lives. But for most sicknesses no \nmedicine is needed. The body itself can usually fight off sickness with rest, \ngood food, drinking lots of liquid, and perhaps some simple home remedies. \n\nPeople may come to you asking for medicine when they do not need any. \n\nYou may be tempted to give them some medicine just to please. But if you do, \nwhen they get well, they will think that you and the medicine cured them. \n\nReally their bodies cured themselves. \n\nInstead of teaching people to depend on medicines they do not need, take \ntime to explain why they should not be used. Also tell people what they can \ndo themselves to get well. \n\nThis way you are helping people to rely on local resources (themselves), \nrather than on an outside resource (medicine). Also, you are protecting their \nhealth, for there is no medicine that does not have some risk in its use. \n\n\nThree common health problems for which people too often request \nmedicines they do not need are (1) the common cold, (2) minor cough, and (3) \ndiarrhea. \n\nThe common cold is best treated by resting, drinking lots of liquids, and at \nthe most taking aspirin. Penicillin, tetracycline, and other antibiotics do not \nhelp at all (see p. 163). \n\nFor minor coughs, or even more severe coughs with thick mucus or phlegm, \ndrinking a lot of water will loosen mucus and ease the cough faster and better \nthan cough syrup. Breathing warm water vapor brings even greater relief (see \np. 168). Do not make people dependent on cough syrup or other medicines \nthey do not need. \n\nFor most diarrhea of children, medicines do not make them get well. Many \ncommonly used medicines (neomycin, streptomycin, kaolin-pectin, Lomotil, \nchloramphenicol) may even be harmful. What is most important is that the \nchild get lots of liquids and enough food (see p. 155 to 1 56). The key to the \n\nchild’s recovery is the mother, not the medicine. If you can help mothers \nunderstand this and learn what to do, many children’s lives can be saved. \n\n\nw18 \n\n\nMedicines are often used too much, both by doctors and by ordinary people. \nThis is unfortunate for many reasons: \n\n• It is wasteful. Most money spent on medicine would be better spent on \nfood. \n\n% It makes people depend on something they do not need (and often cannot \nafford). \n\n% Every medicine has some risk in its use. There is always a chance that an \nunneeded medicine may actually do the person harm. \n\n% What is more, when some medicines are used too often for minor \nproblems, they lose their power to fight dangerous sicknesses. \n\nAn example of a medicine losing its power is chloramphenicol. The extreme \noveruse of this important but risky antibiotic for minor infections has meant that \nin some parts of the world chloramphenicol no longer works against typhoid \nfever, a very dangerous infection. Frequent overuse of chloramphenicol has \nallowed typhoid to become resistant to it (see p. 58). \n\nFor all the above reasons the use of medicines should be limited. \n\nBut how? Neither rigid rules and restrictions nor permitting only highly \ntrained persons to decide about the use of medicines has prevented overuse. \nOnly when the people themselves are better informed will the limited and \ncareful use of medicines be common. \n\n\nTo educate people about sensible and limited use of medicines \nis one of the important jobs of the health worker. \n\n\nThis is especially true in areas where modern medicines are already in great \nuse. \n\n\n/don't YOu\\ \nthink he r \nneeds an \\a \n\nIN J ECU ON ?)fj f'\\ \n\n\nNO! ALL~HE~HA5 15 A \\ \nCOLO ■ HE WILL GET WELL \nQY HIMSELF LET HIM \nREST GIVE HIM \nG OOP FOOD AND \nLOTS TO DRINK. \n\nstrong medicine \nWon't help and \n\nMIGHT EVEN HARM \n\nVj4lM. J \n\n\nWHEN MEDICINES ARE NOT NEEDED, TAKE TIME TO EXPLAIN WHY. \n\n\nFor more information about the use and misuse of medicines, see Chapter J3, \npage 49. For the use and misuse of injections, see Chapter.9, page 65. For \nsensible use of home remedies, see Chapter _1_. \n\n\nw19 \n\n\nFINDING OUT WHAT PROGRESS HAS BEEN MADE \n(EVALUATION) \n\nFrom time to time in your health work, it helps to take a careful look at what \nand how much you and your people have succeeded in doing. What changes, \nif any, have been made to improve health and well-being in your community? \n\nYou may want to record each month or year the health activities that can be \nmeasured. For example: \n\n• Flow many families have put in latrines? \n\n• How many farmers take part in activities to improve their land and crops? \n\n• How many mothers and children take part in an Under-Fives Program \n(regular check-ups and learning)? \n\nThis kind of question will help you measure action taken. But to find out the \nresult or impact of these activities on health, you will need to answer other \nquestions such as: \n\n• How many children had diarrhea or signs of worms in the past month or \nyear — as compared to before there were latrines? \n\n• How much was harvested this season (corn, beans, or other crops)— as \ncompared to before improved methods were used? \n\n• How many children show normal weight and weight-gain on their Child \nHealth Charts (see p. 297) — as compared to when the Under-Fives \nProgram was started? \n\n• Do fewer children die now than before? \n\nTo be able to judge the success of any activity you need to collect certain \ninformation both before and after. For example, if you want to teach mothers \nhow important it is to breast feed their babies, first take a count of how many \nmothers are doing so. Then begin the teaching program and each year take \nanother count. This way you can get a good idea as to how much effect your \nteaching has had. \n\nYou may want to set goals. For example, you and the health committee may \nhope that 80% of the families have latrines by the end of one year. Every \nmonth you take a count. If, by the end of six months, only one-third of the \nfamilies have latrines, you know you will have to work harder to meet the goal \nyou set for yourselves. \n\n\nSetting goals often helps people work harder and get more done. \n\n\nTo evaluate the results of your health activities it helps to count and measure \ncertain things before, during, and after. \n\nBut remember: The most important part of your health work cannot be \nmeasured. It has to do with the way you and other people relate to each other; \nwith people learning and working together; with the growth of kindness, \nresponsibility, sharing, and hope. It depends on the growing strength and unity \nof the people to stand up for their basic rights. You cannot measure these \nthings. But weigh them well when you consider what changes have been made. \n\n\nTEACHING AND LEARNING TOGETHER— \n\nTHE HEALTH WORKER AS AN EDUCATOR \n\nAs you come to realize how many things affect health, you may think the \nhealth worker has an impossibly large job. And true, you will never get much \ndone if you try to deliver health care by yourself. \n\n\nOnly when the people themselves become actively responsible for their own \nand their community’s health, can important changes take place. \n\n\nYour community’s well-being depends on the involvement not of one person, \nbut of nearly everyone. For this to happen, responsibility and knowledge must \nbe shared. \n\nThis is why your first job as a health worker is to teach— to teach children, \nparents, farmers, schoolteachers, other health workers— everyone you can. \n\nThe art of teaching is the most important skill a person can learn. To teach \nis to help others grow, and to grow with them. A good teacher is not \nsomeone who puts ideas into other people’s heads; he or she is someone \nwho helps others build on their own ideas, to make new discoveries for \nthemselves. \n\nTeaching and learning should not be limited to the schoolhouse or health \npost. They should take place in the home and in the fields and on the road. \n\nAs a health worker one of your best chances to teach will probably be when \nyou treat the sick. But you should look for every opportunity to exchange \nideas, to share, to show, and to help your people think and work together. \n\nOn the next few pages are some ideas that may help you do this. They are \nonly suggestions. You will have many other ideas yourself. \n\n\nTWO APPROACHES TO HEALTH CARE \n\n\nw21 \n\n\nTools for Teaching \n\n\nFlannel-graphs are good for talking with \ngroups because you can keep making new \npictures. Cover a square board or piece of \ncardboard with a flannel cloth. You can place \ndifferent cutout drawings or photos on it. Strips \nof sandpaper or flannel glued to the backs of \ncutouts help them stick to the flannelboard. \n\n\nPosters and displays. \"A picture is worth a v \nthousand words.\" Simple drawings, with or \nwithout a few words of information, can be hung \nin the health post or anywhere that people will \nlook at them. You can copy some of the pictures \nfrom this book. \n\nIf you have trouble getting sizes and shapes right \ndraw light, even squares in pencil over the picture \nyou want to copy. \n\nNow draw the same number of squares lightly, \n\nbut larger, on the poster paper or cardboard. \n\nThen copy the drawing, square for square. \n\nIf possible, ask village artists to draw or paint \nposters. Or have children make posters on \ndifferent subjects. \n\n\nModels and demonstrations help get ideas across. \nFor example, if you want to talk with mothers and \nmidwives about care in cutting the cord of a \nnewborn child, you can make a doll for the baby. \n\nPin a cloth cord to its belly. Experienced midwives \ncan demonstrate to others. \n\n\nColor slides and filmstrips are available on \ndifferent health subjects for many parts of the \nworld. Some come in sets that tell a story. \nSimple viewers and battery-operated projectors \nare also available. \n\n\nA list of addresses where you can send for teaching materials to use for \nhealth education in your village can be found on pages 429 to 432. \n\n\nw22 \n\n\nOther Ways to Get Ideas Across \n\n\nStory telling. When you have a hard time explaining something, a story, \nespecially a true one, will help make your point. \n\nFor example, if 1 tell you that sometimes a village worker can make a better \ndiagnosis than a doctor, you may not believe me. But if I tell you about a \nvillage health worker called Irene, who runs a small nutrition center in Central \nAmerica, you may understand. \n\nOne day a small sickly child arrived at the nutrition center. He had been sent by \nthe doctor at a nearby health center because he was badly malnourished: The child \nalso had a cough, and the doctor had prescribed a cough medicine. Irene was \nworried about the child. She knew he came from a very poor family and that an older \nbrother had died a few weeks before. She went to visit the family and learned that \nthe older brother had been very sick for a long time and had coughed blood. Irene \nwent to the health center and told the doctor she was afraid the child had \ntuberculosis. Tests were made, and it turned out that Irene was right. ... So you see, \nthe health worker spotted the real problem before the doctor — because she knew her \npeople and visited their homes. \n\nStories also make learning more interesting. It helps if health workers are \ngood story tellers. \n\n\nPlay acting. Stories that make important points can reach people with even \nmore force if they are acted out. Perhaps you, the schoolteacher, or someone \non the health committee can plan short plays \nor ‘skits’ with the schoolchildren. \n\n\nFor example, to make the point \nthat food should be protected \nfrom flies to prevent the spread \nof disease, several small children \ncould dress up as flies and buzz \naround food. The flies dirty the \nfood that has not been covered. \nThen children eat this food and \nget sick. But the flies cannot get \nat food in a box with a wire screen \nfront. So the children who eat \nthis food stay well. \n\n\nThe more ways you can find to share ideas, \nthe more people will understand and remember. \n\n\nw23 \n\n\nWorking and Learning Together for the Common Good \n\n\nThere are many ways to interest and involve people in working together to \nmeet their common needs. Here are a few ideas: \n\n1. A village health committee. A group of able, interested persons can be \nchosen by the village to help plan and lead activities relating to the well-being \nof the community — for example, digging garbage pits or latrines. The health \nworker can and should share much of his responsibility with other persons. \n\n2. Group discussions. Mothers, fathers, schoolchildren, young people, folk \nhealers, or other groups can discuss needs and problems that affect health. \nTheir chief purpose can be to help people share ideas and build on what they \nalready know. \n\n3. Work festivals. Community \nprojects such as putting in a water \nsystem or cleaning up the village \ngo quickly and can be fun if \neverybody helps. Games, races, \nrefreshments, and simple prizes \nhelp turn work into play. Use \nimagination. \n\n4. Cooperatives. People can help \nkeep prices down by sharing tools, \nstorage, and perhaps land. Group \ncooperation can have a big \ninfluence on people’s well-being. \n\n5. Classroom visits. Work with the village schoolteacher to encourage \nhealth-related activities, through demonstrations and play acting. Also invite \nsmall groups of students to come to the health center. Children not only learn \nquickly, but they can help out in many ways. If you give children a chance, \nthey gladly become a valuable resource. \n\n6. Mother and child health meetings. It is especially important that pregnant \nwomen and mothers of small children (under five years old) be well informed \nabout their own and their babies' health needs. Regular visits to the health \npost are opportunities for both check-ups and learning. Have mothers keep \ntheir children’s health records and bring them each month to have their \nchildren’s growth recorded (see the Child Health Chart, p. 297). Mothers who \nunderstand the chart often take pride in making sure their children are eating \nand growing well. They can learn to understand these charts even if they \ncannot read. Perhaps you can help train interested mothers to organize and \nlead these activities. \n\n7. Home visits. Make friendly visits to people’s homes, especially homes of \nfamilies who have special problems, who do not come often to the health post, \nor who do not take part in group activities. But respect people’s privacy. If \nyour visit cannot be friendly, do not make it — unless children or defenseless \npersons are in danger. \n\n\nCHILDREN CAN DO AN AMAZING AMOUNT \nOF WORK WHEN IT IS TURNED INTO A GAME! \n\n\nw24 \n\n\nWays to Share and Exchange Ideas in a Group \n\nAs a health worker you will find that the success you have in improving your \npeople’s health will depend far more on your skills as a teacher than on your \nmedical or technical knowledge. For only when the whole community is \ninvolved and works together can big problems be overcome. \n\nPeople do not learn much from what they are told. They learn from what they \nthink, feel, discuss, see, and do together. \n\nSo the good teacher does not sit behind a desk and talk at people. He talks \nand works with them. He helps his people to think clearly about their needs \nand to find suitable ways to meet them. He looks for every opportunity to share \nideas in an open and friendly way. \n\n\nTALK WITH PEOPLE \n\n\nPerhaps the most important thing you can do as a health worker is to \nawaken your people to their own possibilities ... to help them gain confidence \nin themselves. Sometimes villagers do not change things they do not like \nbecause they do not try. Too often they may think of themselves as ignorant \nand powerless. But they are not. Most villagers, including those who cannot \nread or write, have remarkable knowledge and skills. They already make great \nchanges in their surroundings with the tools they use, the land they farm, and \nthe things they build. They can do many important things that people with a lot \nof schooling cannot. \n\nIf you can help people realize how much they already know and have done \nto change their surroundings, they may also realize that they can learn and do \neven more. By working together it is within their power to bring about even \nbigger changes for their health and well-being. \n\nThen how do you tell people these things? \n\nOften you cannot! But you can help them find out some of these things for \nthemselves— by bringing them together for discussions. Say little yourself, but \nstart the discussion by asking certain questions. Simple pictures like the \ndrawing on the next page of a farm family in Central America may help. You \nwill want to draw your own picture, with buildings, people, animals, and crops \nthat look as much as possible like those in your area. \n\n\nw25 \n\n\nUSE PICTURES TO GET PEOPLE TALKING AND THINKING TOGETHER \n\n\nShows group of people apicture similar to this and ask them to discuss it. \nAsk questions that get people talking about what they know and can do. Here \nare some sample questions: \n\n\n• Who are the people in the picture and how do they live? \n\n• What was this land like before the people came? \n\n• In what ways have they changed their surroundings? \n\n• How do these changes affect their health and well-being? \n\n• What other changes could these people make? What else could they \nlearn to do? What is stopping them? How could they learn more? \n\n• How did they learn to farm? Who taught them? \n\n• If a doctor or a lawyer moved onto this land with no more money or tools \nthan these people, could he farm it as well? Why or why not? \n\n• In what ways are these people like ourselves? \n\n\nw26 \n\n\nThis kind of group discussion helps build people’s confidence in themselves \nand in their ability to change things. It can also make them feel more involved \nin their community. \n\nAt first you may find that people are slow to speak out and say what they \nthink. But after a while they will usually begin to talk more freely and ask \nimportant questions themselves. Encourage everyone to say what he or she \nfeels and to speak up without fear. Ask those who talk most to give a chance \nto those who are slower to speak up. \n\nYou can think of many other drawings and questions to start discussions that \ncan help people look more clearly at problems, their causes, and possible \nsolutions. \n\n\nWhat questions can you ask to get people thinking about the different things \nthat lead to the condition of the child in the following picture? \n\n\nTry to think of questions that lead to others and get people asking for \nthemselves. How many of the causes underlying death from diarrhea \n(see p. w7) will your people think of when they discuss a picture like this? \n\n\nw27 \n\n\nMAKING THE BEST USE OF THIS BOOK \n\nAnyone who knows how to read can use this book in \nher own home. Even those who do not read can learn \nfrom the pictures. But to make the fullest and best use \nof the book, people often need some instruction. This \ncan be done in several ways. \n\nA health worker or anyone who gives out the book should make sure that \npeople understand how to use the list of Contents, the Index, the Green Pages \nand the Vocabulary. Take special care to give examples of how to look things \nup. Urge each person to carefully read the sections of the book that will help \nher understand what may be helpful to do, what could be harmful or \ndangerous, and when it is important to get help (see especially Chapters 1, \nJL JL and 8,, and also the SIGNS OF DANGEROUS ILLNESS, p. 42). Point out \nhow important it is to prevent sickness before it starts. Encourage people to \npay special attention to Chapters H and 12, which deal with eating right \n(nutrition) and keeping clean (hygiene and sanitation). \n\nAlso show and mark the pages that tell about the most common \nproblems in your area. For example, you can mark the pages on diarrhea \nand be sure mothers with small children understand about ‘special drink’ (oral \nrehydration, p. 152). Many problems and needs can be explained briefly. But \nthe more time you spend with people discussing how to use the book or \nreading and using it together, the more everyone will get out of it. \n\nYou as a health worker might encourage people to get together in small \ngroups to read through the book, discussing one chapter at a time. Look at \nthe biggest problems in your area— what to do about health problems that \nalready exist and how to prevent similar problems in the future. Try to get \npeople looking ahead. \n\nPerhaps interested persons can get together for a short class using this \nbook (or others) as a text. Members of the group could discuss how to \nrecognize, treat, and prevent different problems. They could take turns \nteaching and explaining things to each other. \n\nTo help learning be fun in these classes you can act out situations. For \nexample, someone can act as if he has a particular sickness and can explain \nwhat he feels. Others then ask questions and examine him (Chapter 3), Use \nthe book to try to find out what his problem is and what can be done about it. \nThe group should remember to involve the ‘sick’ person in learning more about \nhis own sickness — and should end up by discussing with him ways of \npreventing the sickness in the future. All this can be acted out in class. \n\nExciting and effective ways to teach about health care are in the book \nHelping Health Workers Learn, also available from the Hesperian Foundation. \n\nAs a health worker, one of the best ways you can help people use this book \ncorrectly is this: When persons come to you for treatment, have them look up \ntheir own or their child’s problem in the book and find out how to treat it. This \ntakes more time, but helps much more than doing it for them. Only when \nsomeone makes a mistake or misses something important do you need to step \nin and help him learn how to do it better. In this way, even sickness gives a \nchance to help people learn. \n\n\nDear village health worker — whoever and wherever you are, whether you \nhave a title or official position, or are simply someone, like myself, with an \ninterest in the well-being of others — make good use of this book. It is for you \nand for everyone. \n\nBut remember, the most important part of health care you will not find in this \nbook or any other. The key to good health lies within you and your people, in \nthe care, the concern, and appreciation you have for each other. If you want to \nsee your community be healthy, build on these. \n\n\nw29 \n\n\nNOTICE \n\n\nThis book is to help people meet most of their common \nhealth needs for and by themselves. But it does not have all \nthe answers. In case of serious illness or if you are uncertain \nabout how to handle a health problem, get advice from a \nhealth worker or doctor whenever possible. \n\n\nHome Cures \nand Popular Beliefs \n\n\nCHAPTER \n\n\n1 \n\nEverywhere on earth people use home remedies. In some places, the older \nor traditional ways of healing have been passed down from parents to children \nfor hundreds of years. \n\nMany home remedies have great value. Others have less. And some may be \nrisky or harmful. Home remedies, like modern medicines, must be used with \ncaution. \n\n\nTry to do no harm. \n\nOnly use home remedies if you are sure they are safe \nand know exactly how to use them. \n\n\nHOME CURES THAT HELP \n\nFor many sicknesses, time-tested home \nremedies work as well as modern medicines \n— or even better. They are often cheaper. \n\nAnd in some cases they are safer. \n\nFor example, many of the herbal teas \npeople use for home treatment of coughs \nand colds do more good and cause fewer \nproblems than cough syrups and strong \nmedicines some doctors prescribe. \n\nAlso, the ‘rice water’, teas, or sweetened \ndrinks that many mothers give to babies \nwith diarrhea are often safer and do more \ngood than any modern medicine. What \nmatters most is that a baby with diarrhea \nget plenty of liquids (see p. ,151). \n\nThe Limitations \nof Home Remedies \n\nSome diseases are helped by home remedies. Others can be treated better \nwith modern medicine. This is true for most serious infections. Sicknesses like \npneumonia, tetanus, typhoid, tuberculosis, appendicitis, diseases caused by \nsexual contact, and fever after childbirth should be treated with modern \nmedicines as soon as possible. For these diseases, do not lose time trying to \ntreat them first with home remedies only. \n\nIt is sometimes hard to be sure which home remedies work well and which \ndo not. More careful studies are needed. For this reason: \n\n\nFOR COUGHS, COLDS, AND COMMON \nDIARRHEA, HERBAL TEAS ARE OFTEN \nBETTER, CHEAPER, AND SAFER THAN \nMODERN MEDICINES. \n\n\nIt is often safer to treat very serious illnesses with modern \nmedicines — following the advice of a health worker if possible. \n\n\n2 \n\n\nOld Ways and New \n\nSome modern ways of meeting health needs work better than old ones. But \nat times the older, traditional ways are best. For example, traditional ways of \ncaring for children or old people are often kinder and work better than some \nnewer, less personal ways. \n\nNot many years ago everyone thought that mother's milk was the best food \nfor a young baby. They were right! Then the big companies that make canned \nand artificial milk began to tell mothers that bottle feeding was better. This is \nnot true, but many mothers believed them and started to bottle feed their \nbabies. As a result, thousands of babies have suffered and died needlessly \nfrom infection or hunger. For the reasons breast is best, see p. 271. \n\n\nRespect your people’s traditions and build on them. \n\n\nFor more ideas for building on local traditions, see Helping Health Workers \nLearn, Chapter 7. \n\n\nBELIEFS THAT CAN MAKE PEOPLE WELL \n\n\nSome home remedies have a direct effect on the body. Others seem to work \nonly because people believe in them. The healing power of belief can be \nvery strong. \n\nFor example, I once saw a man who \nsuffered from a very bad headache. \n\nTo cure him, a woman gave him a \nsmall piece of yam, or sweet potato. \n\nShe told him it was a strong painkiller. \n\nFie believed her — and the pain went \naway quickly. \n\nIt was his faith in her treatment, \nand not the yam itself, that made \nhim feel better. \n\nMany home remedies work in this \nway. They help largely because peopleV \nhave faith in them. For this reason, \n\nthey are especially useful to cure illnesses that are partly in people’s \nminds, or those caused in part by a person’s beliefs, worry, or fears. \n\n\nIncluded in this group of sicknesses are: bewitchment or hexing, \nunreasonable or hysterical fear, uncertain ‘aches and pains’ (especially in \npersons going through stressful times, such as teenage girls or older women), \nand anxiety or nervous worry. Also included are some cases of asthma, \nhiccups, indigestion, stomach ulcers, migraine headaches, and even warts. \n\n\nFor all of these problems, the manner or ‘touch’ of the healer can be very \nimportant. What it often comes down to is showing you care, helping the sick \nperson believe he will get well, or simply helping him relax. \n\n\n3 \n\n\nSometimes a person’s belief in a remedy can help with problems that have \ncompletely physical causes. \n\nFor example, Mexican villagers have the following home cures for poisonous \nsnakebite: \n\n\nIn other lands people have their own snakebite remedies — often many \ndifferent ones. As far as we know, none of these home remedies has any \ndirect effect against snake poison. The person who says that a home remedy \nkept a snake’s poison from harming him at all was probably bitten by a \nnon-poisonous snake! \n\nYet any of these home remedies may do some good if a person believes in it. \nIf it makes him less afraid, his pulse will slow down, he will move and tremble \nless, and as a result, the poison will spread through his body more slowly. So \nthere is less danger! \n\nBut the benefit of these home remedies for snakebite is limited. In spite of \ntheir common use, may people still become very ill or die. As far as we know: \n\n\nNo home cure for poisonous bites \n\n(whether from snakes, scorpions, spiders, or other poisonous animals) \nhas much effect beyond that of the healing power of belief. \n\n\nFor snakebite it is usually better to use modern treatment. Be prepared: obtain \n‘antivenoms’ or ‘serums' for poisonous bites before you need them (see p. \n105). Do not wait until it is too late. \n\n\n4 \n\n\nBELIEFS THAT CAN MAKE PEOPLE SICK \n\n\nThe power of belief can help heal people. But it can also harm them. If a \nperson believes strongly enough that something will hurt him, his own fear can \nmake him sick. For example: \n\n\nOnce I was called to see a woman \nwho had just had a miscarriage and \nwas still bleeding a little. There was \nan orange tree near her house. So I \nsuggested she drink a glass of orange \njuice. (Oranges have vitamin C which \nhelps strengthen blood vessels.) She \ndrank it — even though she was afraid \nit would harm her. \n\nHer fear was so great that soon \nshe became very ill. I examined her, \nbut could find nothing physically \nwrong. I tried to comfort her, telling \nher she was not in danger. But she \nsaid she was going to die. At last I \ngave her an injection of distilled \n(completely pure) water. Distilled \nwater has no medical effect. But \nsince she had great faith in \ninjections, she quickly got better. \n\n\nActually, the juice did not harm her. What harmed her was her belief that it \nwould make her sick. And what made her well was her faith in injections! \n\nIn this same way, many persons go on believing false ideas about witchcraft, \ninjections, diet, and many other things. Much needless suffering is the result. \n\nPerhaps, in a way, I had helped this woman. But the more I thought about it, \nthe more I realized I had also wronged her; I had led her to believe things that \nwere not true. \n\nI wanted to set this right. So a few days later, when she was completely well, \n\nI went to her home and apologized for what I had done. I tried to help her \nunderstand that not the orange juice, but her fear had made her so sick. And \nthat not the injection of water, but her freedom from fear had helped her get \nwell. \n\nBy understanding the truth about the orange, the injection, and the tricks of \nher own mind, perhaps this woman and her family will become freer from fear \nand better able to care for their health in the future. For health is closely \nrelated to understanding and freedom from fear. \n\n\n5 \n\n\nMany things do harm only because \npeople believe they are harmful. \n\n\nWITCHCRAFT— BLACK MAGIC— AND THE EVIL EYE \n\n\nIf a person believes strongly enough that someone has the power to harm \nhim, he may actually become ill. Anyone who believes he is bewitched or has \nbeen given the evil eye is really the victim of his own fears (see Susto, p. 24). \n\n\nA ‘witch’ has no power over \nother people, except for her ability \nto make them believe that she has. \nFor this reason: \n\n\nIt is impossible to bewitch \na person who does not believe \nin witchcraft. \n\n\nSome people think that they \nare ‘bewitched’ when they have \nstrange or frightening illnesses \n(such as tumors of the genitals or \ncirrhosis of the liver, see p. 328). \nSuch sicknesses have nothing to \ndo with witchcraft or black magic. \nTheir causes are natural. \n\n\nDo not waste your money at ‘magic centers’ that claim to cure \nwitchcraft. And do not seek revenge against a witch, because it will not \nsolve anything. If you are seriously ill, go for medical help. \n\n\n6 \n\n\nQUESTIONS AND ANSWERS ON SOME FOLK BELIEFS \nAND HOME REMEDIES \n\n\nThese examples are from the mountains of Mexico, the area that I know best. \nPerhaps some of the beliefs of your people are similar. Think about ways to \nlearn which beliefs in your area lead to better health and which do not. \n\n\nWhen people think \nsomeone is bewitched, is it \ntrue that he will get well if \nhis relatives harm or kill \nthe witch? \n\n\nFALSE! No one is ever \nhelped by harming \nsomeone else. \n\n\nIs it true that when the ‘soft \nspot’ on top of a baby’s \nhead sinks inward this \nmeans the baby will die \nof diarrhea unless he \ngets special treatment? \n\n\nThis is often true. The 'soft \nspot’ sinks because the \nbaby has lost too much \nliquid (see p. 151). Unless \nhe gets more liquid soon, \nhe may die (see p. 152). \n\n\nIs it true that if the \nlight of the eclipsing \nmoon falls on a \npregnant mother, \nher child will be born \ndeformed or retarded? \n\n\n/ \n\n\nThis is not true! But \nchildren may be born \nretarded, deaf, or deformed \nif the mother does not use \niodized salt, if she takes \ncertain medicines, or for \nother reasons (see p. 318). \n\n\nIt is true that soft light \nis easier on the eyes of \nboth the mother and \nthe newborn child. But \nthere should be enough \nlight for the midwife to \nsee what she is doing. \n\n\n7 \n\n\nIs it true that a newborn \\\\ / X \n\nbaby should not be bathed / \n\n. until the cord falls off? / /d~~ \n\n^ yf ~ i ■ \n\nTrue! The stump of the \nn cord should be kept dry \n ^ ^ \n\n,J I I 1 I I ! 1 \n\nBegins a day or more after giving \n\n■ 1 ! ! I 1 ! 1 \n\n_ 40o| j person gets worse \n\nbirth. Starts with a slight fever, \n\n1 1 1 and fever rises /i i'-' \n\nwhich often rises later. Foul-smelling \n\n1 1 | 1 1 J | 1 \n\n_ 3a=l i usually begins with 1y i i \n\nvaginal discharge. Pain and \n\n,J jlow fever'V-^] \\ | \n\nsometimes bleeding. j \n\n1 I 1 i t l i i \n\n- 36°l l 1 J i III \n\n12 34 56 70 \n\n1 \n\n| Days following childbirth \n\nAll of these illnesses can be dangerous. In addition to those shown here, \nthere are many other diseases that may cause similar signs and fever. For \nexample, fevers that last for more than 1 month, or night sweats, may be \ncaused by the HIV/AIDS virus (see p. 399). When possible, seek medical help. \n\n\n29 \n\n\nCHAPTER \n\nHow to Examine \na Sick Person \n\n\n■ To find out the needs of a sick person, first you must ask important questions \nand then examine him carefully. You should look for signs and symptoms that \nhelp you tell how ill the person is and what kind of sickness he may have. \n\nAlways examine the person where there is good light, preferably in the \nsunlight — never in a dark room. \n\nThere are certain basic things to ask and to look for in anyone who is sick. \nThese include things the sick person feels or reports (symptoms), as well as \nthings you notice on examining him (signs). These signs can be especially \nimportant in babies and persons unable to talk. In this book the word ‘signs’ is \nused for both symptoms and signs. \n\nWhen you examine a sick person, write down your findings and keep \nthem for the health worker in case he is needed (see p. 44). \n\nQUESTIONS \n\nStart by asking the person about \nher sickness. Be sure to ask the \nfollowing: \n\nWhat bothers you most right now? \n\nWhat makes you feel better or \nworse? \n\nHow and when did your sickness \nbegin? \n\nHave you had this same trouble \nbefore, or has anyone else in \nyour family or neighborhood \nhad it? \n\nContinue with other questions in order to learn the details of the illness. \n\nFor example, if the sick person has a pain, ask her: \n\nWhere does it hurt? (Ask her to point to the exact place with one finger.) \n\nDoes it hurt all the time, o.r off and on? \n\nWhat is the pain like? (sharp? dull? burning?) \n\nCan you sleep with the pain? \n\nIf the sick person is a baby who still does not talk, look for signs of pain. \nNotice his movements and how he cries. (For example, a child with an earache \nsometimes rubs the side of his head or pulls at his ear.) \n\n\n30 \n\n\nGENERAL CONDITION OF HEALTH \n\nBefore touching the sick person, look at him carefully. Observe how ill or \nweak he looks, the way he moves, how he breathes, and how clear his mind \nseems. Look for signs of dehydration (see p. 151) and of shock (p. 77). \n\nNotice whether the person looks well nourished or poorly nourished. Has he \nbeen losing weight? When a person has lost weight slowly over a long period \nof time, he may have a chronic illness (one that lasts a long time). \n\nAlso note the color of the skin and eyes. These sometimes change when a \nperson is sick. (Dark skin can hide color changes. So look at parts of the \nbody where the skin is pale, such as palms of the hands or soles of the feet, \nthe fingernails, or the insides of the lips and eyelids.) \n\n• Paleness, especially of the lips and inside the eyelids, is a sign of anemia (p. 124). \nSkin may also go lighter as a result of tuberculosis (p. 1 79), or kwashiorkor (p. 1 13). \n\n• Darkening of the skin may be a sign of starvation (see p. 1 12). \n\n• Bluish skin, especially blueness or darkness of the lips and fingernails, may mean \nserious problems with breathing to. 79, 167, and 313) or with the heart (p. 325). \nBlue-gray color in an unconscious child may be a sign of cerebral malaria (p. 186). \n\n• A gray-white coloring, with cool moist skin, often means a person is in shock (p. 77). \n\n• Yellow color (jaundice) of the skin and eyes may result from disease in the liver \n(hepatitis, p. 172, cirrhosis, p. 328, or amebic abscess, p. 145) or gallbladder (p. \n329). It may also occur in newborn babies (p. 274), and in children born with \nsickle cell disease (p. 321). \n\nLook also at the skin when a light is shining across it from one side. This can \nshow the earliest sign of measles rash on the face of a feverish child (p. 31 1). \n\nTEMPERATURE \n\nIt is often wise to take a sick person’s temperature, even if \nhe does not seem to have a fever. If the person is very sick, \ntake the temperature at least 4 times each day and write it down. \n\nIf there is no thermometer, you can get an \nidea of the temperature by putting the back \nof one hand on the sick person's forehead \nand the other on your own or that of another \nhealthy person. If the sick person has a \nfever, you should feel the difference. \n\nIt is important to find out when and how the fever comes, how long it lasts, \nand how it goes away. This may help you identify the disease. Not every fever \nis malaria, though in some countries it is often treated as such. Remember \nother possible causes. For example: \n\n• Common cold, and other virus infections (p. 163). The fever is usually mild. \n\n• Typhoid causes a fever that goes on rising for 5 days. Malaria medicine does not help. \n\n• Tuberculosis sometimes causes a mild fever in the afternoon. At night the person often \nsweats, and the fever goes down. \n\n\n31 \n\n\nHow to Use a Thermometer \n\nEvery family should have a thermometer. Take the temperature of a sick \nperson 4 times a day and always write it down. \n\n\nHow to read the thermometer (using one marked in degrees centigrade — ° C): \nTurn the thermometer until High Fever \n\n\nThe point where the silver line Th is thermometer \n\nstops marks the temperature. marks 40 degrees C. \n\n\nHow to take the temperature: \n\n1. Clean the thermometer well with soap \nand water or alcohol. Shake it hard, with \na snap of the wrist, until it reads less than \n36 degrees. \n\n2. Put the thermometer . . . \n\n\nunder the tongue \n(keeping the or \n\nmouth shut) \n\n\nin the armpit if there \nis danger of biting \nthe thermometer \n\n\ncarefully, in the anus \nor of a small child \n\n(wet or grease it first) \n\n\n3. Leave it there for 3 or 4 minutes. \n\n4. Read it. (An armpit temperature will read a little lower than a mouth \nreading; in the anus it will read a little higher.) \n\n5. Wash the thermometer well with soap and water. \n\nNote: In newborn babies a temperature that is unusually high or unusually low \n(below 36°) may mean a serious infection (see p. 275). \n\n♦ To learn about other fever patterns, see p._26 to 27. \n\n♦ To learn what to do for a fever, see p. 75. \n\n\n32 \n\n\nBREATHING (RESPIRATION) \n\nPay special attention to the way the sick person breathes — the depth (deep \nor shallow), rate (how often breaths are taken), and difficulty. Notice if both \nsides of the chest move equally when she breathes. \n\nIf you have a watch or simple timer, count the number of breaths per minute \n(when the person is quiet). Between 12 and 20 breaths per minute is normal for \nadults and older children. Up to 30 breaths a minute is normal for children, and \n40 for babies. People with a high fever or serious respiratory illnesses (like \npneumonia) breathe more quickly than normal. More than 40 shallow breaths a \nminute in an adult, or 60 in a small child, usually means pneumonia. \n\nListen carefully to the sound of the breaths. For example: \n\n• A whistle or wheeze and difficulty breathing out can mean asthma (see \np. 167). \n\n• A gurgling or snoring noise and difficult breathing in an unconscious \nperson may mean the tongue, mucus (slime or pus), or something else is \nstuck in the throat and does not let enough air get through. \n\nLook for ‘sucking in' of the skin between ribs and at the angle of the neck \n(behind the collar bone) when the person breathes in. This means air has \ntrouble getting through. Consider the possibility of something stuck in the \nthroat (p. 79), pneumonia (p. 171), asthma (p. 167), or bronchitis (mild sucking \nin, see p. 170). \n\nIf the person has a cough, ask if it keeps her from sleeping. Find out if she \ncoughs up mucus, how much, its color, and if there is blood in it. \n\nPULSE (HEARTBEAT) \n\nTo take the person’s pulse, \nput your fingers on the wrist \nas shown, (Do not use your \nthumb to feel for the pulse.) \n\n\nIf you cannot find the pulse \nin the wrist, feel for it in the \nneck beside the voicebox, \n\n\nor put your ear directly on \nthe chest and listen for the \nheartbeat (or use a \nstethoscope if you have one), \n\n\nPay attention to the strength, the rate, and the regularity of the pulse. If you \nhave a watch or timer, count the pulses per minute. \n\nNORMAL PULSE FOR PEOPLE AT REST \n\n\nadults from 60 to 80 per minute \n\nchildren 80 to 100 \n\nbabies 100 to 140 \n\n\nThe pulse gets much faster with exercise and when a person is nervous, \nfrightened, or has a fever, As a general rule, the pulse increases 20 beats per \nminute for each degree (°C) rise in fever. \n\nWhen a person is very ill, take the pulse often and write it down along with \nthe temperature and rate of breathing. \n\nIt is important to notice changes in the pulse rate. For example: \n\n• A weak, rapid pulse can mean a state of shock (see p. 77). \n\n• A very rapid, very slow, or irregular pulse could mean heart trouble \n(see p. 325), \n\n• A relatively slow pulse in a person with a high fever may be a sign of \ntyphoid (see p. 188). \n\n\nEYES \n\nLook at the color of the white part of the eyes. Is it normal, red (p. 219), or \nyellow? Also note any changes in the sick person’s vision. \n\nHave the person slowly move her eyes up and down and from side to side. \nJerking or uneven movement may be a sign of brain damage. \n\nPay attention to the size of the pupils (the black ‘window’ in the center of the \neye). If they are very large, it can mean a state of shock (see p. 77). If they are \nvery large, or very small, it can mean poison or the effect of certain drugs. \n\nLook at both eyes and note any difference between the two, especially in the \nsize of the pupils: \n\n\nA big difference in the size of the pupils is almost always a medical \nemergency. \n\n• If the eye with the larger pupil hurts so badly it causes vomiting, the \nperson probably has GLAUCOMA (see p. 222). \n\n• If the eye with the smaller pupil hurts a great deal, the person may have \nIRITIS, a very serious problem (see p. 221). \n\n• Difference in the size of the pupils of an unconscious person or a person \nwho has had a recent head injury may mean brain damage. It may also \nmean STROKE (see p. 327). \n\nAlways compare the pupils of a person who is unconscious or has had a \nhead injury. \n\n\nEARS, THROAT, AND NOSE \n\nEars: Always check for signs of pain and \ninfection in the ears — especially in a child with \nfever or a cold. A baby who cries a lot or pulls \nat his ear often has an ear infection (p. 309). \n\nPull the ear gently. If this increases pain, the \ninfection is probably in the tube of the ear (ear \ncanal). Also look for redness or pus inside the ear. \n\nA small flashlight or penlight will help. But never \nput a stick, wire, or other hard object inside the ear. \n\n\nFind out if the person hears well, or if one side is more deaf than the other. \nRub your thumb and fingers together near the person’s ear to see if he can \nhear it. For deafness and ringing of the ears see page 327. \n\nThroat and Mouth: With a torch (flashlight) or sunlight examine the mouth \nand throat. To do this hold down tongue with a spoon handle or have the \nperson say ‘ahhhhh...’ Notice if the throat is red and if the tonsils (2 lumps at \nthe back of the throat) are swollen or have spots with pus (see p. 309). Also \nexamine the mouth for sores, inflamed gums, sore tongue, rotten or abscessed \nteeth and other problems. (Read Chapter 17.) \n\nNose: Is the nose runny or plugged? (Notice if and how a baby breathes \nthrough his nose.) Shine a light inside and look for mucus, pus, blood; also \nlook for redness, swelling, or bad smell. Check for signs of sinus trouble or \nhayfever (p. 165). \n\n\nSKIN \n\nIt is important to examine the sick person’s whole body, no matter how mild \nthe sickness may seem. Babies and children should be undressed completely. \nLook carefully for anything that is not normal, including: \n\n• sores, wounds, or splinters \n\n• rashes or welts \n\n• spots, patches, or any unusual markings \n\n• inflammation (sign of infection with \nredness, heat, pain and swelling) \n\n• swelling or puffiness \n\n• swollen lymph nodes (little lumps in the \nneck, the armpits, or the groin, see p. 88) \n\nAlways examine little children between the \nbuttocks, in the genital area, between the fingers \nand toes, behind the ears, and in the hair (for \nlice, scabies, ringworm, rashes, and sores). \n\nFor identification of different skin problems, \nsee pages 196-198. \n\n\n• abnormal lumps or masses \n\n• unusual thinning or loss of hair, \nor loss of its color or shine \n\n\n35 \n\n\nTHE BELLY (ABDOMEN) \n\n\nIf a person has pain in the belly, try to find out exactly where it hurts. \n\nLearn whether the pain is steady or whether it suddenly comes and goes, \nlike cramps or colic. \n\nWhen you examine the belly, first look at it for any unusual swelling or lumps. \n\nThe location of the pain often gives a clue to the cause (see the following \npage). \n\n\nFirst, ask the person Then, beginning on the opposite side from the spot \n\nto point with one finger where he has pointed, press gently on different parts \n\nwhere it hurts. of the belly to see where it hurts most. \n\n\nSee if the belly is soft or hard and whether the person can relax his stomach \nmuscles. A very hard belly could mean an acute abdomen — perhaps \nappendicitis or peritonitis (see p. 94). \n\nIf you suspect peritonitis or appendicitis, do the test for rebound pain \ndescribed on page 95. \n\nFeel for any abnormal lumps and hardened areas in the belly. \n\nIf the person has a constant pain in the stomach, with nausea, and has not \nbeen able to move her bowels, put an ear (or stethoscope) on the belly, like \nthis: \n\n\nListen for gurgles in the \nintestines. If you hear \nnothing after about 2 \nminutes, this is a danger sign. \n(See Emergency Problems of \nthe Gut, p. 93. ) \n\n\nA silent belly is like a silent dog. Beware! \n\n\n36 \n\n\nThese pictures show the areas of the belly that usually hurt when a person \nhas the following problems: \n\n\nGallbladder \n\n(see p. 329) \n\nthe pain \noften reaches \nto the back \n\n\nLiver \n\n\nUrinary system \n\n(see p. 2341 \n\n\nInflammation or \n\n\ntumor of the ovaries, \n\n\nNote: For different causes of back pain see p. 173. \n\n\n37 \n\n\nMUSCLES AND NERVES \n\n\nIf a person complains of numbness, weakness, or loss of control in part of \nhis body, or you want to test it: notice the way he walks and moves. Have him \nstand, sit, or lie completely straight, and carefully compare both sides of his \nbody. \n\n\nFace: Have him smile, frown, open his eyes wide, and \nsqueeze them shut. Notice any drooping or weakness on \none side. \n\nIf the problem began more or less suddenly, think of a \nhead injury (p. 91), stroke (p. 327), or Bell’s palsy (p. 327). \n\nIf it came slowly, it may be a brain tumor. Get medical advice \n\nAlso check for normal eye movement, size of pupils (p. 217), and how well \nhe can see. \n\nArms and legs: Look for loss of muscle. Notice — or measure — difference in \n\n\nWatch how he moves and walks. If muscle loss or weakness affects the \nwhole body, suspect malnutrition (p. 1 12) or a chronic (long-term) illness like \ntuberculosis. \n\nIf muscle loss and weakness is uneven or worse on one side, in children, \nthink first of polio (p. 314); in adults, think of a back problem, a back or head \ninjury, or stroke. \n\nFor more information on muscle testing and physical examination of disabled \npersons, see Disabled Village Children , Chapter 4, \n\n\nAlso have him hold his arms straight \nout and turn his hands up and down. \n\n\nHave him lie down and lift one leg \nand then the other. \n\n\n38 \n\n\nCheck for stiffness or tightness of different muscles: \n\n• If the jaw is stiff or will not open, suspect tetanus (p. 182) \nor a severe infection of the throat (p. 309) or of a tooth \n(p. 231). If the problem began after he yawned or was \nhit in the jaw, he may have a dislocated jaw. \n\n\nIf the neck or back is stiff and bent \nbackwards, in a very sick child, suspect \nmeningitis. If the head will not bend \nforward or cannot be put between the \nknees, meningitis is likely (p. 185). \n\n\n• If a child always has some stiff muscles and makes strange or jerky \nmovements, he may be spastic (p. 320). \n\n\n• If strange or jerky movements come suddenly, with loss of consciousness, \n\n\nhe may have fits (p. 178). If fits \nhappen often, think of epilepsy. \n\nIf they happen when he is ill, the \ncause may be high fever (p. 76) \nor dehydration (p. 151) or tetanus \n(p. 182) or meningitis (p. 185). \n\n\nTo test a person’s reflexes when you suspect tetanus, see p. 183. \n\n\nTo check for loss of feeling in the hands, feet, or other \nparts of the body: \n\n\nHave the person cover his eyes. Lightly touch \nor prick the skin in different places. Ask him to say \n'yes' when he feels it. \n\n% Loss of feeling in or near spots or patches on the \nbody is probably leprosy (p. 191 ). \n\n\n* Loss of feeling in both hands or feet \nmay be due to diabetes (p. 127) \n\nor leprosy. \n\n* Loss of feeling on one side only could \ncome from a back problem (p. 174) \nor injury. \n\n\n39 \n\n\nHow to Take Care \nof a Sick Person \n\n\nchapter \n\n4 \n\n\nSickness weakens the body. To gain strength and get well quickly, \nspecial care is needed. \n\n\nThe care a sick person receives is frequently \nthe most important part of his treatment. \n\n\nMedicines are often not necessary. But good care is always important. \nThe following are the basis of good care: \n\n\n1 . The Comfort of the Sick Person \n\n\nA person who is sick should \nrest in a quiet, comfortable place \nwith plenty of fresh air and light. \nHe should keep from getting too \nhot or cold. If the air is cold or \nthe person is chilled, cover him \nwith a sheet or blanket. But if the \nweather is hot or the person has \na fever, do not cover him at all (s< \n\n\n/ \n\n\n/ \n\n\npi \n\n\n2. Liquids \n\nIn nearly every sickness, especially when there is \nfever or diarrhea, the sick person should drink \nplenty of liquids: water, tea, juices, broths, etc. \n\n\n3. Personal Cleanliness \n\nIt is important to keep the sick person \nclean. He should be bathed every day. \n\nIf he is too sick to get out of bed, \nwash him with a sponge or \ncloth and lukewarm water. His \nclothes, sheets, and covers \nmust also be kept clean. \n\nTake care to keep crumbs and \nbits of food out of the bed, \n\n\nA SICK PERSON SHOULD \nBE BATHED EACH DAY \n\n\n4. Good Food \n\nIf the sick person feels like eating, let him. Most \nsicknesses do not require special diets. \n\nA sick person should drink plenty of liquids and \neat a lot of nourishing food (see Chapter 1 1 ). \n\nIf the person is very weak, give him as much \nnourishing food as he can eat, many times a day. \n\nIf necessary, mash the foods, or make them into \nsoups or juices. \n\nEnergy foods are especially important — for \nexample, porridges of rice, wheat, oatmeal, potato, \nor cassava. Adding a little sugar and vegetable oil \nwill increase the energy. Also encourage the sick person to drink plenty of \nsweetened drinks, especially if he will not eat much. \n\nA few problems do require special diets. These are explained on the \nfollowing pages: \n\n\nstomach ulcers and heartburn p. 128 \n\nappendicitis, gut obstruction, acute abdomen \n\n(in these cases take no food at all) p. 93 \n\ndiabetes p. 127 \n\nheart problems p. 325 \n\ngallbladder problems p. 329 \n\n\nSPECIAL CARE FOR A PERSON \nWHO IS VERY ILL \n\n1 . Liquids \n\nIt is extremely important that a very sick person drink enough liquid. If he \nonly can drink a little at a time, give him small amounts often. If he can barely \nswallow, give him sips every 5 or 10 minutes. \n\nMeasure the amount of liquids the person drinks each day. An adult needs to \ndrink 2 liters or more every day and should urinate at least a cup (60 cc.) of \nurine 3 or 4 times daily. If the person is not drinking or urinating enough, or if \nhe begins to show signs of dehydration (p. 151), encourage him to drink more. \nHe should drink nutritious liquids, usually with a little salt added. If he will not \ndrink these, give him a Rehydration Drink (see p. 152). If he cannot drink \nenough of this, and develops signs of dehydration, a health worker may be \nable to give him intravenous solution. But the need for this can usually be \navoided if the person is urged to take small sips often. \n\n\n2. Food \n\nIf the person is too sick to eat solid foods, give her soups, milk, juices, \nbroths, and other nutritious liquids (see Chapter 11). A porridge of cornmeal, \noatmeal, or rice is'also good, but should be given together with body-building \nfoods. Soups can be made with egg, beans, or well-chopped meat, fish, or \nchicken. If the person can eat only a little at a time, she should eat several \nsmall meals each day. \n\n3. Cleanliness \n\nPersonal cleanliness is very important for a seriously ill person. She should \nbe bathed every day with warm water. \n\nChange the bed clothes daily and each time they become dirty. Soiled or \nbloodstained clothes, bedding, and towels of a person with an infectious \ndisease should be handled with care. To kill any viruses or germs, wash these \nin hot soapy water, or add some chlorine bleach. \n\n\n4. Changing Position in Bed \n\nA person who is very weak and cannot turn over alone should be helped to \nchange position in bed many times each day. This helps prevent bed sores \n(see p. 214). \n\nA child who is sick for a long time should be held often on her mother’s lap. \n\nFrequent changing of the person’s position also helps to prevent pneumonia, \na constant danger for anyone who is very weak or ill and must stay in bed for a \nlong time. If the person has a fever, begins to cough, and breathes with fast, \nshallow breaths, she probably has pneumonia (see p. 171). \n\n\n5. Watching for Changes \n\nYou should watch for any change in the sick person's condition that may tell \nyou whether he is getting better or worse. Keep a record of his ‘vital signs’. \nWrite down the following facts 4 times a day: \n\n\ntemperature pulse breathing \n\n(how many degrees) (beats per minute) (breaths per minute) \n\n\nAlso write down the amount of liquids the person drinks and how many times \na day he urinates and has a bowel movement. Save this information for the \nhealth worker or doctor. \n\nIt is very important to look for signs that warn you that the person’s sickness \nis serious or dangerous. A list of Signs of Dangerous Illness is on the next \npage. If the person shows any of these signs, seek medical help immediately. \n\n\n42 \n\n\ny \n\n\nSIGNS OF DANGEROUS ILLNESS \n\n\nA person who has one or more of the following \nsigns is probably too sick to be treated at home \nwithout skilled medical help. His life may be in \ndanger. Seek medical help as soon as possible. \n\nUntil help comes, follow the instructions on the \npages indicated. \n\n\npage \n\n1 . Loss of large amounts of blood from anywhere in the body . .82, 264, 281 \n\n2. Coughing up blood 179 \n\n3. Marked blueness of lips and nails (if it is new) 30 \n\n4. Great difficulty in breathing; does not improve with rest 167, 325 \n\n5. The person cannot be wakened (coma) 78 \n\n6. The person is so weak he faints when he stands up 325 \n\n7. A day or more without being able to urinate 234 \n\n8. A day or more without being able to drink any liquids 151 \n\n9. Heavy vomiting or severe diarrhea that lasts for more than one day or \n\nmore than a few hours in babies 151 \n\n10. Black stools like tar, or vomit with blood or feces 128 \n\n1 1. Strong, continuous stomach pains with vomiting in a person \n\nwho does not have diarrhea or cannot have a bowel movement 93 \n\n12. Any strong continuous pain that lasts for more than 3 days 29 to 38 \n\n13. Stiff neck with arched back, with or without a stiff jaw 182, 185 \n\n14. More than one fit (convulsions) \n\nin someone with fever or serious illness 76, 185 \n\n15. High fever (above 39°C) that cannot be \n\nbrought down or that lasts more than 4 or 5 days 75 \n\n16. Weight loss over an extended time 20, 400 \n\n17. Blood in the urine 146, 234 \n\n1 8. Sores that keep growing and do not go away with treatment ... 191, 196, \n\n211, 212 \n\n19. A lump in any part of the body that keeps getting bigger 196, 280 \n\n20. Problems with pregnancy and childbirth: \n\nany bleeding during pregnancy 249, 281 \n\nswollen face and trouble seeing in the last months 249 \n\nlong delay once the waters have broken and labor has begun . . . . 267 \nsevere bleeding 264 \n\n\nWHEN AND HOW TO LOOK FOR MEDICAL HELP \n\n\nSeek medical help at the first sign of a dangerous illness. Do not wait until \nthe person is so sick that it becomes difficult or impossible to take him to a \nhealth center or hospital. \n\n\nIf a sick or injured person’s condition could be made worse \nby the difficulties in moving him to a health center, try to \nbring a health worker to the person. But in an \nemergency when very special attention or an \noperation may be needed (for example, \nappendicitis), do not wait for the health \nworker. Take the person to the health \ncenter or the hospital at once. \n\nWhen you need to carry a \nperson on a stretcher, make sure \nhe is as comfortable as possible \nand cannot fall out. If he has any \nbroken bones, splint them before \nmoving him (see p. 99). If the \nsun is very strong, rig a sheet \nover the stretcher to give shade \nyet allow fresh air to pass under- \nneath \n\n\nWHAT TO TELL THE HEALTH WORKER \n\nFor a health worker or doctor to recommend treatment or prescribe medicine \nwisely, she should see the sick person. If the sick person cannot be moved, \nhave the health worker come to him. If this is not possible, send a responsible \nperson who knows the details of the illness. Never send a small child or a \nfool. \n\n\nBefore sending for medical help, examine the sick person carefully and \ncompletely. Then write down the details of his disease and general condition \n(see Chapter J3). \n\nOn the next page is a form on which you can make a PATIENT REPORT. \nSeveral copies of this form are at the end of this book. Tear out one of these \nforms and carefully complete the report, giving all the details you can. \n\n\nWhen you send someone for medical help, \nalways send a completed information form with him. \n\n\nPATIENT REPORT \n\n\nTO USE WHEN SENDING FOR MEDICAL HELP \n\nName of the sick person: Age: \n\nMale Female Where is he (she)? \n\nWhat is the main sickness or problem right now? \n\n\nWhen did it begin? \n\nFlow did it begin? \n\nPlas the person had the same problem before? When? \n\nIs there fever? Flow high? ° When and for how long? \n\nPain? Where? What kind? \n\nWhat is wrong or different from normal in any of the following? \n\nSkin: Ears: \n\nEyes: Mouth and throat: \n\nGenitals: \n\nUrine: Much or little? Color? Trouble urinating? \n\nDescribe: Times in 24 hours: Times at night: \n\nStools: Color? Blood or mucus? Diarrhea? \n\nNumber of times a day: Cramps? Dehydration? Mild or \n\nsevere? Worms? What kind? \n\nBreathing: Breaths per minute: Deep, shallow, or normal? \n\nDifficulty breathing (describe): Cough (describe): \n\nWheezing? Mucus? With blood? \n\nDoes the person have any of the SIGNS OF DANGEROUS ILLNESS listed on \npage 42? Which? (give details) \n\n\nOther signs: \n\nIs the person taking medicine? What? \n\nHas the person ever used medicine that has caused a rash, hives (or bumps) \n\nwith itching, or other allergic reactions? What? \n\nThe state of the sick person is: Not very serious: Serious: \n\nVery serious: \n\n\n45 \n\n\nHealing Without \nMedicines \n\n\nCHAPTER \n\n5 \n\n\nFor most sicknesses no medicines are needed. Our bodies have their own \ndefenses, or ways to resist and fight disease. In most cases, these natural \ndefenses are far more important to our health than are medicines. \n\n\nPeople will get well from most sicknesses \n—including the common cold and ‘flu’ — \nby themselves, without need for medicines. \n\n\nTo help the body fight off or overcome a sickness, often \nkeep clean get plenty of rest \n\n\nall that is needed is to: \n\neat well and drink \na lot of liquid \n\n\nEven in a case of more serious illness, when a medicine may be needed, \n\nit is the body that must overcome the disease; the medicine only helps. \nCleanliness, rest, nutritious food, and lots of water are still very important. \n\nMuch of the art of health care does not — and should not — depend on use of \nmedications. Even if you live in an area where there are no modern medicines, \nthere is a great deal you can do to prevent and treat most common \nsicknesses — if you learn how. \n\n\nMany sicknesses can be prevented or treated without medicines. \n\n\nIf people simply learned how to use water correctly, this alone might do \nmore to prevent and cure illnesses than all the medicines they now use . . . and \nmisuse. \n\n\n46 \n\n\nHEALING WITH WATER \n\nMost of us could live without medicines. But no one can live without water. In \nfact, over half (57%) of the human body is water. If everyone living in farms and \nvillages made the best use of water, the amount of sickness and death \n— especially of children — could be reduced. \n\nFor example, correct use of water is basic both in the prevention and \ntreatment of diarrhea. In many areas diarrhea is the most common cause of \nsickness and death in small children. Contaminated (unclean) water is often \npart of the cause. \n\nAn important part of the prevention of diarrhea and many other illnesses is to \nmake sure that drinking water is safe. Protect wells and springs from dirt and \nanimals by putting fences or walls around them. Use cement or rock to provide \ngood drainage around the well or spring, so that rain or spilled water runs \naway from it. \n\n\nWhere water may be contaminated, \nan important part of the prevention of \ndiarrhea is to boil or filter the water used \nfor drinking or for preparing foods. This is \nespecially important for babies. Babies' \nbottles and eating utensils should also \nbe boiled. If regular boiling of bottles is \nnot possible, it is safer to use a cup and \nspoon. Washing hands with soap and \nwater after a bowel movement (shitting) \nand before eating or handling foods is \nalso important. \n\n\nA common cause of death in children \nwith diarrhea is severe dehydration, \nor loss of too much water from the body \n(see p. 151). By giving a child with \ndiarrhea plenty of water (best with \nsugar or cereal and salt), dehydration \ncan often be prevented or corrected \n(see Rehydration Drink, p. 152). \n\n\nGiving lots of liquids to a child with diarrhea is more important than any \nmedicine. In fact, if enough liquid is given, no medicine is usually needed in \nthe treatment of diarrhea. \n\n\nOn the next 2 pages are a number of other situations in which it is often \nmore important to use water correctly than to use medicines. \n\n\n2 0 1 2 m < m CD T) \n\n\nTimes When the Right Use of Water \nMay Do More Good than Medicines \n\n\n47 \n\n\nto help prevent \n\n1 . diarrhea, worms, \ngut infections \n\n\n2. skin infections \n\n\n3. wounds becoming \ninfected; tetanus \n\n\nto treat \n\n1 . diarrhea, \ndehydration \n\n2. illnesses with fever \n\n\n3. high fever \n\n\n4. minor urinary \ninfections (common \nin women) \n\n5. cough, asthma, \nbronchitis, \npneumonia, \nwhooping cough \n\n\nPREVENTION \n\n\nuse water see page \n\nboil or filter drinking 135 \nwater, wash hands, \netc. \n\n\nbathe often 133 \n\nwash wounds well 84, 89 \n\nwith soap and clean \nwater \n\n\nTREATMENT \n\n\nuse water \n\ndrink plenty of \nliquids \n\n\ndrink plenty of \nliquids \n\n\nremove clothing \nand soak body \nwith cool water \n\n\n75 \n\n\n76 \n\n\ndrink plenty of 235 \n\nwater \n\n\ndrink a lot of 168 \n\nwater and breathe \nhot water vapors \n(to loosen mucus) \n\n\n48 \n\n\nto treat \n\nuse water \n\nsee page \n\n6. sores, impetigo, \nringworm of skin \nor scalp, cradle \ncap, pimples \n\nscrub with soap \nand clean water \n\n201, 202, \n205, 211, \n215 \n\n7. infected wounds, \nabscesses, boils \n\nhot soaks or \ncompresses \n\n88, 202 \n\n8. stiff, sore muscles \nand joints \n\nhot compresses \n\n102, 173, \n174 \n\n9. strains and sprains \n\nthe first day: soak \njoint in cold water; \nthen use hot soaks \n\n102 \n\n&%\\ \n\n10. itching, burning, or \nweeping irritations \nof the skin \n\ncold compresses \n\n193, 194 \n\n1 1 . minor burns \n\nhold in cold water \nat once \n\n96 \n\n12. sore throat or \ntonsillitis \n\ngargle with warm \nsalt water \n\n309 \n\n13. acid, lye, dirt, or \nirritating \n\nsubstance in eye \n\nflood eye with cool \nwater at once, and \ncontinue for 30 \nminutes \n\n219 \n\n14. stuffed up nose \n\nsniff salt water \n\n164 \n\n15. constipation, \nhard stools \n\ndrink lots of water \n(also, enemas are \nsafer than laxatives, \nbut do not overuse) \n\n15, 126 \n\n16. cold sores or \nfever blisters \n\nhold ice on blister \nfor 1 hr. at first sign \n\n232 \n\nIn each of the above cases (except pneumonia) when water is used \ncorrectly, often medicines are not needed. In this book you will find many \nsuggestions for ways of healing without need for medicine. Use medicines \nonly when absolutely necessary. \n\n\nRight and Wrong Uses \nof Modern Medicines \n\n\nCHAPTER \n\n\n49 \n\n\n6 \n\nSome medicines sold in pharmacies or village stores can be very useful. But \nmany are of no value. Of the 60,000 medicines sold in most countries, the \nWorld Health Organization says that only about 200 are necessary. \n\nAlso, people sometimes use the best medicines in the wrong way, so that \nthey do more harm than good. To be helpful, medicine must be used \ncorrectly. \n\nMany people, including most doctors and health workers, prescribe far more \nmedicines than are needed — and by so doing cause much needless sickness \nand death. \n\n\nThere is some danger in the use of any medicine. \n\n\nSome medicines are much more dangerous than others. Unfortunately, \npeople sometimes use very dangerous medicines for mild sicknesses. (I have \nseen a baby die because his mother gave him a dangerous medicine, \nchloramphenicol, for a cold.) Never use a dangerous medicine for a mild \nillness. \n\n\nREMEMBER: MEDICINES CAN KILL \n\n\nGuidelines for the use of medicine: \n\n1 . Use medicines only when necessary. \n\n2. Know the correct use and precautions for any medicine you use (see the \nGREEN PAGES). \n\n3. Be sure to use the right dose. \n\n4. If the medicine does not help, or causes problems, stop using it. \n\n5. When in doubt, seek the advice of a health worker. \n\nNote: Some health workers and many doctors give medicines when none is \nneeded, often because they think patients expect medicine and will not be \nsatisfied until they get some. Tell your doctor or health worker you only want \nmedicine if it is definitely needed. This will save you money and be safer for \nyour health. \n\n\nOnly use a medicine when you are sure it is needed \nand when you are sure how to use it. \n\n\n50 \n\n\nTHE MOST DANGEROUS MISUSE OF MEDICINE \n\nHere is a list of the most common and dangerous errors people make in \nusing modern medicines. The improper use of the following medicines causes \nmany deaths each year. BE CAREFUL! \n\n1. Chloramphenicol (Chloromycetin) (p. 357) \n\nThe popular use of this medicine for simple diarrhea and \nother mild sicknesses is extremely unfortunate, because it is \nso risky. Use chloramphenicol only for very severe illnesses, \nlike typhoid (see p. 188). Never give it to newborn babies. \n\n2. Oxytocin (Pitocin), Pituitrin, and Ergonovine (Ergotrate) (p. 391) \n\nUnfortunately, some midwives use these medicines to speed \nup childbirth or ‘give strength’ to the mother in labor. This \npractice is very dangerous. It can kill the mother or the child. \nUse these medicines only to control bleeding after the child \nis born (see p. 266). \n\n3. Injections of any medicine \n\nThe common belief that injections are usually better \nthan medicine taken by mouth is not true. Many times \nmedicines taken by mouth work as well as or better \nthan injections. Also, most medicine is more \ndangerous injected than when taken by mouth. Injections given to a child \nwho has a mild polio infection (with only signs of a cold) can lead to paralysis \n(see p. 74). Use of injections should be very limited (read Chapter 9 carefully). \n\n4. Penicillin (p. 351) \n\nPenicillin works only against certain types of infections. Use of penicillin for \nsprains, bruises, or any pain or fever is a great mistake. As a general rule, \ninjuries that do not break the skin, even if they make large bruises, have no \ndanger of infection; they do not need to be treated with penicillin or any other \nantibiotic. Neither penicillin nor other antibiotics helps colds (see p. 163). \n\nPenicillin is dangerous for some people. Before using it, know its risks and \nthe precautions you must take — see pages 70 and 351 . \n\n5. Kanamycin and Gentamicin (Garamycin) (p. 359) \n\nToo much use of these antibiotics for babies has caused permanent hearing \nloss (deafness) in millions of babies. Give to babies only for life-threatening \ninfections. For many infections of the newborn, ampicillin works as well and is \nmuch less dangerous. \n\n\n51 \n\n\n6. Anti-diarrhea medicines with hydroxyquinolines (Clioquinol, \n\ndi-iodohydroxyquinoline, halquinol, broxyquinoline: Diodoquin, \n\nEnteroquinoJ, Amicline, Quogyl, and many other brand names) (p. 370) \n\nIn the past clioquinols were widely used to treat diarrhea. These dangerous \nmedicines are now prohibited in many countries — but in others are still sold. \n\nThey can cause permanent paralysis, blindness, and even death. For treatment \nof diarrhea, see Chapter 13. \n\n7. Cortisone and cortico-steroids (Prednisolone, dexamethasone, and others) \n\nThese are powerful anti-inflammatory drugs that are occasionally needed for \nsevere attacks of asthma, arthritis, or severe allergic reactions. But in many \ncountries, steroids are prescribed for minor aches and pains because they \noften give quick results. This is a big mistake. Steroids cause serious or \ndangerous side effects — especially if used in high doses or for more than a few \ndays. They lower a person’s defenses against infection. They can make \ntuberculosis much worse, cause bleeding of stomach ulcers, and make bones \nso weak that they break easily. \n\n8. Anabolic steroids (Nandrolone decanoate, Durabolin, Deca-Durabolin, \n\nOrabolin; stanozolol, Cetabon; oxymetholone, Anapolon; ethylestrenol, \n\nOrganaborat. There are many other brand names.) \n\nAnabolic steroids are made from male hormones and are mistakenly used in \ntonics to help children gain weight and grow. At first the child may grow faster, \nbut he will stop growing sooner and end up shorter than he would have if he \nhad not taken the medicine. Anabolic steroids cause very dangerous side \neffects. Girls grow hair on their faces like boys, which does not go away, even \nwhen the child stops taking the medicine. Do not give growth tonics to \nchildren. Instead, to help your child grow, use the money to buy food. \n\n9. Arthritis medicines (Butazones: oxyphenbutazone, Amidozone; and \n\nphenylbutazone, Butazolidin) \n\nThese medicines for joint pain (arthritis) can cause a dangerous, sometimes \ndeadly, blood disease (agranulocytosis). They can also damage the stomach, \nliver, and kidneys. Do not use these dangerous medicines. For arthritis, \naspirin (p. 379) or ibuprofen (p. 380) is much safer and cheaper. For pain and \nfever only, acetaminophen (p. 380) can be used. \n\n\n10. Vitamin B12, liver extract, and iron injections (p. 393) \n\n\nVitamin B12 and liver extract do not help anemia or ‘weakness’ \nexcept in rare cases. Also, they have certain risks when injected. \nThey should only be used when a specialist has prescribed them \nafter testing the blood. Also, avoid injectable iron, such as Inferon. \nTo combat anemia, iron pills are safer and work as well (see p. 124). \n\n\n52 \n\n\n11. Other vitamins (p. 392) \n\nAs a general rule, DO NOT INJECT VITAMINS. Injections are more \ndangerous, more expensive, and usually no more effective than pills. \n\nUnfortunately, many people waste their money on syrups, tonics, and 'elixirs’ \nthat contain vitamins. Many lack the most important vitamins (see p. 118). But \neven when they contain them, it is wiser to buy more and better food. \nBody-building and protective foods like beans, eggs, meat, fruit, vegetables, \nand whole grains are rich in vitamins and other nutrients (see p. 111). Giving a \nthin, weak person good food more often will usually help him far more than \ngiving him vitamin and mineral supplements. \n\n\nA person who eats well does not need extra vitamins. \n\n\nTHE BEST WAY TO GET VITAMINS: \n\n\nFor more information about vitamins, when they are necessary, and the foods \nthat have them, read Chapter 1_[, especially pages 1 1 1 and 118. \n\n\n12. Combination medicines \n\nSometimes, 2 or more medicines are combined in the same pill or tonic. \nUsually they are less effective, and more expensive, when prepared this way. \nSometimes they do more harm than good. If someone wants to prescribe \ncombination medicines, ask him or her to prescribe only the medicine that is \nreally necessary. Do not waste your money on these medicines. \n\nSome common combination medicines that should be avoided are: \n\n• cough medicines which contain medicines both to suppress a cough and \nalso to get rid of mucus. (Cough medicines are almost always useless and \na waste of money, whether or not they combine medicines.) \n\n* antibiotics combined with anti-diarrhea medicine \n\n• antacids to treat stomach ulcers together with medicine to prevent \nstomach cramps \n\n* 2 or more pain medicines (aspirin with acetaminophen — sometimes also \nwith caffeine) \n\n\n53 \n\n\n13. Calcium \n\nInjecting calcium into a vein can be extremely dangerous. It \ncan quickly kill someone if not injected very slowly. Injecting \ncalcium into the buttocks sometimes causes very serious \nabscesses or infections. \n\n\nNever inject calcium without first seeking medical advice! \n\n\nNote: In Mexico and other countries where people eat a lot of corn tortillas or \nother foods prepared with lime, it is foolish to use calcium injections or tonics \n(as is often done to ‘give strength’ or ‘help children grow’). The body gets all \nthe ca\n…[truncated]", "summary": "Where There Is No Doctor a viCCaat heeded cart handbook -revised edition % Vavld Werner mcfi Carol Thuman and Jane MaxwdC mtfv drawings hy David Werner Compiled by noonya Library of Congress Cataloging-in-Publication Data Werner, David, 1934- Where there is no doctor: a village health care handbook / by David Werner; with Caro! Thuman and Jane Maxwell. — Rev. ed. Includes Index. ISBN 0-942364-15-5 1. Medicine, …", "source_url": "https://archive.org/details/Where_There_Is_No_Doctor_A_Village_Health_Care_Handbook_David_Werner", "pdf_url": "https://archive.org/details/Where_There_Is_No_Doctor_A_Village_Health_Care_Handbook_David_Werner", "case": "hesperian", "tags": ["hesperian", "medicines", "person", "medicine", "health", "children", "signs", "infections", "fever", "foods", "diarrhea"], "page_count": 0} {"title": "Information for Mothers and Midwives. Lesson from Book \"Where there is no doctor\"", "content": "COMMUNITY HEALTH CELL \n37/7, (First Floor) St. Marke BR \n\n\nM-1 6 Ranaatora - 560.001 3 \n| INFORMATION FOR MOTHERS \n19 AND MIDWIVES \n\n\nThis is a reprint from \n\n\nRR There Is-No Docher \n\n\n(Indian adaptation) \n\n\npublished by the \n\n\nVoluntary Health Association of India \nC-14 Community Centre \nSafdarjung Development Area \nNew Delhi 110016 \n\n\nCOMM Ute tase PELL \n\n\n—— 291 \n\n\nCHAPTER \n\n\nINFORMATION FOR MOTHERS \n7 ) AND MIDWIVES. \n\n\nTHE MENSTRUAL PERIOD \n(MONTHLY BLEEDING IN WOMEN) \n\n\nMost girls have their first ‘period’ or monthly bleeding between the ages of 11 \nand 16. This means that they are now old encugh to become pregnant. \n\n\nThe normal period comes once every 28 days or so, and lasts 3 to 6 days. \nHowever, this varies a lot in different women. \n\n\nIrregular or painful periods are common in adolescent (teenage) girls. This does \nnot usually mean there is anything wrong. \n\n\nIf your menstrual period is painful: \n\n\nThere is no need for you to It often helps to walk around | or to take hot drinks, or put \nstay in bed. In fact, lying and do light work or your feet in hot water. \nquietly can make the pain exercises... \n\nworse. \n\n\nAlso, it may help to take baralgan (p.416) or to put hot compresses on the belly. \n\n\nDuring the period—as at all times—a woman should take care to keep clean, get \nenough sleep, and eat a well-balanced diet. She can eat everything she normally \neats and can continue to do her usual work. It is not harmful to have sex during \nthe menstrual period. \n\nShe should change her pads everyday. If she uses a cloth, she should wash \nand change everyday. \n\n\n292 LIM } 7.0 8 ait =e diate cg SS \n\n\n1S: \nSigns of menstrual er \n- some irregularity in the length of time between periods is normal for certain \nwomen, but for others it may be a sign of chronic illness, anemia, malnutrition, OF \npossibly an infection or tumor in the womb. \n\n\ne |f a period does not come when it should, this may be a sign of pregnancy. But \nfor many girls who have recently begun to menstruate, and for women over 40, \n\n‘t is often normal to miss or have irregular periods. Worry or emotional upset may \nalso cause a woman to miss her period. \n\n\ne If bleeding starts during pregnancy, this almost always is the beginning of a \nmiscarriage (death of the developing baby, see O32 7%: \n\n\ne If the menstrual period lasts more than 6 days, results in unusually heavy \nbleeding, or comes more than once a month, seek medical advice. \n\n\nTHE MENOPAUSE \n(WHEN WOMEN STOP HAVING PERIODS) \n\n\nThe menopause or climacteric 1s the time ina \nwoman’s life when the menstrual periods stop coming. \nAfter menopause, she can no longer bear children. In \ngeneral, this ‘change of life’ happens between the ages \nof 40 and 50. The periods often become irregular for \nseveral months before they stop completely. \n\n\nDuring menopause, it is normal for a woman to \nfeel many discomforts—anxiety, distress, ‘hot flashes’ \n(suddenly feeling uncomfortably hot), pains that \ntravel all over the body, sadness, etc. After \nmenopause is over, most women feel better again. \n\n\nWomen who have severe bleeding or a lot of pain in \nthe belly during menopause, or who begin to bleed \nagain after the bleeding has stopped for months or \nyears, should seek medical help. An examination is \nneeded to make sure they do not have cancer or \nanother serious problem (see p.326):. \n\n\n293 \n\n\nPREGNANCY \nSigns of pregnancy: \n\n\nAll these signs are normal: \n\n\ne The woman misses her period \n(often the first sign). \n\n\ne ‘Morning sickness’ (nausea or \nfeeling you are going to vomit, \nespecially in the morning). This is \nworse during the second and third \nmonths of pregnancy. \n\n\ne She may have to urinate more \noften. \n\n\ne The belly gets-bigger. \n\n\ne The breasts get bigger. \n\n\ne ‘Mask of pregnancy’ (dark areas \non the face, breasts, and belly). \n\n\nNy \nHf] \n\ne Finally, during the fifth month or This is the normal position of the baby in \nso, the child begins to move in the womb. the mother at 9 months. \n\n\nHow to Stay Healthy during Pregnancy: \n\n\n¢ It is very important to eat well. The body needs food rich in proteins, \nvitamins, and minerals, especially iron. (Read Chapter 1 1 in this book.) \n\ne Use iodized salt to increase the chances that the child will be born alive and \nwill not be retarded. (But to avoid swelling of the feet and other problems, do \nnot use very much salt.) \n\n¢ Keep clean. Bathe or wash regularly and brush your teeth every day. \n\n\n® In the last month of pregnancy, it is perhaps best to avoid sexual contact to \nkeep from breaking the bag of waters and causing an infection. \n\n¢ Avoid taking medicines if at al! possible. Some medicines can harm the \ndeveloping baby. Asa rule, only take medicines recommended by a health worker \nor doctor. (If a health worker is going to prescribe a medicine, and you think that \n\n\nyou might be pregnant, tell him so.) You can take aspirin or antacids once in a \nwhile if you need them. Vitamin and iron pills are often helpful and do no harm \n\n\nwhen taken in the right dosage. \n\n\n* Do not smoke or drink during pregnancy. Smoking and drinking are bad for \nthe mother and harm the developing baby. \n\n\n¢ Stay far away from children with measles, especially German measles (see \nRubella, p. 359). \n¢ Continue to work and get exercise, but try not to get too tired. \n\n\n294 \n\n\nMinor Problems during Pregnancy: \n\n\nNausea or vomiting: Normally, this is worse in the morning, during the \nSec ond or third month of pregnancy. It helps to eat something dry, like crackers \nor dry bread, before you get out of bed in the morning. Do not eat large meals, \nbut rather smaller amounts of food several times a day. In severe cases, take an \nantihistamine (see p.419) when you go to bed and when you get up in the \nmorning. Avoid greasy foods. \n\n\n2. Burning or pain in the pit of the stomach or chest (acid indiers ae and heart \nburn—see p. 149): Eat only small amounts of food at one time. |f possible, drink \nmilk. Avoid taking antacids. It helps to suck hard candy. Try to sleep with the \nchest and head lifted up some with pillows or blankets. \n\n\n3. Swelling of the feet: Rest at different times during the day with your feet up \n(see p.215). Eat less salt and avoid salty foods. Tea made from corn silk may help \n(see p. 21). If the feet are very swollen, and the hands and face also swell, seek \nmedical advice. Swelling of the feet usually comes from the pressure of the child \nin the womb during the last months. It is worse in women who are anemic, © \nmalnourished, or who eat a lot of salt. So eat nutritious food with little or no salt. \n\n\n4. Low back pain: This is common in pregnancy. It can be hetped by exercise - \nand taking care to stand and sit with the back straight (p.212). \n\n\n5. Anemia and malnutrition: Many women in rural areas are anemic even’ \nbefore they are pregnant, and become more anemic during pregnancy. To make a \nhealthy baby, a woman needs foods rich in protein and iron. If she is very pale \nand weak or has other signs of anemia and malnutrition (see p.125' and146), she \nneeds to eat more protein. She can get this by eating beans, groundnuts, chicken, \nmilk, cheese, eggs, meat, fish, and dark green leafy vegetables. She should also \ntake iron pills (9.424), especially if it is hard to get enough nutritious foods. This \nway she will strengthen her blood to resist dangerous bleeding after childbirth. lf \npossible, iron pills should also contain some folic acid and vitamin C. \n\n\n6. Swollen veins (varicose veins): These are common \niN pregnancy, due to the weight of the baby pressing on \nthe veins that come from the legs. Put your feet up \noften, as high as you can (see p.213). If the veins get \nvery big or hurt, wrap them like this with an elastic \nbandage. Take off the bandages at night. \n\n\n7. Piles (hemorrhoids): These are \nvaricose veins in the anus. They \nresult from the weight of the baby in. \nthe womb. \n\n\nTo relieve the pain, knee! with the \nbuttocks in the air like this: \n\n\nAlso see p.213. \n\n\n8. Constipation: Drink plenty of water. Eat fruits and food with a lot of \n\n\nnatural fiber, like fruits, tapiocaor bran. Get plenty of exercise. Do not take \nstrong laxatives. \n\n\n295 \nDanger Signs in Pregnancy: \n\n\n1. Bleeding: |f a woman begins to bleed during pregnancy, even a little, this is \na danger sign. She is probably having a miscarriage (losing the baby). The woman \nshould lie quietly and send for a health worker. Bleeding late in pregnancy (after \n6 months) may mean the placenta (afterbirth) is blocking the birth opening \n(placenta previa). Without expert help, the woman could hleéd to death. Try to \nget her to a hospital at once. Bae \n\n\n2. Severe anemia: The woman is weak, tired, and has pale or transparent skin \n(see The Signs of Anemia, p. 146). If not treated, she might die from blood loss \nat childbirth. If anemia is severe, a good diet is not enough to correct the \ncondition in time. See a health worker and get pills or injections of iron salts (see \np.424). If possible, she should have her baby in a hospital, in case extra blood is \nneeded. \n\n\n3. Swelling of the feet, hands, and face, with headache; dizziness, and some: . \ntimes blurred vision, are signs of toxemia or poisoning of pregnancy. Sudden \nweight gain, high blood pressure, and a lot of protein in the urine are other \n“important signs. So if you can do so, go to a midwife or health worker who can \nmeasure these things. \n\n\nTo treat TOXEMIA OF PREGNANCY a woman should: \n\n\n¢ Stay quiet and in bed at least for a few hours in the afternoon. \n\n¢ Avoid salt. (Use no salt; eat no foods that contain salt.) \n\n¢ |f she does not get better quickly, has trouble seeing, swells more in the face, \nor has fits (convulsions), get medical help fast. Her life is in danger. \n\n\nae If you have a headache or trouble \nseeing, | \n\n\nDURING THE LAST 3 MONTHS - - \nOF PREGNANCY: \n\n\nand \n\n\nif your face and hands begin to \nswell, you may be suffering from \n.—— TOXEMIA OF PREGNANCY. \n\n\nGET MEDICAL HELP ! \n\n\nIf only your feet swell, it \nprobably is not serious. But watch \nout for other signs of toxemia. \n\nUse little or no salt. a \n\n\n-~* \n\n\nTo help prevent TOXEMIA OF PREGNANCY: eat nutritious food, making sure \nto get enough protein (p. 128) and use very little salt. \n\n\n296 \n\n\nCHECK-UPS DURING PREGNANCY (PRENATAL CARE) \n\n\nMany health centers and midwives encourage pregnant women to come for \nregular prenatal (before birth) check-ups and to talk about their health needs. If \nyou are pregnant and have the chance to go for these check-ups, you will learn-. \nmany things to help you prevent problems and have a healthier baby. \n\n\nIf you are a midwife, you can orovide an important service to mothers-to-be \n(and babies-to-be) by inviting them to come for prenatal check-ups—or by going \nto see them. It is a good idea to see them once a month for the first 8 months of \npregnancy, and once a week during the last month. \n\n\nHere are some important things prenatal care should cover: \n1. Sharing information \n\n\nAsk the mother about her problems and needs. Find out how many pregnancies \nshe has had, when she had her last baby, and any problems she may have had \nduring pregnancy or childbirth. Talk with her about ways she can help herself and \nher baby be healthy, including: \n\n\n¢ Eating right. Encourage her to eat foods rich in protein, vitamins, iron, and \ncalcium (see Chapter 11). \n\n¢ Good hygiene (Chapter 12). \n\n¢ The importance of taking few or no medicines (p. 66). \n\n¢ The importance of not smoking (p. 178) and not drinking alcoholic drinks \n(p47 7). \n\n¢ Getting enough exercise and rest. \n\n¢ Tetanus vaccination to prevent tetanus in the newborn. (Give at the 6th, 7th, \nand 8th month if first time. If she has been vaccinated against tetanus \nbefore, give one booster during the 7th month.) \n\n\n2. Nutrition \n\n\nDoes the mother look well nourished? Is she anemic? If so, discuss ways of \neating better. If possible, see that she gets iron pills—preferably with folic acid and \nvitamin C. Advise her about how to handle morning sickness (p. 294) and heart- \nburn (p. 149). | \n\n\nIs she gaining weight normally? If possible, weigh her each visit. Normally she \nshould gain 8 to 10 kilograms during the nine months of pregnancy. If she stops \ngaining weight, this is a bad sign. Sudden weight gain in the last months is a \n\n\ndanger sign. If you do not have scales, try to judge if she is gaining weight by how \nshe looks. \n\n\nOr make \na simple \nscales. \n\n\nbricks or ————————> \nother objects \n\nof known \n\nweight \n\n\n297 \n\n\n3. Minor problems \n\n\nAsk the mother if she has any of the common problems of pregnancy. Explain \nthat they are not serious, and give what advice vou can (see p. 294). \n\n\n4. Signs of danger \n\n\n. Check for each of the danger signs on page 295. Take the mother’s pulse each \nvisit. This will let you know what is normal for her in case she has problems later \n(for example shock from toxemia or severe bleeding). If you have a blood pressure \ncuff (see p. 147), take her blood pressure. And weigh her. Watch out especially \nfor the following danger signs: \n\n\nsudden weight gain signs of \nswelling of hands and face toxemia of \nmarked increase in blood pressure pregnancy (p. 295) \nsevere anemia (p. 146) \n\nany. bleeding (p. 295) \n\n\nSome midwives may Have paper ‘dip sticks’ or other methods for measuring the \nprotein and sugar-in the urine. High protein may be a sign of toxemia. High sugar \nis a sign of diabetes (p. 149). \n\n\nIf any of the danger signs appear, see that the woman gets medical help as \nsoon as possible. \n\n\n5. Growth and position of the baby in the womb \nFeel the mother’s womb each time she visits; or show her how to do it herself. \n\n\n_% , ty \n2 — \n\n7 — oa. A . Normally the womb will be 2 \n7 ones wr Apes fingers higher each month. \n6 months (12 cme a \nAe oy oe ae At 4% months it is usually \n3 onthe at the level of the navel. \n\neer \n\n\nEach month write down how many finger widths the \nwomb is above or below the navel. If the womb seems too \nbig or grows too fast, it may have more water in it than \nnormal. If so, you may find it more difficult to feel the \nbaby inside. Too much water in the womb means greater \nrisk of severe bleeding during childbirth and may mean the \nbaby is deformed. \n\n\nTry to feel the baby’s position in the womb. Ait BP. \nappears to be lying sideways, the mother should go to \\ \n\na doctor before labor begins, because an operation may be \nneeded. For checking the baby’s position near the time of \n\n\nbirth, see page 303. \n\n\n298 \n\n\n| Fet \n\n6. Baby’s heartbeat (feta! heartbeat) etoscope \nAfter 5 months, listen for the baby’s heartbeat and check \n\nfor movement. You can try putting your ear against the belly, \n\nbut it may be hard to hear. It will be easier if you get a \n\nfetoscope. (Or make one. Fired clay or hard wood works well.) \nIf the baby’s heartbeat is heard loudest: If the heartbeat is heard loudest above \nbelow the navel in the last month, the the navel, his head is bg up. It may \n\n\nbaby is head down and will pres be... be a breech birth. \n_born head first. \n\n\n\\f you have a watch with a second hand, count the baby’s heartbeats. From \n120 to 160 per minute is normal. If less than 120, something is wrong. (Or \nperhaps you counted wrong or heard the mother’s heartbeat. Check her Sia The \nbaby’s heartbeat is often hard to hear. It takes practice.) \n\n\n7. Preparing the mother for labor \n\n\nAs the birth approaches, see the mother more often. |f she has other children, \nask her how long labor lasted and if she had any problems. Talk with her about \nways to make the birth easier and less painful (see the next pages). You may want \nto have her practice deep, slow breathing, so that she can do this during the \ncontractions of labor. Explain the importance of relaxing between contractions. \n\n\nIf there is any reason to suspect the labor may result in problems you cannot \nhandle, send the mother to a health center or hospital to have her baby. Be sure \nshe is near the hospital by the time labor begins. \n\n\nHOW A MOTHER CAN TELL THE DATE \nWHEN SHE IS LIKELY TO GIVE BIRTH: \n\n\nStart with the date the last menstrual period began, subtract 3 months, \nand add 7 days. \n\n\nFor example, suppose your last period began May 10. \n\n\nMay 10 minus 3 months is February 10, \nplus 7 days is February 17. \nThe baby is likely to be born around February 17. \n\n\n8. Keeping records \n\n\nPO compare your findings from month to month and see how the mother is \nprogressing, it helps to keep simple records. On the next page is a sample record \nsheet. Change it as you see fit. A larger sheet of paper would be better. Each \n\n\nmother can keep her own record sheet and bring it when she comes for her \ncheck-up. \n\n\n299 \n\n\n-YOLPEWUOJUL SLYZ 4OJ BULZSA2 4O GuLsNseaw yO SUBaW aAeY OYM SAALMPLUI 4OJ PapN[ oUt a4ue aS2U lx \n\n\nHLYIg \noe oe ee bce \nen ey a \n\nA, [aq uL samMol \n\n1 ue -atig Ceke \nuoizeuLan \n\nese oop MEG \nyzeRe4g 40 \n\nLoree a \n\n\nSULBA BSODLUPRA \n\n\nyaem 4ST \nuung Peay 6 \nuoizediysuod \n\n\n7994 540 \nBul, [ams awos \n\n\n8 \n\n\n| 4a}.S00q \n40 puz z \n\n\n3SI \n\n\nINIDIVA \nSANVL3L \n\n\n[aaeu ayz 40 \n[aAa_t Ze quom \n\n\nSSBUXILS \nfuLusow \n\npue ‘easneu \n*ssaupsily \n\n\nSJUBWSAOW YST Y S \npPag Ray cea] S \n\n\n(g[aaeu ayz (-) ; \nmolaq 40 (+) aroge| gWOM NI|3NIUN|. 3NIUN \n\n\n(6~z2 ‘d aS) |(auanas|SWI1GOUd YONIW SN3ddVH LISIA \nsuabuty Auew Moy) NI NI ' N3140 40 \nAWOM 4O 3ZIS|NOILISOd| YVONS|NI3LOUd QNIVVIMS|SNOIS YSONVG| VIWSNY}HLIV3H Wu3N3 LWHM qLva HLNOW \nSHLYIG YSHLO HLIM SW3A1d0ud HLYIG YOS JLvVad 31VaVdOdd GOIYad IWNYLSNSW LSV1 40 31LVvd \n\n\nHLYIGQ IHD LSV1 JO 3LVd S39V N3SYdTIHD 30 YSaWAN a9V AWN \n\n\nFW) TWIVNsed 30 THOITy \n\n\n300 \n\n\nTHINGS A MOTHER SHOULD HAVE READY \nBEFORE GIVING BIRTH \n\n\nEvery pregnant woman should have the following things ready by the seventh \nmonth of pregnancy: \nA lot of very clean cloths or rags. A new razor blade. (Do not unwrap \n\n\nuntil you are ready to cut the \numbilical cord.) \n\n\nRAZOR \n\n\n/ BLADES \\ \n\n\n(If you do not have a new razor \nblade, have clean, rust-free scissors \nready. Boil them just before cutting \nthe cord.) \n\n\nA clean scrub brush for cleaning the \nhands and fingernails. \na oa i if {4 z \nae . a s Sterile gauze or patches of \nthoroughly cleaned cloth for \n\n\nee Ki \\ ey covering the navel. \n\n\nAlcohol Cc) \n\nfor rubbing Ps \n\nhands A \n\nafter $ Two ribbons or strips of clean cloth \nwashing : for tying the cord. \n\nthem. e a ee \n\n\nBoth patches and \nribbons should \nbe wrapped and \nsealed in paper \npackets and then \nbaked in an oven \nor ironed. \n\n\nClean cotton. \n\n\n¢ \n\n\n301 \n\n\nAdditional Supplies \nfor the Well-Prepared Midwife or Birth Attendant \n\n\nFlashlight (torch). Fetoscope—or fetal \nstethoscope—for listening \n\n\nto the baby’s heartbeat ” \nthrough the mother’s \nbelly. \n\n\nSuction bulb for sucking \n\nmucus out of the baby’s nose Blunt-tipped scissors for cutting the \nand mouth. cord before the baby is all the way \nborn (extreme emergency only). \n\n\n= \n~~ ae \n\n\nTwo clamps (hemostats) for \nclamping the umbilical cord or \nclamping bleeding veins from tears \nof the birth opening. \n\n\nSeveral ise of ergonovine \n(or ergometrine). \n\n\n: ‘ j : Sterile needle and gut thread for \n\n\nsewing tears in the birth opening. \n\n\nTwo bowls—1 for washing hands and 1 forcatching \nand examining the afterbirth. \n\n\nSilver nitrate drops for the \nbaby’s eyes. \n\n\neu \n\n\n302 \n\n\nPREPARING FOR BIRTH \n\n\nBirth is a natural event. When the mother is healthy and everything goes well, \nthe baby can be born without help from anyone. In a normal birth, the less the \nmidwife or birth attendant does, the more likely everything will go well. \n\n\nDifficulties in childbirth do occur, and sometimes the life of the mother or \nchild may be in danger. If there is any reason to think that a birth may be \ndifficult or dangerous, a skilled midwife or experienced doctor shouid be present. \n\n\nDanger Signs that Make It Important that a Doctor \nor Skilled Midwife Attend the Birth: \n\n\ne |f the woman begins to bleed before labor. \ne |f there are signs of toxemia of pregnancy (see p. 295). \ne |f the woman is suffering from a chronic or acute illness. \n\n\ne If the woman is very anemic, or if her blood does not clot normally (when \nshe cuts herself). \n\n\ne \\f she has had serious trouble or severe bleeding with other births. \ne |f she has a hernia. | \n\ne If it looks like she will have twins (see p.315). \n\ne If it seems the baby is not in a normal position in the womb. \n\n\ne Ifthe bag of waters breaks and labor does not begin within a few hours. (The \ndanger is even greater if there is fever.) \n\n\nTHE BIRTHS WITH THE GREATEST CHANCE OF PROBLEMS ARE: \n\n\nthe first birth and the last births after having | \nmany children \n\n\n——- \n\n\n303 \n\n\nChecking if the Baby Is in a Good Position \n\nTo make sure the baby is head down, in the normal position for birth, feel for \nhis head, like this: | \n1. Have the mother breathe out all the way. \n\n\nWith the thumb and 2 fingers, push in here, \njust above the pelvic bone. \n\n\nWith the other hand, feel the top of the \nwomb. \n\n\nThe baby’s butt is Butt up \nlarger and wider. feels larger a \nhigh up. \n\n\nButt down \nfeels larger \nlow down. \n\n\nHis head is hard and- \nround. \n\n\n2. Push gently from side to side, first with one hand, then the other. \n\n\nIf the baby still is high in \nthe womb, you can move \nthe head a little. But if it \nhas already engaged \n(dropped lower) getting \nready for birth, you can- \nnot move it. = \nA ‘voman’s first baby \nsometimes engages 2 \nweeks before labor begins. \nLater babies may not \nengage until labor starts. \n\n\nIf the baby’s butt \nis pushed gently \nsideways, the \nbaby’s whole body \nwill move too. \n\n\nBut if the head is \npushed gently side- \nways, it will bend \n\nat the neck and the \nback will not move. \n\n\nIf the baby’s head is down, his birth is likely to go well. oy \nIf the head is up, the birth may be more difficult (a breech birth), and it is \n\n\nsafer for the mother to give birth in or near a hospital. \n\n\nIf the baby is sideways, the mother should have her baby in a hospital. She \nand the baby are in danger (see p. 313). \n\n\n304 \n\n\nSIGNS THAT SHOW LABOR IS NEAR \n\n\ne A few days before labol begins, the baby moves lower in the womb. This lets \nthe mother breathe more easily, but she may need to urinate more often because \nof pressure on the bladder. (In the first birth these signs can appear up to 2 weeks \nbefore delivery.) \n\n\n® Ashort time before the labor begins, a small plug of mucus (jelly) may come \nout. Or some mucus may come out for 2 or 3 days before labor begins. Some- \ntimes it is tinted with blood. This is normal. \n\n\n_@ The contractions (sudden tightening of the womb) or labor pains may start | \nup to several days before childbirth; at first a long time usually passes between \ncontractions—several minutes or even hours. When the contractions become \nstronger, regular, and more frequent, labor is beginning. \n\n\n® Some women have a few practice contractions weeks before labor. This is \nnormal. On rare occasions, a woman may have false labor. This happens when the © \ncontractions are coming strong and close together, but then stop for hours or \ndays before childbirth actually begins. Sometimes walking or an enema will help - \ncalm the contractions if they are false or bring on childbirth if they are real. \n\n\nLabor pains are caused by contractions or tightening of the womb. \n\n\nBetween contractions the womb is relaxed like this: \n\n\n™— | | ee \\ \n\n\nThe contractions cause the cervix or ‘door of the womb’ to open—a little \nmore each time. \n\n\na The bag of waters that holds the baby in the womb usually breaks with a \nflood of liquid sometime after labor has begun. If the waters break before the \ncontractions start, this usually means the beginning of labor. After the waters \n\n\nbreak, the mother should keep very clean. Walking back m : \nand \non labor more quickly. : nd forth may ee bring \n\n\n305 \n\n\nTHE STAGES OF LABOR \n\n\nLabor has 3 parts or stages: \n\n\n# The first stage lasts from the beginning of the strong contractions until the \nbaby drops into the birth canal. \n\n\n# The second stage lasts rom the dropping of the baby into the birth canal \nuntil it is born. \n\n\n# The third stage lasts from the birth of the baby until the placenta (afterbirth) \ncomes out. \n\n\nTHE FIRST STAGE OF LABOR usually lasts 10 to 20 hours or more when it is \nthe mother’s first birth, and from 7 to 10 hours in later births. This varies a lot. \n\n\nDuring the first stage of labor, the mother should not try to hurry the birth. It \nis natural for this stage to go slowly. The mother may not feel the progress and \nmay begin to worry. Try to reassure her. Tell her that most women have the same \nconcern. \n\n\nThe mother should not push or bear down until the child is beginning to move \ndown into the birth canal, and she feels she has to push. \n\n\nThe mother should keep her bowels and bladder empty. \n\n\nlf the bladder and the \n\nbowels are full, they get in \nthe way when the baby is \n‘being born. \n\n\nBLADDER FULL \n\n\nOF URINE FECES \n\n\n(STOOLS) \n\n\nDuring labor, the mother should urinate often. If she has not moved her bowels \nin several hours, an enema may make labor easier. During labor the mother should \ndrink water or other liquids often. Too little liquid in the body can slow down or \nstop labor. If labor is long, she should eat lightly, as well. If she is vomiting, she \nshould sip a little Rehydration Drink, herbal tea, or fruit juices between each \n\n\ncontraction. \n\n\nDuring labor the mother should change positions often or even get up and walk \nabout from time to time. \n\n\n306 \nDuring the first stage of labor, the midwife or birth attendant should: \n\n\n» Wash the mother’s belly, genitals, buttocks, and legs well with soap and \nwarm water. The bed should be in a clean place with enough light to see clearly. \n\ne Spread clean sheets, towels, or newspapers On the bed and change them \nwhenever they get wet Or dirty. a ere | \n\n*¢ Have a new, unopened razor blade ready for cutting the cord, or boil a pair \nof scissors for 15 minutes. Keep the scissors in the boiled water in a covered pan \n\n\nuntil they are needed. \n\n\nThe midwife should not massage or push on the belly. She should not ask the \nmother to push or bear down at this time. \n\n\nif the mother is frightened or in great pain, have her take deep, slow, regular \nbreaths during each contraction, and breathe normally between them. This will | \nhelp control the pain and calm her. 7 e \n\n\nTHE SECOND STAGE QF LABOR, in which the child is born: Sometimes this — \nbegins when the bag of waters breaks. It is usually easier thansthe first stage and \ntakes less time. During the contractions the mother bears down (pushes) with all \nher strength. Between contractions, she may seem exhausted and half asleep. This \nis normal. \n\n\nTo bear down, the mother should take a deep breath and push hard with her \nstomach muscles, as if she were having a bowel movement. If the child comes \nslowly after the bag of waters breaks, the mother can double her knees like this, \nwhile \n\n\nsquatting, “i sitting propped up, or lying down. \n\n\nWhen the birth opening of the mother stretches, and the baby’s head begins to \nshow, the midwife or helper should have everything ready for the birth of the \nbaby. At this time the mother should try not to push, so that the head comes ou \nmore sighs @ This helps prevent tearing of the opening (see p. 315 for more — \ndetails). \n\n\nina normal birth, the midwife never needs to put her hand or finger inside th \nmother. This is the most common cause of dangerous infections of the mother \nafter the birth. \n\n\nWhen the head comes out, the midwife may support it, but must never pull \non it. \n\n\naa a \n\n\nSa \n\n\n307 \n\n\n< \n\n\nNow try not to push hard. Take \nmany short, fast breaths. This \nhelps prevent tearing the opening \n(see p. 269). \n\n\nThen the baby’s body turns to \none side so the shoulders can \n\n\ncome out. \n\n\nThe head usually comes out face \ndown. \n\n\nif the shoulders get stuck after the head comes out: \n\n\nThen she can raise the head a \nlittle so that the other shoulder \n\n\ncomes out. \n\n\nThe midwife can take the baby’s \nhead in her hands and lower it \nvery carefully, so the shoulder \n\n\ncan come out. \n\n\nAll the force must come from the mother. The midwife should never pull on \n\n\nthe head, because pulling harms the baby. \n\n\n308 \n\n\nTHE THIRD STAGE OF LABOR begins when the baby has been born and lasts \nuntil the placenta (afterbirth) comes out. Usually, the placenta comes out by \nitself 5 mintues to an hour after the baby. In the meantime, care for the baby. \n\n\nCARE OF THE BABY AT BIRTH \n\n\nImmediately after the baby comes out: \n\n\ne Put the baby’s head down so that the mucus \ncomes out of his mouth and throat. Keep it this \nway until he begins to breathe. \n\n¢ Keep the baby be/ow the level of the mother \nuntil the cord is tied. (This way, the baby gets \nmore blood and will be stronger.) \n\n¢ If the baby does not begin to breathe right \naway, rub his back with a towel or a cloth. \n\n¢ If he still does not breathe, clean the mucus out of his nose and mouth with \na suction bulb or a clean cloth wrapped around your finger. = \n\n¢ if the baby has not begun to breathe within one minute after birth, start \nMOUTH-TO-MOUTH BREATHING at once (see p. 92,93) \n\n¢ Wrap the baby in a clean cloth. It is very important not to let him get cold, \nespecially if he is premature (born too early). \n\n\nHow to Cut the Cord: \n\n\nWhen the child is born, the cord pulses and is fat and blue. WAIT. \n\n\nAfter a while, the cord becomes thin and white. It stops pulsing. Now tie it in 2 \nplaces with very clean, dry strips of cloth, string, or ribbon. These should have \nbeen recently ironed or heated in an oven. Cut between the ties, like this: \n\n\nIMPORTANT: Cut the cord with a clean, unused razor blade. Before unwrapping \nit, wash your hands very well. If you do not have a new razor blade, use freshly \nboiled scissors. Always cut the cord close to the body of the newborn baby. Leave \n\n\nonly about 2 centimeters attached to the baby. These precautions help prevent \ntetanus (see p.225). | \n\n\nee oa \n\n\n309 \n\n\nCare of the Cut Cord: \n\n\nThe most important way to protect the freshly cut cord from infection is to \nceep it dry. To help it dry out, the air must get to it. |f the home is very clean and \nchere are no flies, leave the cut cord uncovered and open to the air. \n\n\nIf there are dust and flies, cover the cord lightly. It is best to use sterile gauze. \nCut it with boiled scissors. Put it on like this: \n\n\nCut the gauze here! \n\n\n4. Des \n\n\nIf you do not have sterile gauze, you can cover the navel with a very clean and \n\n\nfreshly ironed cloth. It is better not to use a belly band, but if you want to use \none, use a thin, light cloth, like cheesecloth, and be sure it is loose enough to let \n\n\n-air in under it, to keep the navel dry. Do not make it tight. \n\n\nBe sure the baby’s nappy (diapers) does not cover the navel, so that the cord \ndoes not get wet with urine. \n\n\nCleaning the Newborn Baby: \n| The baby is covered with a white waxy substance called Vermix. This is. \nantiseptic. Do not remove it. It will fall \"away by itself in 2 or 3 days.” \nWith a warm, soft, damp cloth, gently clean away any blood or fluid. \n\n\n| after the cord drops off (usually 5 to 8 \n\n\nIt is better not to bathe the baby unti . | \nter, using a mild soap. \n\n\ndays). Then bathe him daily in warm wa \n\n\nPut the Newborri Baby to the Breast at Once: \n\n\nther’s breast as soon as the cord is cut. If the baby \n\n\nPlace the baby at its mo \nke the afterbirth come out sooner and to prevent or \n\n\nnurses, this will help to ma \ncontrol heavy bleeding. \n\n\n310 \nTRE DELIVERY OF THE PLACENTA (AFTERBIRTH) \n\n\nNormally, the placenta comes out 5 minutes to an hour after the baby is born, \nbut sometimes it is delayed for many hours (see below). \n\n\nChecking the afterbirth: \n\n\nWhen the afterbirth comes out, \npick it up and examine it to see if it \nis complete. If it is torn and there \nseem to be pieces missing, get \nmedical help. A piece of placenta \nleft inside the womb can cause \ncontinued bleeding or infection. \n\n\nWhen the placenta is delayed in coming: \n\n\nIf the mother is not losing much blood, do nothing. Never pull on the cord. \nThis could cause dangerous hemorrhage (heavy bleeding). \n\n\nIf the mother is losing blood, feel the womb (uterus) through the belly. If it is \nsoft, do the following: | \n\n\nMassage the womb carefully, until it ge’ If the placenta does not come out soon, \n\n\nhard. This should make it contract and and bleeding continues, push downward \n\npush out the placenta. on the top of the womb very carefully, \nwhile \nsupporting \nthe bottom \n\ni\" Vee e of the womb \n\n\nIf the placenta still does not come out, and the heavy bleeding continues, try to \ncontrol the bleeding as follows and seek medical help fast. \n\n\nHEMORRHAGING (HEAVY BLEEDING) \n\n\nWhen the placenta comes out, there is always a brief flow of blood. It normally \nlasts only a few minutes and not more than a quarter of a liter (1 cup) of blood is \nlost. (A little bleeding may continue for several days and is usually not serious.) \nBleeding can often be slowed down by putting the baby to the breast. If he will \nnot suck, perhaps someone can stroke or stimulate the mother’s nipples. \n\n\nWARNING: Sometimes a woman may be bleeding severely inside without much \nblood coming out. Feel her belly from time to time. If it seems to be getting \n\n_ bigger, it may be filling with blood. Check her pulse often and watch for signs of \nshock (p.89). \n\n\n311 \n\n\nIf heavy bleeding continues, or if the mother is losing « \n; a great deal of \n- through a steady trickle, do the following: see Bal of blood \n\n\n: ¢ Get medical help fast. |f the bleeding does not stop quickly, the mother may \nneed to be given serum blood ina vein (a transfusion). | \n\n\n¢ If you have ergonovine or oxytocin, use it, following the instructions on the \nnext page. (Use oxytocin instead of ergonovine if the placenta is still inside.) \n\n\n¢ The mother should drink a lot of liquid (water, fruit juices, tea, soup, Or \n: Rehydration Drink—p. 182}. If she grows faint or has a fast, weak pulse or shows \n3 other signs of shock, put her legs up and her head down (see p. 89). \n\n\ne |f the mother is losing a lot of blood, and is in danger of bleeding to death, \ntry to stop the bleeding like this: . \n\n\nand with the other hand massage \nthe bottom of the womb. \n\n\nthe womb get hard. Then lift the \n\n\nMassage the belly until you can feel \nwomb with one hand, | \n\n\n= \n) \n\n\nAs soon as the womb gets firm and bleeding stops, stop massaging it until it gets soft \nagain. Check it every minute or so. \n\n\ne |f the bleeding continues in spite of massaging the womb, do the following: \n\n\nUsing all of your weight, press down with Lome nr \nboth hands, one over the other, on the \nbelly just below the navel. You should ee: dy \n\n\ncontinue pressing down a long time after \nthe bleeding stops. Zw \n\n\n- a \n\n\ne |f the bleeding is still not under control: \n\n\nGrasp the womb between your hands and squeeze hard. \nKeep squeezing it firmly until the bleeding has stopped \n\n\nfor several minutes or until. i \nyou get medical help. | \n\n\n312 \n\n\nTHE CORRECT USE OF OXYTOCINS: _ \nERGONOVINE, OXYTOCIN, P/TOCIN, ETC. \n\n\nOxytocics are medicines that contain ergonovine, ergometrine, or oxytocin. \nThey cause contractions of the uterus and its blood vessels. They are important \n_ but dangerous drugs. Used the wrong way, they can cause the death of the mother \n“or the child in her womb. Used correctly, sometimes they can save lives. These are’ \ntheir correct uses: \n\n\n1. To control bleeding after-childbirth. This is the most important use of these \n‘medicines. Ina case of heavy bleeding after the placenta has come out, inject one \n0.5mg.ampule of ergonovine or ergometrine maleate (Methergin, etc.p. 423) — \nin the muscle. If she continues to bleed for half an hour, inject “2 amoule more and \n\ntake her to the health center. After bleeding is controlled, continue giving 1 tablet. \nevery 4 hours for 24:hours. If no ergonovine is available, or if heavy bleeding Start. \nbefore the placenta.comes Out, inject oxytocin (Pitocin. p.423) instead. \n\n\nIMPORTANT: Each expectant mother, and the midwife, should have ready » \nenough ampules of ergonovine to combat heavy bleeding if it occurs. But these \nmedicines should be used-only in serious cases. \n\n2. To help prevent heavy bleeding after birth. A woman who has suffered from \nheavy bleeding after previous births can be given 1 ampule (or 2 pills) of \nergonovine immediately after the placenta comes out, If she continues to bleed \nafter half an hour, give'another dose and take her to the héalth center. \n\n\n3. To contro! the bleeding of a miscarriage (p.327). The use of Oxytocics can \nbe dangerous, and only a skilled health worker should use them. But, if the \nwoman is rapidly losing blood and medical help is far away, use an Oxytocic as \nSuggested above. Oxytocin (Pitocin) is probably best. \n\n\nWARNING: The use of Ergotrate, Pitocin, or Pituitrin to hasten childbirth or \nGive strength’ to the mother in labor is very dangerous for both her and the child \nThe times when oxytocics are needed before the baby is born are very rare, and it \nis better that only a trained birth attendant use them then. Never use oxytocics \nbefore the child is born! : \n\n\nTHE USE OF OxXYTOCICS | CAN KILL THE \nDURING CHILDBIRTH TO MOTHER, THE \n\n\n‘GIVE STRENGTH' TO BABY, OR BOTH. \nTHE MOTHER... | | \n\n\nThere is no safe medicine for giving strength to the mother or for making the \nbirth quicker or easier. \n\n\nlf yOu want the woman to Have enough strength for childbirth, have her eat \nbody-building and Protective foods during the full 9 months of pregnancy. Also \nencourage her to have children less often. Suggest that she not get pregnant again \n\n\nuntil enough time:has passéd for her to regain her full strength (see Family \nPlanning, p.329). 3 | | \n\n\n313 \nDIFFICULT BIRTHS \n\n\nIt is important to get medical help as quickly as possible when there is any \nserious problem during labor. Many problems or complications may come up, \nsome more serious than others. Here are a few of the more common ones: \n\n\n1. LABOR STOPS OR SLOWS DOWN, or lasts a very long time after being \nstrong or after the waters break. This has several possible causes. \n\n\n8 The woman may be frightened or upset. This can slow down or even stop _ \ncontractions. Talk to her. Try to reassure her. Explain that the birth is slow, but \nthere are no serious problems. Encourage her to change her position often, and to \n\n\n- drink, eat, and urinate. \n\n\n= The baby may be in an unusual position. \nFeel the belly between contractions to see if \nthe baby is sideways. Sometimes the midwife \ncan turn the baby through gentle handling of \nthe woman's belly. Try to work the baby \naround little by little between contractions, \nuntil the head is down. But do not use force \nas this could tear the womb. If the baby can- \nnot be turned, try to get the mother to a \nhospital. \n\n\n= If the baby is facing forward rather than \nbackward, you may feel the lumpy arms and legs \nrather than the rounded back. This is usually no big \nproblem, but labor may be longer and cause the \nwoman more back pain. She should change positions \noften, as this may help turn the baby. \n\n\n\" 'e head may be too large to fit through the woman’s hip bones \nBe «more ae in a woman with very narrow hips (and very unlikely \nin a woman who has given normal birth before). You may feel that the baby does \nnot move down. If you suspect this problem, try to get the mother to a aly \nas she may need an operation (cesarian). Women with very narrow hips should \n\n\nhave at least their first child in or near a hospital. \n\n\nas been vomiting or has not been drinking, she may be \n\n\n« If the mother h tractions. Have her sip Rehydration \n\n\ndehydrated. This can slow down or stop con \nDrink or other liquids between contractions. \n\n\n314 \n\n\n2. BREECH DELIVERY (the buttocks \ncome out first). Sometimes the midwife can \ntell if the baby is in the breech position by \nfeeling the mother’s belly (p.303) and ~ \nlistening to the baby’s heartbeat (p. 298). \n\n\nA breech birth may be easier in this position: \n\n\nIf the baby’s legs come out, but not the arms, wash your hands very well, rub \nthem with alcohol (or wear sterile gloves), and thers ©. \n\n\nslip your fingers inside and push the or press his arms against his body, \nbaby’s shoulders toward the back, like this: like this:. Ae \n\n\nYass \n\nJ H ‘ \n\n( { \n\n\\ pony ay s ts ~ 6 \na o3s sen! , ie . =; \neth Bs } \n\n‘ « e 4 .7 \n‘ \na d } \n’ \n\n\nIf the head gets stuck, have the mother lie face \nup. Put your finger in the baby’s mouth and \npush his head towards his chest. At the same \ntime have someone push the baby’s head down a \nby pressing on the mother’s belly like this-——————» \n\n\nHave the mother push hard. But never pull on \nthe body of a baby. \n\n\n3. PRESENTATION OF AN ARM (hand \nfirst). If the baby’s hand comes out first, get \nmedical help right away. An operation may be \nneeded to get the baby out. \n\n\n4. Sometimes the CORD IS WRAPPED \nAROUND THE BABY’'S NECK so tightly he \nCannot come out all the way. Try to slip the \nloop of cord from around the baby's neck. \nIf you cannot do this, you may have to clamp or tie and cut the cord. Use boiled \nblunt-tipped scissors. 3 \n\n\n5. FECES IN THE BABY’S MOUTH AND NOSE. When the waters break, if \nyou see they contain the baby’s first black stools (meconium), the baby may be \nin danger. If he breathes any of the feces into his lungs, he may die. As soon as his _ \nhead is out, tell the mother not to push, but to take short, rapid breaths. Before \nthe baby starts breathing, take time to suck the feces out of his nose and mouth. \nwith a suction bulb. Even if he starts breathing right away, keep sucking until you \nget all the feces out. \n\n\net ~f “a \n\n\n315 \n\n\nia \n\n6. TWINS. Giving birth to twins is often more difficult \nand dangerous—both for the mother and babies—than \ngiving birth to a single baby. \n\n\nTo be safe, the mother should give birth \nto twins in a hospital. \n\n\nBecause with twins labor often begins early, the mother \nshould be within easy reach of a hospital after the seventh \n~ month of pregnancy. \n\n\n_ Signs that a woman is likely to have twins: \n\n\n.* The belly grows faster and the womb is larger than usual, especially in the \n~ last months (see p. 297). \n~ . e lf the woman gains weight faster than normal, or the common problems of \n| pregnancy (morning sickness, backache, varicose veins, piles, swelling, and ; \n\n. difficult breathing) are worse than usual, be sure to check for twins. \n~ @ =f you can feel 3 or more large objects (heads and buttocks) ina womb that \nseems extra large, twins are likely. \n\ne Sometimes you can hear 2 different heartbeats (other than the mother’s)— \n\nbut this is difficult. \n\n\nDuring the last months, if the woman rests a lot and is careful to avoid hard \nwork, twins are less likely to be born too early. \n\n\nTwins are often born small and need special care. However, there is no truth in \nbeliefs that twins have strange or magic powers. \n\n\nTEARING OF THE BIRTH OPENING \n\n\nThe birth opening must stretch a lot for the baby to come out. Sometimes it \ntears. Tearing is more likely if it is the mother’s first baby. \n\n\nTearing can usually be prevented if care is taken: | \n\n\nWhen the birth opening is It may also help to put hot \n\n\nThe mother should try to = hgiceie p \n\nstop pushing when the baby’s _ stretching, the midwife can compresses against the skin \n\n~ head is coming out. This gives support it with one hand and _ below the birth opening. \nher birth opening time to with the other hand gently » Start when it begins to \nstretch. In order not to push, keep the head from coming stretch. \n\n\nshe should pant (take many too fast, like this: \n\n\nshort rapid Sree V \n/f \n\n\ny Se - \n\n\nIf a tear does happen someone who knows how should carefully sew it shut \nafter the placenta comes out (see P- 99 and415). \n\n\nee \n\n\n316: \n\n\nCARE OF THE NEWBORN BABY \nThe Cord: \n\n\né i . . 7 . kept \nTo prevent the freshly cut cord from becoming infected, it should be \nclean ane dry. The drier it is, the sooner it will fall off and the navel will heal. For \n\n\nthis reason, it is better not to use a belly band, or if one is used, to keep it very \nloose (see p. 225 and 309). \n\n\nThe Eyes: \n\n\nTo protect a newborn baby’s eyes from dangerous \nconjunctivitis, put a drop of 1% silver nitrate, or a \nlittle tetracycline eye Ointment, in each eye as soon as \nhe is born (p. 226}. This is especially important if | \neither parent has ever had signs of gonorrhea (p. 280). \n\n\nKeeping the Baby Warm—But Not Too Warm: \n\n\nProtect the baby from cold, but also from too much heat. Dress him as warmly \nas you feel like dressing yourself. \n\n\nIN COLD WEATHER \n\n\nBUT IN HOT WEATHER \nBABY HAS A FEVER) \n\n\noN \n= \nrege \n\n\n(OR WHEN THE \n\n\nWRAP THE BABY WELL. \n\n\nLEAVE HIM NAKED. \n\n\nTo keep a baby just warm enough, keep him close to his mother’s body. \n\n\nCleanliness: \n\n\nIt is important to follow the Guidelines of Cleanliness as discussed in Chapter \n12. Take special care with the following: \n\n\n¢ Change the baby’s diapers (nappy) or bedding each time he wets or dirties \nthem. If the Skin gets red, change the diaper more often—or better, leave it \noff! (See p. 256:) | \n\n\n¢ After the cord drops off, bathe the baby daily with mild SOap and warm \nwater, 3 \n\n\n¢ If there are flies or mosquitos, cover the baby’s crib with Mosquito netting \nOr a thin cloth. \n\n\n,¢ Persons with open sores, colds, sore throat, tuberculosis, or other infectious \n, illnesses should not touch or go near the baby. \n\n\nKeep the baby in a clean Place away from smoke and dust. \n\n\n317 \n\n\n| (Also see “The Best Diet for Small Children,” p. 141.) \n\n\nBreast milk is by far the best food for a baby. Babies who nurse on breast milk \nare healthier, grow stronger, and are less likely to die. This is why: \n\n\nf \n\nt \n\n| s Breast milk has a better balance of what the baby needs than does any other \n\n. milk, whether fresh, canned, or powdered. \n\na \n\n| 8 Breast milk is clean. When other foods are given, especially by bottle feeding, \nit is very hard to keep things clean enough to prevent the baby from getting \n\n\ndiarrhea and other sicknesses. \n= The temperature of breast milk is always right. \n\n\n® Breast milk has things in it (antibodies) that protect the baby against certain \nillnesses, such as measles and polio. \n\n\nThe mother should give her breast to the baby as soon as he is born. For the \nfirst few days the mother’s breasts usually produce very little milk. This is normal. \nShe should not start bottle feeding her baby, but should nurse her baby often. \nThe baby’s sucking will help her produce more milk. \n\n\nA mother whose breasts make enough milk should give her baby only breast » \nmilk for the first 4 to 6 months. After that, she should continue to breast feed her \nbahy, but should begin to give him other nourishing foods also (see p. 142). \n\n\nHOW A MOTHER CAN PRODUCE MORE MILK: \n\n\nShe should... \n\n\n@ drink plenty of liquids, \n\npecially milk, milk products, and body-building \ns beans, dals, green leafy vegetables and fruits | \namount of milk \n\n\n-@ eat as well as possible, es \nfoods (see p. 128), ‘such a \nlike papaya, dry fish and garlic increase the \n\n¢ get plenty of sleep and avoid getting very tired or upset, \n\n\n¢ nurse her baby more often. \n\n\nBOTTLE-FED BABIES ARE MORE LIK \nTO GET SICK AND DIE. \n\n\nELY BREAST-FED BABIES ARE HEALTHIER. \n\n\n318 \n\n\nCare in Giving Medicines to the Newborn: \n\n\nMany medicines are dangerous for the newborn. Use only medicines you are \nsure are recommended for the newborn and use them only when they are \nabsolutely necessary. Be sure you know the right dose and do not give too much. \n“Chloramphenicol is especially dangerous to the newborn... . and even more \ndangerous if the baby is premature or underweight (less than 2 kilograms). \n\n\nILLNESSES OF THE NEWBORN \n\n\nIt is very important to notice any problem or illness a baby may have—and to \nact quickly. ieee is \n\n\nDiseases that take days or weeks to kill adults \ncan kill a baby in a matter of hours. \n\n\nProblems the Baby is Born with: (Also see p. 363) \n\n\nThese may result from something that went wrong with the development of the — \n\n\nbaby in the womb or from damage to the baby while he was being born. Examine \nthe baby carefully immediately after birth. If he shows any of the following signs, \nsomething is probably seriously wrong with him: \n\n\ne If he does not breathe as soon as he is born. \n\ne If his pulse cannot be felt or heard, or is less than 100 per minute. \n\ne If his face and body are white, blue, or yellow after he has begun breathing. \n\ne If his arms and legs are floppy—he does not move them by himself or when \nyou pinch them. \n\ne |f he grunts or has difficulty breathing after the first 15 minutes. \n\n\nSome of these problems may be caused by brain damage at birth. They are \nalmost never caused by infection (unless the waters broke more than 24 hours \nbefore birth). Common medicines probably will not help. Try to get medical help. \n\n\nIf the baby does not urinate or have a bowel movement in the first 2 days, also \nseek medical help. \n\n\nProblems that Result after the Baby is Born \n(in the first days or weeks): \n\n\n_ 1. Pus or a bad smell from the navel (cord) is a dangerous sign. Watch for early \nsigns of tetanus (p.223) ora bacterial infection of the blood (p. 321). Soak the \ncord in hydrogen peroxide, paint it with gentian violet (0.409), and leave it open \nto the air. If the skin around the cord becomes hot and red, treat with ampicillin \n(p. 399) or with penicillin and streptomycin (p. 4.00) . \n\n\n2 Either low temperature (below 35°) or high fever can be a sign of infection. \nHigh fever (above 3S) /s dangerous for the newborn. Take off all clothing and \n\n\n319 \n\n\n3. Fits (convulsions, see p. 217). If the bab l \ni )e y also has fever, treat it as just \ndescribed. Be sure to check for dehydration. Fits that begin the day of ak are \nprobably caused by brain damage at birth. If fits begin several days later, look \ncarefully for signs of tetanus (p. 223) or meningitis (p.2:25). \n\n\n4, The baby does not gain weight. During the first days of life, most babies lose \na little weight. This is normal. After the first week, a healthy baby should gain \nabout 200 gm. a week. By two weeks the healthy baby should weigh as much as \nhe did at birth. If he does not gain weight, or loses weight, something is wrong. \nDid the baby seem healthy at birth? Does he feed well? Examine the baby \ncarefully for signs of infection or other problems. If you cannot find out the \ncause of the problem and correct it, get medical help. \n\n\n9. Vomiting. When healthy babies burp (or bring \nup air they have swallowed while feeding), some- \ntimes a little milk comes up too. This is normal. \nHelp the baby bring up air after feeding by holding \nhim against your shoulder and patting his back \ngently, like this. \n\n\nlf a baby vomits when you lay him down after \nnursing, try sitting him upright for a while after \neach feeding. \n\n\nA baby who vomits violently, or so much and so BURP YOUR BABY \noften that he begins to lose weight or become AFTER FEEDING \ndehydrated, is ill. If the baby also has diarrhea, he \nprobably has a gut infection (p. 188). Bacterial infection of the blood (see the \nnext pages), meningitis (p. 2.25), and other infections may also cause vomiting. \n\n\nIf the vomit is yellow or green, there may be a gut obstruction (p. 1 07) \nespecially if the belly is very swollen or the baby has not been having bowel \n\n\nmovements. Take the baby to a health center at once. \n\n\nthan 4 hours pass and the baby still will \n\n\ntops sucking well. |f more \nee ee : f the baby seems very sleepy or ill, or if \n\n\nnot nurse, this is a danger sign—especially | \nhe cries or moves differently from normal. Many illnesses can cause these signs, \n\n\nbut the most common and dangerous causes in the first 2 weeks of life are a \nbacterial infection of the blood (see next 2 pages) and tetanus (p.223). \n\n\nrsing during the second to fifth day of life \n\n\nho stops nu \nfees bacterial infection of the blood. \n\n\nmay have a \no fifteenth day \n\n\n) i i fifth t \nho stops nursing during the \nphsnsis may have tetanus. \n\n\n320 \n\n\nIf a Baby Stops Sucking Well or Seems III: \n\n\nExamine him carefully and completely as described in Chapter 3. Be sure to \ncheck the following: \n\n\n» Notice if the baby has difficulty breathing. If the nose is stuffed up, suck it \nout as shown on page 201. Fast breathing (50 or more breaths a minute), blue \ncolor, grunting, and sucking in of the skin between the ribs with each breath are \nsigns of pneumonia (p.209). Small babies with pneumonia often do not cough; \nsometimes none of the common signs are present. If you suspect pneumonia, \ntreat as for a bacterial infection of the blood (see the next page). \n\n\n» Look at the baby’s skin color. \n\n\nIf the lips and face are blue, consider pneumonia (or a heart defect or other \nproblem the baby was born with). \n\n\nif the face and whites of the eyes begin to get yellow (jaundiced) in the first . \nday of life or after the fifth day, this is serious. Get medical help. Some yellow \ncolor between the second and fifth day of life is usually not serious. Give the \nbaby plenty of liquid—Rehydration Drink is best, in addition to breast milk \n(p. 182). Take off all his clothes and put him in bright light near a window (but \nnot direct sunlight). \n\n\n# Feel the soft spot on top of the head (fontanel). See p. 6. \n\n\nIf the soft spot is ; If the soft spot is \n\n\nSUNKEN, : SWOLLEN, \n\n\nDEHYDRATED. MENINGITIS. \n\n\nIMPORTANT: \\f a baby has meningitis and dehydration at the same time, the \n\n\nsoft spot may feel normal. Be sure to check for other signs of both dehydration \n(see p. 181) and meningitis (see p.225). \n\n\n® Watch the baby’s movements and expression on his face. \n\n\nStiffness of the body and/or strange movements \nmay be signs of tetanus, meningitis, or brain \ndamage from birth or fever. If, when the baby is \ntouched or moved, the muscles of his face and \nbody suddenly tighten, this could be tetanus. \nSee.if his jaw will open arid check his knee \nreflexes (p.224). ~, atk \n\n\n321 \n\n\nIf the baby’s eyes roll back or flutter when he makes sudden or violent \nmovements, he probably does not have tetanus. Such fits may be caused by \n\n\n# Look for signs of a bacteria] infection in the blood. \n\n\nBacterial Infection in the Blood (Septicemia): \n\n\nNewborn babies cannot fight infections well. Therefore, bacteria that enter the \nbaby’s skin or cord at the time of birth often get into the blood and spread \nthrough his whole body. Since this takes a day or two, septicemia is most \ncommon after the second day of life. \n\n\nSigns: \n\n\nSigns of infection in newborn babies are different from those in older children. \nIn the baby, almost any sign could be caused by a serious infection in the blood. \nPossible signs are: \n\n\ne does not suck well e swollen belly \n\n\nyellow skin (jaundice) \n\n\ne seems very sleepy \nfits (convulsions) \n\n\ne very pale (anemic) \n¢ vomiting or diarrhea e times when the baby turns blue \ne fever or low temperature (below 35°) \n\n\nEach of these signs may be caused by something other than septicemia, but if \nthe baby has several of these signs at once, septicemia is likely. \n\n\nNewborn babies do not always have a fever when they have a serious infection \nThe temperature may be high, low, or normal. \n\n\nTreatment when you suspect septicemia in the newborn: \n¢ Inject ampicillin (p. 399) \n¢ Or inject penicillin \n\n\n* Be sure the baby has enough liquids. Spoon feed breast milk and \nRehydration Drink, if necessary (see p. 182). \n\n\n¢ Try to get medical help. \n\n\nInfections in newborn babies are weiipni 267 io Saad \ni ible, get medical heip. ; \n\nOften there is no fever. If possible, edical \n\nwith ampicillin as described above. Ampicillin is one of the safest \n\nand most useful antibiotics for babies. \nLAS -_~ G be \n\ngr f $) ; See | * . \n\n\n322 \n\n\nTHE MOTHER’S HEALTH AFTER CHI LDBIRTH \n\n\nDiet and Cleanliness: \n\n\nAs was explained in Chapter 11, after she gives birth to a ons yeah \nand should eat every kind of nutritious food she can get. es oes er ed \navoid any kind of food. Foods that are especially good for her at m pe. : i \nchicken, eggs, meat, fish, fruits, vegetables, grains, beans, grounanuts, : Bee: a \nshe has is chapatties. rice and dal , she should eat them together at eac ; \nand other dairy products help the mother make plenty of milk tor her baby. \n\n\nThe mother can and should bathe in the first few days after giving birth. In the \nfirst week it is better if she bathes with a wet towel and does not go Into the \nwater, Bathing is not harmful following childbirth. In fact, women who let many \ndays go by without bathing may get infections that will make their skin unhealthy \nand their babies sick. \n\n\nDuring the days and weeks following childbirth, the mother should: \n\n\neat nutritious foods and bathe regularly. \n\n\nAg \n\n\nChildbirth Fever (Infection after Giving Birth): \n\n\nSometimes a mother develops fever and infection after childbirth, usually \nbecause the midwife was not careful enough to keep everything very clean or \nbecause she put her hand inside the mother. \n\n\nTie signs of childbirth fever are: chills or fever, headache or low back pain, \n\n\nsometimes pain in the belly, and a foul-smelling or bloody discharge from the \nvagina. \n\n\nTreatment: \n\n\nVaginal wash with warm water and vinegar or potassium permanganate \nwill help (p 286) She should do it three times a day till she is better. Penicillin \nOther antibiotics (ampicillin or sulfadiazine) may be used instead. \n\n\nChildbirth fever can be very dangerous. \nif the mother does not get well soon, get medical help. \n\n\nBie 3. ate \n\n\n323 \n\n\nCARE OF THE BREASTS \n\n\nTaking good care of the breasts is j \nmportant for the health of both th \na, rela Wipe should be started the same day the baby is eee \nnot suck much, but this lets the mother’ ae \nsucking, and helps prevent sore nipples. So... other's body get used to his \n\n\nBEGIN BREAST FEEDING THE SAME DAY THE BABY IS BORN. \n\n\nThe milk that the breast makes for the first two days is called co/ostrum. This is thin \nand watery . Often mothers believe that this milk has gone bad. So they do not feed \nthe baby with this milk. This is not truel Colostrum contains a lot of antibodies in it \nwhich protect the baby against infections. It also has a lot of proteins: If the baby \nstarts sucking on the first day, the breasts will also produce more milk. \n\n\nNormally, the breasts make as much milk as the baby needs. If the baby \nempties them, they begin to make more. If the baby does not empty them, soon \nthey make less. But when a baby gets sick and stops sucking, after a few days the \nmother’s breasts stop making milk. So when the baby is able to suck again, and \nneeds a full amount of milk, there may not be enough. For this reason, \n\n\nWhen a baby is sick and unable to take much milk, \nit is important that the mother keep producing lots of milk \nby milking her breasts with her hands. » \n\n\nTO MILK YOUR BREASTS: \n\n\nTake hold of the breast \nway back, like this, \n\n\n! \n\n\nthen move your hands \nforward, squeezing, \n\n\neee and finally, squeeze the \nmilk out of the nipple. \n\n\nortant to milk the breasts when the baby stops sucking \nm getting too full. When they are too full, they \nfully full is more likely to develop an abscess. \nking them even if he wants to. \n\n\nAnother reason it is imp \nis that this keeps the breasts fro \nare painful.-A breast that is pain \nAlso, the baby may have trouble suc \n\n\nWhen your baby is too weak to suck, squeeze milk out of your breasts by hand \n\n\nand give it to the baby by spoon or dropper. \n\n\n324 \nAlways keep your breasts clean. Before breast feeding your baby, wipe your \n\n\nnipples with a clean, moist cloth. Do not use soap each time you clean your \nnipples, as this may lead to cracking of the skin, sore nipples, and infection. \n\n\nSore Nipples: \n\n\nSore nipples may develop when the baby bites \non the nipple instead of taking the whole thing NORMAL \ninto his mouth. This is most likely to happen in \nwomen who have short nipples. \n\n\nNIPPLE \n\n\nPrevention: \n\n\nIf a woman with short nipples \nsqueezes her nipples like this several \ntimes a day during pregnancy, this \nwill make it easier for her child to \nsuck, and she will be less likely to \nget sore nipples. \n\n\nTreatment: \n\n\nIt is important to keep breast feeding the baby, even though this hurts. First let \nhim suck the side that is least sore. Only stop breast feeding if the nipple oozes a \nlot of blood or pus. In this case, milk the breast by hand until the nipple heals. \nWhen the baby feeds again on the breast, be sure the whole nipple enters his \nmouth. \n\n\nBreast Abscess (Infection Inside the Breast, Mastitis): \n\n\nA breast abscess may result from an infection that \nenters through a sore or cracked nipple. This is most \ncommon during the first weeks or months of breast \nfeeding. \n\n\nBRN AZ \nTN a aha \n: (pie \n\n\nSigns: \n\n\nPart of the breast becomes hot, red, swollen, and very painful. Lymph nodes in \nthe armpit are often sore and swollen. A severe abscess sometimes bursts and \ndrains pus. \n\n\nPrevention: \n\n\n¢ Keep the breast clean. If a sore nipple or painful cracks develop, breast feed \nthe baby for shorter periods, but more often. \n\n\n¢ Also put a little vegetable oi! or baby oil on the nipples after each feeding. \n\n\nTreatment: \n\n\n¢ Let the baby continue to feed fr \n\n\n‘ om the absce bike al \nwhichever is less painful. ssed breast, or milk it by hand, \n\n\n¢ Use hot compresses to ease the pain. Also take aspirin \n\n\n¢ Take an antibiotic as for childbirth fever (see p.322). \n\n\nDifferent kinds of breast lumps: \n\n\nA painful, hot lump in the breast of a nursing mother \n__ ts probably‘a breast abscess (infection). \nA painless breast lump may be cancer. \n\n\nBreast Cancer: \n\n\nCancer of the breast is fairly common in women, and is always dangerous. \nSuccessful treatment depends on spotting the first sign of possible cancer and \n\n\ngetting medical care soon. Surgery is usually necessary . \nQe \nAX ieee \nge ee = ce \n\n\nSigns of breast cancer: \n\n\ne The woman may notice a lump, often in \nthis part of the breast. \n\ne Or the breast may have an abnormal \ndent or dimple—or many tiny pits like \nthe skin of an orange. \n\ne Often there are large but painless lymph \nnodes in the armpit. \n\ne The lump grows slowly. \n\ne At first it usually does not hurt or get \nhot. Later it may hurt. \n\n\nSELF-EXAMINATION OF THE BREASTS: \n\n\nEvery woman should learn how to \nexamine her own breasts for possible \nsigns of cancer. Once a month: \n\n\n¢ Look at your breasts carefully \nfor any new difference between the \ntwo in size or shape. Try to notice any \nof the above signs. \n\n¢ While lying with a pillow or \nfolded blanket under your back, feel \nyour breasts with the flat of your \n\n\n325 \n\n\n326 \n\n\nfingers. Press your breast and roll it \nbeneath your finger tips. Start near \nthe nipple and go around the breast \nSie. nae up into the armpit. \n\n2h ¢ Then squeeze your nipples and \ncheck whether blood or a discharge \n; comes out. \n\n\nIf you find a lump or any other abnormal sign, get medical advice. Many lumps \nare not cancer, but it is important to find out early. \n\n\nLUMPS OR GROWTHS IN THE LOWER PART OF THE BELLY \n\n\nThe most common lump.is, of course, caused by \nthe normal development of a baby. Abnormal \nlumps or masses may be caused by: \n\n\n= acyst or watery swelling in one of the ovaries \n\n\n-® by a baby that has accidentally begun to \ndeveiop outside of the womb (ectopic \npregnancy), or | \n\n\n® cancer \n\n\nAll 3 of these conditions are usually painless or \nmildly uncomfortable at first, and become painful later. All require medical \n\n\nattention—usually surgery. If you find any unusual, gradually growing lump, seek \nmedical advice. \n\n\nCancer of the Womb: \n\n\nCancer of the uterus (womb), cervix (neck of the womb), or ovaries is most \ncommon in women over 40. The first sign may be anemia or unexplained bleeding. \n\n\nLater, an uncomfortable or painful lump in the belly may be noticed. \n\n\nAt the first suspicion of cancer, seek medical help. \n\n\nHome remedies are not likely to help. \n\n\nere \n\n\n327 \n\n\nOut-of-Place or Ectopic Pregnancy: \n\n\nata Sometimes a baby begins to form \nwhere a baby Outside the womb, in one of the \n\n: tubes that comes from t i \n\nis normally : he ovaries. \nmade , \n\n\nThere may be abnormal \nmenstrual bleeding together with \nto ovary signs of pregnancy—also cramps low \nin the belly and a tender lump \novary— outside the womb. - \nwhere the \neggs are \n\n_A baby that begins to form out \n\nof place usually cannot live. \n\nEctopic pregnancy requires surgery \n. In a hospital. If you suspect this \n\n\nvulva— problem, seek medical advice soon, \nor lips of as dangerous bleeding could start \nvagina any time. \n\n\nMISCARRIAGE (SPONTANEOUS ABORTION) \n\n\nA miscarriage is the loss of the unborn baby. Miscarriages are most frequent in \nthe first 3 months of pregnancy. Usually the baby is imperfectly formed, and this \nis nature’s way of taking care of the problem. \n\n\nThe embryo of a miscarriage \nmay be no longer than 1 or 2 \ncentimeters. \n\n\nMost women have one or more miscarriages in | \ntheir lifetime. Many times they do not realize that \nthey are having a miscarriage. They may think their \nperiod was missed or delayed, and then came back \nin a strange way, with big blood clots. A woman \nshould learn to know when she is having a \nmiscarriage, because it could be dangerous. \n\n\n30 days \n\n\nA woman who has heavy bleeding after she has \nmissed one or more periods probably is having a \nmiscarriage. \n\n\nA miscarriage is like a birth in that the embryo \n(the beginning of the baby) and the placenta (after- \nbirth) must both come out. Bleeding often \ncontinues until both are completely out. \n\n\nTreatment: \nnerally there is no problem. The woman should \n\n\ning, ge \nIf there is no heavy bleeding, 9 hould be treated with the same care and \n\n\nstay in bed, and the miscarriage s \nprecautions as a birth. \n\n\n328 \n\n\nIf there is heavy bleeding, or bleeding continues for many days: \n\n\n¢ Get medical help. A simple operation may be needed to clean out the womb \n(dilatation and curettage or D and C). \n\n\n¢ Stay in bed until the heavy bleeding stops and for 2 or 3 days after the \nmiscarriage. \n\n\n¢ If the bleeding is extreme, follow the instructions on page 313. \n\n\n¢ |f fever or other signs of infection develop, treat as for Childbirth Fever (see \np: 322). . \n\n\nIf you have \nbleeding and \n\n\nremain lying down until \neverything comes out, \n\n\nsuspect a and the bleeding stops. \n\n\nmiscarriage, \n\n\nHIGH RISK MOTHERS AND BABIES \n\n\nA note to midwives or health workers and anyone who cares: \n\n\nSome women are more likely to have difficult births and problems following \nbirth, and their babies are more likely to be underweight and sick. Often these \nare mothers who are single, homeless, poorly nourished, very young, mentally \nslow, or who already have malnourished or sickly children. \n\n\nThe book Where There I s No Doctor is available \nat Rs 29/- plus postage. Multiple copies of reprints \nof various chapters are also available, \n\n\nPlease write to: \n\n\nPublications Officer \n\nVoluntary Health Association of India \nC-14 Community Centre \n\nSafdarjung Development A rea \n\n\nNew Delhi 110016 \nRs. 2.50 \n\n\n", "summary": "COMMUNITY HEALTH CELL 37/7, (First Floor) St. Marke BR M-1 6 Ranaatora - 560.001 3 | INFORMATION FOR MOTHERS 19 AND MIDWIVES This is a reprint from RR There Is-No Docher (Indian adaptation) published by the Voluntary Health Association of India C-14 Community Centre Safdarjung Development Area New Delhi 110016 COMM Ute tase PELL —— 291 CHAPTER INFORMATION FOR MOTHERS 7 ) AND MIDWIVES. THE MENSTRUAL PERIOD (MONTHLY BLEEDING IN WOMEN) Most girls have…", "source_url": "https://archive.org/details/sochara.62.informationformo0000wern", "pdf_url": "https://archive.org/details/sochara.62.informationformo0000wern", "case": "hesperian", "sub_case": "Werner, David", "tags": ["hesperian"], "page_count": 0} {"title": "Instructions and Precautions for Injections. Lesson from Book \"Where there is no doctor\"", "content": "COMMUNITY SZ ALTH CTL \n\n\n47/1, (First Fleor) St. Marks Road \n\n\nMd-28 Bandatore - 580 091, \nINSTRUCTIONS AND PRECAUTIONS \n9) FOR INJECTIONS \n\n\nThis is a reprint from \n\n\nWhere There Is No Doctor \n\n\n(Indian adaptation) \n\n\npublished by the \n\n\nVoluntary Health Association of India \nC-14 Community Centre \nSafdarjung Development Area \nNew Delhi 110016 \n\n\nCOMMUSt ry WEA TH CELL | 77 \n\n\nCHAPTER \n\n\nINSTRUCTIONS AND PRECAUTIONS \nFOR INJECTIONS \n\n\nWHEN TO INJECT AND WHEN NOT TO. \n\n\nInjections are not needed fied. Most sicknesses that require medical treatment \ncan be treated as well or better with medicines taken by pent. As a general rule: \n\n\nIt is more dangerous to inject \nmedicine than to take it by mouth. \n\n\nInjections should be used only when absolutely necessary, Except in \nemergencies, they should be given only by health workers or persons trained in \ntheir use. | \n\n\nThe only times medicines should be injected are: \n\n\n1. When the recommended medicine does not come in a form that can be taken \nby mouth. \n\n\n2. When the person vomits often, cannot swallow, or is unconscious. \n\n\n3. In certain unusual emergencies and special cases (see the next page). \n\n\nWHAT TO DO WHEN THE DOCTOR PRESCRIBES INJECTIONS \n\n\nDoctors and other health workers sometimes prescribe injections when they are \nnot needed. After all, they can charge more money for injections. They forget \nthe problems and dangers of giving them in rural areas. \n\n\n1, If a health worker or healer wants to give you an injection, be sure the \nmedicine is appropriate and that he takes all the necessary precautions, \n\n\n2. |\\f a doctor prescribes injections, explain that you live where no one is well \ntrained to give injections and ask if it would be possible to prescribe a medicine to \ntake by mouth. \n\n\n3. If a doctor wants to prescribe injections of vitamins, liver extract, or vitamin \nB72, but has not had your blood tested, tell him you would prefer to see another \ndoctor. \n\n\n78 \nEMERGENCIES WHEN IT IS IMPORTANT TO GIVE INJECTIONS \n\n\nIn case of the following sicknesses, get medical help as fast as you can. If there \nwill be any delay in getting help or in taking the sick person to a health center, \ninject the appropriate medicine as soon as possible. For details of the doses, \nconsult the pages listed below. Before injecting, know the possible side effects and \ntake the needed precautions. \n\n\nFor these sicknesses | Inject these medicines \n\n\nSevere pneumonia (p 208) \nInfections after childbirth (p. 322) penicillin in high doses (p. 398'+99 \nGangrene (p. 254) \nTetanus (p. 222) penicillin (p. 397=98) \nand tetanus antitoxin (p.421 ) \nand phenobarbital (p.422) \nor diazepam (p.423) \n\n\nAppendicitis (p.108) penicillin or ampicillin \n\n\nPeritonitis (p,108) and bullet wound in strong doses (p. 399) \nor other puncture wound in the \n\n\nbelly \n\n\nPoisonous snakebite (p.121) snake antivenin (p. 421) \n\n\nScorpion sting (p.123) scorpion antivenin (p. 421) \n\n\nMeningitis (p. 225) penicillin (p. 398) in very high doses \nwhen you do not suspect or ampicillin (p.399 400) \n\n\ntuberculosis \n\n\nMeningitis (p.226) ampicillin or penicillin together \nwhen you suspect tuberculosis with streptomycin (p.399~ 400)” \n} and other ‘anti- tuberculosis \n\n\ndrugs (p. 403) \n\n\nVomiting (p.192) when it antihistamines, for example, \ncannot be controlled promethazine (p.419,420) \n\n\nSevere allergic reaction \n\n\nallergic shock, (p. 83) Adrenalin (p. 419) \nand severe asthma, (p. 204) \n\n\nThe following chronic illnesses generally require injections. but they are \nrarely emergencies. It is best to consult a health worker for treatment. \n\n\nTuberculosis (9.219 220) streptomycin (p.403.404) together \n\n\nwith INH tablets and PAS tablets \n(p. 404) \n\n\nsyphilis (p.281) procaine penicillin in very high \nGonorrhea (p.280) doses (p. 399) \n\n\n79 \n\n\nWHEN NOT TO INJECT: \n\n\nNever give injections if you can get medical help quickly. \nNever give an injection for a sickness that is not serious. \nNever give injections for a cold or the flu. \n\n\nNever inject a medicine that is not recommended for the illness you \nwant to treat. \n\n\nNever inject a medicine unless you know and take all the recommended \nprecautions. \n\n\nAvoid giving injections especially to smail children when \nthere is an epidemic of polio in your village. \n\n\nMEDICINES NOT TO INJECT \n\n\nIn general, it is better never to inject the following: \n\n\n1. Vitamins. Rarely are injected vitamins any better than vitamins taken by \nmouth. Injections.are more expensive and more dangerous. Use vitamin pills \nor syrups rather than iniections. Better still, eat foods rich in vitamins (see \n0.130). \n\n\n2. Liver extract and vitamin B12. Do not inject them! Ferrous sulfate pills will \n\n\ndo more good for almost all cases of anemia (see p. 424) \n\n\n3. Calcium. Injected into a vein calcium is extremely dangerous, if not given \nvery slowly. An injection in the buttock may Cause a large abscess. Untrained \npeople should never inject calcium. \n\n\n4. Penicillin, Nearly all infections that require penicillin can be effectively \ntreated with penicillin taken by mouth. Penicillin is more dangerous when \ninjected. Use injectable penicillin only for dangerous infections. \n\n\n5. Penicillin with streptomycin. Avoid this combined medicine. Never use it \n\n\nfor colds or the flu (p.200). \n\n\n6. Chloramphenicol or tetracycline. These medicines do as much or more good \n\n\nwhen taken by mouth. Use capsules or syrups rather than injections (p.401). \n\n\n7. Intravenous (1.V.) solutions. These should be used only for severe \n\n\ndehydration and given only by someone who is well trained. When not given \ncorrectly they can cause dangerous infections or death (p. 64). \n\n\n8. Intravenous medicines. There is so much danger in injecting any medicine in \n\n\nthe vein that only well-trained health workers should do it. However, never \ninject into a muscle (the buttock) medicine that says ‘for intravenous use \nonly’. Also, never inject in the vein medicine that says for intramuscular use \nonly’. \n\n\nsO \n\n\nRISKS AND PRECAUTIONS \n\n\nThe risks of injecting any medicines are (1) infection caused by germs entering \nwith the needle and (2) allergic or poisonous reactions caused by the medicine. \n\n\n1. To lower the chance of infection \nwhen injecting, take great care that \neverything is completely clean. It is \nvery important to boil the needle and \nsyringe before injecting. After boiling, \ndo not touch the tip of the needle with your \nfingers or with anything else. \n\n\nAlways boil the needle before each injection, \nespecially if you are using the same needle \nfor many persons. Carefully follow all of \n\nthe instructions for injections (see following \npages) cs \n\n\n| \n\n\nAn abscess like this one comes from \ninjecting with a needle that has not \nbeen well boiled and is not sterile \n(completely clean and germ-free). \n\n\n2. This child was injected with a needle \nthat was not sterile. \n\n\nThe dirty needle caused an infection that \n\n\nproduced a large painful abscess (pocket \nof pus)and ‘gave the child a fever. \n\nFinally, the abscess burst as shown in \nthe picture below. \n\n\nThe child was injected for a cold. It \nwould have been far better to give him no? \nmedicine at all. Rather than doing him . \n\n\ngood, the injection caused the child \nsuffering and harm. \n\n\n81 \n\n\n3. To avoid problems like this: \n\nInject only when absolutely necessary. \n\n* Boil the syringe and needle just before \ngiving the injection and be very careful \nto keep them completely clean. \n\n* Use only the medicine recommended for \nthe disease and be sure that it is still \n\nin good condition and not spoiled: \n\n* Inject in the correct place. (Notice \n\nthat this child was injected too low on the \n‘buttock, where it is possible to damage \nthe nerve. \n\n\n4. It is very important to know what \n\nreactions medicine can produce and to \ntake the recommended precautions before | \ninjecting. - \n\n\nDANGEROUS REACTIONS FROM INJECTING \nCERTAIN MEDICINES \n\n\nCertain drugs like penicillin, ampicillin, and antitoxins are likely \nto give severe allergic reactions. Before injecting the full dose of \nany of these medicines, ALWAYS DO A SENSITIVITY TEST * to find \nOut. if the person is sensitive to the medicine. \n\n\nAlways keep adrenalinready before and after doing a sensitivity \ntest. \n\n\nHow to do a sensitivity test. \n¢ Prepare the syringe for injection as shown in page 85 \n\n\n¢ Use avery small needle \n\n\ne Clean the skin of the inner side of the forearm with soap and water \nor alcohol \n\n\n* Be sure the skin is dry before injecting \n\n\nLL TT RT ISN RE Ae SO ETP A RN TEI \n\n\n- * 7 e.¢ ‘ * { ) Af 4 “\\f Tt \\V rc | - \nDavid Werner has not included the ‘sensitivity test’ in his original book, as he tee thay subi Atesl dbas Ty iB \nnot prove that a person is not sensitive to the medicine G//1, (First Floor) St. Marke 5. 4 \n——_ tr - “s m4 ¥ af nN S Noa -_ \n\n\n82 \n\n\n® Hold the syringe flat against the skin \n\n\n@ Inject Q)1 ml. of the medicine just into the skin so that a raised area, J \nthe size of a pea, is formed,. Do not injoct under the skin. \n\n\n@ Remove the needle and wait for 30 minutes. ; a 4 \n\n\n4 \n\n\nPZ \nWatch for the following signs: Sf-———— \n\n\nsite of the injection becomes red, painful, or swells up \n\n\nhives or a rash with itching \nswelling anywhere \n\ndifficult breathing \n\nsigns of shock (see p. 83) \n\n\ndizzy spells with nausea \n(wanting to vomit) \n\n\nproblems with vision \nringing in the ears or deafness \nsevere back pain \n\ndifficulty urinating \n\n\nlf any of the signs appear, DO NOT INJECT THE REST OF THE \nMEDICINE. DO NOT EVER GIVE THE MEDICINE TO THE SAME \nPERSON AGAIN.Inject 2 mi. of adrenalin for adults and % ml. for \nchildren. \n\n\nlf none of these signs appear within 30 minutes, then inject the \nrest of the medicine in the muscle of the buttocks as shown in \npage. 86 \n\n\nSometimes a person who shows no signs of allergic reaction after a sensitivity test \n\n\nmay show the signs after a full dose. Always keep adrenalin ready even after doing \na sensitivity test. \n\n\nlf a person complains of hives or rash a few days after getting a full dose of the \n\n\ninjection, he is probably allergic to the medicine. Do not give him the same medicine \nagain. \n\n\nSometimes, hives or arash with itching can appear a few hours or several days after \ngetting an injection. \n\n\n83 \n\n\nThe following groups of medicines sometimes produce a dangerous reaction \ncalled ALLERGIC SHOCK a short time after injection: \n\n\n® penicillins (including ampicillin) \n\n\nsnake antivenin \n\n\nscorpion antivenin \ns antitoxins that are made from horse serum \n\n\ntetanus antitoxin \n\n\nThe risk of Allergic snock is greater in a person who has previously oN \ninjected with one of these medicines or with another medicine of the same group. \nThis risk is especially great if the medicine caused an allergic reaction (hives, \nitching, swelling, or trouble breathing) a few hours or days after the injection was \ngiven. \n\n\nRarely, ALLERGIC SHOCK may \nresult from the sting of a wasp or bee or \nfrom medicine taken by mouth. ie \n\n\nq \n\n\nTo prevent a serious reaction from an injection: \n\n\n1. Use injections only when absolutely necessary. \n\n\n2. Before injecting one of the medicines listed above, always have ready Z \nampules of Adrenalin (p. 419) and an ampule of an antihistamine like \npromethazine (Phenergan, p.419) or diphenhydramine (Benadryl, p.420). \n\n\n3. Before injecting, always ask if at any other time a similar injection caused \nitching or other reactions. if the person says yes, do not use this medicine or any \nother medicine of the same group, either injected or taken by mouth. \n\nIf he says no, do a sensitivity test before injecting the full dose of the medicine \n\n\n4. In very serious cases, like tetanus or snakebite, if there is a good chance that \nthe antitoxin might produce an allergic reaction (if the person suffers from \nallergies or asthma or has had horse serum before), inject promethazine or \ndiphenhydramine 15 minutes before giving the antitoxin: adults, 3 ml.; children \n1 or 2 ml. depending on their size. \n\n\n5. After injecting any medicine, always stay with the person for 30 minutes to \nwatch for any of the following signs of ALLERGIC SHOCK: \n\ne cool, moist, pale, gray skin (cold sweat) \n\n@ weak, rapid pulse or heartbeat \n\ne difficulty breathing \n\n\ne loss of consciousness \nThese signs can appear even if the sensitivity test was normal. \n\n\n6. If these signs appear, immediately inject Adrenalin: adults, % ml.; children, \n% mt. Treat the person for SHOCK (see p..89). Follow by giving an antihistamine \nin double the normal dose. \n\n\n84 \n\n\nHow to Avoid Serious Reactions \nto a Penicillin Injection & \n\n\n1. For mild to moderate infections: 2. Before injecting ask the person: \n\n\ngive penicillin pills ao “Have you ever had \nhives, itching, swelling, or \n\n\ntrouble breathing after \ngetting an injection of \npenicillin?” \n\n\ninstead of injections. \n\n\nIf the answer is yes, do not use penicillin o \nampicillin. Use another antibiotic like \nerythromycin (p. 400) or a sulfonamide (p.402). \nIf the answer is no, do a sensitivity test. \n\n\nOSS etree \n\n\n3. Before injecting penicillin: 4, After injecting: \n\n\nalways have ampules of \nADRENALIN ready. \n\n\ni \nADRENALIN \n\n\\s \nADRENALIN \n\n\nstay with the person for at least 30 \nminutes. \n\n\n5. If the person becomes very pale, his heart beats very fast, he \nhas difficulty breathing, or he starts to faint, immediately inject \ninto a muscle half an ampule of ADRENALIN (a quarter of an \nampule in small children) and repeat in 10 minutes if necessary. \n\n\n— \n\n\n85 \n\n\nHOW TO PREPARE A SYRINGE FOR INJECTION \n\n\n: ps \n1. Take the syringe apart » gee \nand boil it and the \n\n\n5 aa ~)at \nneedle for 15 minutes. as \n\n\naa \n\n\nprem di eg \n\ncatty) \n3. Put the needle and the syringe \ntogether, touching only the base of \nthe needle and the button of the \nplunger. ee \n\n\n—_—= \n\n\n5. Fill the syringe. = 6. Rub the rubber of the 7. Inject the t \\ \n(Be careful that / , bottle with clean cloth distilled water. , \nthe needle does 7 f wet with alcohol into the bottle \n\nnot touch f- or boiled ~~“). with the \n\nthe outside water. ., Leonor’ f powdered \n\nof the Zee medicine. \n\n\nampule.) \n\n\n8. Shake until the \n\n\nmedicine dissolves. again. \n\n\n9. Fill the syringe \n\n\n2. Pour out the boiled \nwater without touching \nthe syringe or the needle. \n\n\n4. Clean the ampule of distilled \nwater well, then break off the top. \n\n\n10. Remove all air. \nfrom the eee \nsyringe. \n\n\nBe very careful not to touch the tip of the needle with anything not even the cotton \nwith alcohol. If by chance the tip of the needle touches your finger or something \n\n\nelse, boll it again. \n\n\n86 . \n\n\nWHERE TO GIVE AN INJECTION \n\n\nIt is preferable to inject in the muscle of the buttocks, always in the upper outer \nquarter. \n\n\n: Never inject children under 2 years of \nues age in the buttock. Inject them in the \nee upper outer part of the thigh. \n\n\nHOW TO INJECT \n\n\n1. Clean the skin with soap and water 2. Put the needle straight in, all the \n(or alcohol—but to prevent severe pain, way. (If it is done with one quick \nbe sure the alcohol is dry before movement, it hurts less.) \n\ninjecting). \n\n\n3. Before injecting, pull back 4. |f no blood enter \non the plunger. (If blood enters inject the medicine \nthe syringe, take the needle slowly. \n\nout and put it in somewhere \n\nelse.) \n\n\n5. Remove the needle \nand clean the skin \nagain. \n\n\n6. After injecting, rinse the syringe and needle at i \nf once. Squirt water through the \npeace and then take the syringe apart and wash it. Boil before using again. \n\n\nThe book Where There Ts No Doctor is available \nF plus postage. Multiple copies of reprints \ns chapters are also available, . 73a \n\n\nPublications Officer . | : oo \n/ Voluntary Health Association of India \n_C-14 Community Centre \n\n\nSafdarjung Development A rea \nNew Delhi 110016 cae. \n\n\n", "summary": "COMMUNITY SZ ALTH CTL 47/1, (First Fleor) St. Marks Road Md-28 Bandatore - 580 091, INSTRUCTIONS AND PRECAUTIONS 9) FOR INJECTIONS This is a reprint from Where There Is No Doctor (Indian adaptation) published by the Voluntary Health Association of India C-14 Community Centre Safdarjung Development Area New Delhi 110016 COMMUSt ry WEA TH CELL | 77 CHAPTER INSTRUCTIONS AND PRECAUTIONS FOR INJECTIONS WHEN TO INJECT AND WHEN NOT TO. Injections are not…", "source_url": "https://archive.org/details/sochara.instructionsprec0000wern", "pdf_url": "https://archive.org/details/sochara.instructionsprec0000wern", "doc_date": "1981", "case": "hesperian", "sub_case": "Werner, David", "tags": ["hesperian"], "page_count": 0} {"title": "Where there is no dentist", "content": "Where There \nIs No Dentist \n\nby Murray Dickson \n\n\n\n\nwith an Introduction by David Werner, \nauthor of Where There Is No Doctor \n\n\n\nCompiled by noonya \n\n\n\nLibrary of Congress Cataloging in Publication Data \n\nCatalog card No. 82-84067 \n\nDickson, Murray \n\nWhere there is no dentist. \n\nIncludes index. \n\nPalo Alto, CA: Hesperian Foundation \nISBN: 0-942364-05-8 \n\nFirst edition, November 1983 \nSeventh Printing, July 1996 \n\n\n\nPUBLISHED BY: \n\nThe Hesperian Foundation \n\nP.O. Box 1692 \n\nPalo Alto, California 94302 \n\nU. S. A. \n\nCopyright ©1983 by The Hesperian Foundation \n\n\n\n\nThis book is certainiy not intended to be the iast word in community \ndentai care. It is only a beginning. The author hopes to rewrite and \nimprove the book with suggestions from readers. \n\nNote on the use, adaptation, and translation of this book: \n\nEach country is special, with its own \nparticular customs, health needs, and \nways of caring for people. \n\nThis book, therefore, must be adapted \nby dental workers in each country, using \nthe language that is common to the local \nhealth workers there. \n\nThe author would be pleased to assist \nin any way with those who would translate \nor adapt the book. \n\nThe Hesperian Foundation encourages others to copy, reproduce or adapt \nto meet local needs, any or all parts of this book, including the illustrations, \n\nprovided the parts reproduced are distributed free or at cost \n-not for profit. \n\nAny organization or person who wishes to copy, reproduce or adapt, any or \nall parts of this book for commeroial purposes, must first obtain permission \nto do so from the Hesperian Foundation. \n\nPlease contact the Hesperian Foundation before beginning any transla- \ntion or adaptation to avoid duplication of efforts, and for suggestions \nabout adapting the information in this book. The foundation would appreci- \nate receiving a copy of any materials in which text or illustrations from this \nbook have been used. \n\nWe would like to rewrite this book and incorporate many of your ideas. \nIf you have a suggestion, please write to Murray Dickson at The Hesperian \nFoundation. Better yet, if you write your own manual, please set aside \ntwo copies and send one to The Hesperian Foundation, Box 1692, Palo \nAlto, California 94302, USA. Send the other to AHRTAG (Appropriate \nHealth Resources and Technologies Action Group), 29-35 Farringdon \nRoad, London EC1M 3JB, England. Both organizations would like to help \npass along your ideas to others. \n\n\n\n\nTHANKS \n\nWhere There Is No Dentist is here to fill a need. To many people, it has seemed that \nthe existing books about dental care were either too incomplete or too complicated. \n\nIf this book fills that need, it is only because a number of people worked hard to make \nit happen. To them I owe my sincere thanks. \n\nMuch has hapoened since that day in Papua New Guinea when David Werner's \nletter arrived. His challenge was simple: \"Since no one else has written a dental manual \nlike this, why don't you?\" With David's encouragement and constant support, I was \nable to take teaching notes and produce a suitable draft that was the basis for this \nbook. To you, David, for your patience in helping me learn, my heartfelt thanks. \nThanks also to T rude Bock and Bill Bower for the home, food, direction, and support, \nduring a short visit to The Hesperian Foundation in which the book took a definite \nturn for the better. \n\nMichael Blake deserves special mention. As editor of Where There Is No Dentist, it \nwas he who took the manuscript and nursed it along to completion. Michael's \ncommitment to finishing the book was vital, and I sincerely appreciate it. \n\nMy thanks go to Maggie Leung for typing the final draft, and to those dedicated \npersons who helped get the book into final form: Annaloy Nickum (page design); \n\nHal Lockwood (typesetting and paste-up); Paul Chandler, Serena Clayton, and Elaine \nRossi (proofreading); Pat Bernier (typing): and Howard Uno (photostats). \n\nFor their outstanding drawings, I am exceedingly grateful to: June Mehra, Janet \nElliott de Jacques, Michael Marzolla, Joan Thompson, Mindy Mead, Arlene Ustin- \nCartagena, and Lynn Gordon. My own drawings in the manual appear amateurish in \ncomparison. \n\nI want to thank the many persons who reviewed the manuscript and offered \nvaluable suggestions: Ken Cripwell, Bill Bower, Jeff More, Aaron Yaschine, Rosalie \nWarpeha, Norma Francisco, Mike Muller, Marcia Anderson, Phil Haskett, Bert Ball, \n\nTom Coles, Sunil Mehra, and John Rogers. In particular, thanks to Chris Lennox who, \nfaced with stressful times in Papua New Guinea, found time to read through two \ndrafts; and to David Morley for his ideas for improving the book and his assistance \nwith its eventual publication. \n\nFor their financial help, I am grateful to the Ella Lyman Cabot Trust, Muttart \nFoundation, the Canadian Organization for Development through Education, and the \nJames C. Penney Foundation. \n\nI thank the C.V. Mosby Company and Dr. Kenneth Snawder for permission to \nadapt several drawings from the Handbook of Clinical Pedodontics, and the \nMedical Missionary Association (6 Canonbury Place, London N1 2NJ, U.K.) \nfor permission to use parts of David Halestrap's book Simple Dental Care. \n\nThis book is based upon several years of practical experience, made possible by \nthe Canadian Organization CUSO. For this opportunity, and for CUSO's active interest \nand involvement in this book, I most gratefully say thanks. \n\nFinally, I want to acknowledge my family's contribution. For weeks on end, my \nwife, Gerri, faithfully read and discussed with me each part of the book as it changed \nand was rewritten. She did this cheerfully, at a time when she was fully occupied in a \ngraduate study program. For much longer than I had anticipated, Gerri and our two \nboys, Michael and Brennan, had to tolerate my preoccupations. \n\nMy parents endured my wanderings and search for answers to human problems \nwith love and a growing sense of understanding. It is my only disappointment that \nthey did not live to see this book in its final form. \n\n\n\n\nCONTENTS \n\n\n\nINTRODUCTION, by David Werner \n\nPart One: Learning and Teaching about Teeth and Gums \n\nChapter 1 : Your Own Teeth and Gums 1 \n\nChapter 2: Teaching Family and Friends In Your Community 9 \n\nChapter 3: Teaching Children At School 17 \n\nChapter 4: School Activities for Learning About Teeth and Gums 33 \n\nChapter 5: Taking Care of Teeth and Gums 59 \n\nPart Two; Treating Dental Problems \n\nChapter 6: Examination and Diagnosis 71 \n\nChapter 7: Treating Some Common Problems 81 \n\nChapter 8; Scaling Teeth 121 \n\nChapter 9: Injecting Inside the Mouth 129 \n\nChapter 10: Cement Fillings 137 \n\nChapter 11: Taking Out a Tooth 147 \n\nREFERENCE PAGES 163 \n\nThe Dental Kit \n\nRecords, Reports, and Surveys \nStory Telling \n\nDental Health Teaching Materials \n\nVOCABULARY 182 \n\n\n\nINDEX \n\n\n\n187 \n\n\n\nINTRODUCTION \n\nby David Werner \n\n\n\nA healthy tooth is a living part of the body. It is connected by \n'life-lines' of blood and nerve to a person's heart and brain. To separate \nthe tooth from the body, or even to interrupt those 'life-lines', means \ndeath to the tooth. It also means pain and injury to the body, to the \nperson. \n\nLet us look at it another way. The health of the teeth and gums is \nrelated to the health of the whole person, just as the well-being of a \nperson relates to the health of the entire community. \n\nBecause of this, the usual separation between dentistry and general \nhealth care is neither reasonable nor healthy. Basic care of the teeth and \ngums— both preventive and curative— should be part of the 'know-how' of \nall primary health care workers. Ideally, perhaps. Where There Is No \nDentist should be a part of Where There Is No Doctor. Think of it as a \ncompanion volume, both to Where There Is No Doctor and Helping Health \nWorkers Learn. \n\nMurray Dickson has taken care to write this book in a way that will \nhelp the readers see dental care as part of community health and \ndevelopment. The approach is what we call 'people centered.' \n\nWhere There Is No Dentist is a book about what people can do for \nthemselves and each other to care for their gums and teeth. It is written \nfor: \n\n• village and neighborhood health workers who want to learn more \nabout dental care as part of a complete community-based approach \nto health; \n\n• school teachers, mothers, fathers, and anyone concerned with \nencouraging dental health in their children and their community; \nand \n\n• those dentists and dental technicians who are looking for ways to \nshare their skills, to help people become more self-reliant at lower \ncost. \n\nJust as with the rest of health care, there is a strong need to \n'deprofessionalize' dentistry— to provide ordinary people and community \nworkers with more skills to prevent and cure problems in the mouth. \n\nAfter all, early care is what makes the dentist's work unnecessary— and \nthis is the care that each person gives to his or her own teeth, or what a \nmother does to protect her children's teeth. \n\n\n\n\nWhile dental disease is decreasing in richer countries, it is on the increase \nin most poor countries. One reason for this is that people are eating fewer \ntraditional (unrefined) foods and more pre-packaged commercial foods, \noften sweetened with refined sugar. \n\nEven as the need for dental care is growing, there are still far too few \ndentists in poor countries. Most of those few work only in the cities, \nwhere they serve mostly those who can afford their expensive services. \n\nPeople in many countries cannot afford to pay for costly professional \ndental care. Even in rich countries, persons who do not have dental \ninsurance often do not get the attention they need— or go into debt to \nget it. \n\nTwo things can greatly reduce the cost of adequate dental care: popular \neducation about dental health, and the training of primary health workers \nas 'dental health promoters'. In addition, numbers of 'community dental \ntechnicians' can be trained— in 2 to 3 months plus a period of \napprenticeship— to care for up to 90% of the people who have problems \nof pain and infection. \n\nDentists' training usually includes complicated oral surgery, root canal \nwork, orthodontics (straightening teeth), and other complex skills. Yet \nmost dentists rarely do more than pull, drill, and fill teeth— skills that \nrequire a fraction of the training they have received. The simpler, more \ncommon dental problems should be the work of community dental \ntechnicians who are on the 'front lines' (the villages), with secondary \nhelp from dentists for more difficult problems. \n\nWould this reduce quality of service? Not necessarily. Studies have \nshown that dental technicians often can treat problems as well as or better \nthan professional dentists. In Boston (U.S.A.), for example, a study \nshowed many of the basic treatments commonly given by dentists to be \ndone just as well, and often better, by dental technicians with much \nshorter training. \n\nFortunately, in some countries skilled dental technicians have managed \nto become the major providers of the most needed dental services. In \nIndia, there are still 'street-corner' dental technicians with foot-pedal \ndrills, who drill and fill teeth at remarkably low cost. \n\nIn Honduras, dental technicians (who learn largely from each other, \nstarting as helpers) have formed their own union. Their political strength \nrecently was tested when, in the town of T rujillo, a dentist tried to put a \ntechnician out of business. The local technician had removed an infected \nroot left mistakenly by the dentist. The technician had commented on \nthe dentist's carelessness, and the dentist heard about it. The dentist sent \na policeman who shut down the technician's office and took away his \ntools. However, the dental technicians' union took this to court. They \nargued their rights to practice dentistry, because they are the only persons \n\n\n\n\nworking in marginal communities where dentists' prices are too high for \nthe people. The court decided in favor of the technicians, and ordered the \ndentist to return the technician's tools and pay him for work lost. \n\nIn other countries dentists and community dental workers work in \ncloser harmony. In Guatemala, -Ecuador, Papua New Guinea, and \nMozambique, dental technicians are now recognized by the Ministries of \nHealth. In Papua New Guinea and Ecuador, professional dentists train and \nsupervise them to provide dental care to school children. In Ecuador, they \nwork mostly as dentist assistants, bringing high quality services to more \npeople while decreasing costs. The 'dental therapists' in Papua New Guinea \nare trained to extract, drill, and fill teeth, as well as to work on prevention \nof dental problems in school children. \n\nIn Guatemala and Mozambique, dentists from the dental school have \ntrained village health promoters as dental workers who work with people \nof all ages. Their training includes community dental health education, \ncleaning of teeth, extractions, and drilling and filling. These health \nworkers are provided with the few basic instruments needed to provide \nthese services. \n\nIn Project Piaxtia, Mexico (with which I and the Hesperian Foundation \nhave worked for many years), visiting dentists have also helped train \nvillage 'dentics'. They, in turn, now teach basic dental skills to the part- \ntime village health workers. These village dentics, some of whom have had \nonly 3 to 6 years of primary school, now practice— and teach— a wider \nrange of dental skills than the average dentist. Their activities include \ndental health campaigns with school children, community puppet shows \nabout low-cost dental self-care, cleaning of teeth, extractions, drilling and \nfilling, and the making of dentures (false teeth). Several of the dental \nworkers can now do root canal work— a special treatment to remove the \ncentral nerve in order to save an infected tooth. One of the village dentics, \nremembering what he had seen a dentist do, taught himself how to do \nroot canals when his girlfriend had an infected front tooth that he did not \nwant to pull. (He had also learned to check the tooth from time to time \nafterward to .make sure this treatment had been successful.) \n\nWe still have much to learn about dental health. Dentists need to learn \nfrom the knowledge of the local people, as well as the people from the \ndentists. \n\nWe have learned that villagers with little formal education often can \nlearn skills with their hands— such as tooth extractions, puppetry, or \nsurgery— much faster than university students (who have never learned to \nuse their hands for much more than pushing pencils). We also have \nobserved that the best way to learn dentistry is not through school but \nthrough practice, helping someone with more experience who is willing \nto teach. \n\n\n\n\nWhere There Is No Dentist has 2 parts. The first part (Chapters 1.-5) \ndiscusses teaching and learning about preventive care. It begins by \nencouraging the health worker to examine herself and her family. To be \na good example is the best way to teach. \n\nThe second part (Chapters 6-1 1 ) talks about diagnosing and treating \ncommon dental problems. It is especially for those who live where they \ncannot reach or afford a dentist. A poor neighborhood in the city can be \nas distant and neglected as a far-off village. This second part is intended \nmainly for health workers who have helped organize people to meet their \nown needs. \n\nMurray Dickson— a Canadian with primary care experience in Northern \nCanada, Nigeria, Papua New Guinea, and Mozambique— has written this \nbook in clear, simple language. He takes care to use popular names instead \nof unfamiliar scientific words. For example, instead of speaking of 'dental \nplaque' the author speaks of the 'coating of germs on the teeth,' Such \nsimple language does not weaken the message. The message is stronger \nbecause everyone understands. \n\nThe author has said: \n\nI am sure some dentists will disagree with parts of this book. Some \npoints of disagreement may be small, like the failure to use accepted \ndental terminology. Other ideas, particularly the suggestion that non- \ndental people can be trained to provide many kinds of treatments, may \nmake some dentists angry. \n\nThe book is meant to be a source for argument and discussion. This \nway, it may stimulate others to write the kind of manual that is really \nneeded in their countries. \n\nWe hope that this will be only the first volume of Where There Is No \nDentist. It takes the reader as far as simple extraction (pulling) of teeth \nand placement of temporary fillings. As we have seen, village workers can \nalso learn a wide range of more difficult dental skills. We hope that later \nvolumes of Where There Is No Dentist will include permanent fillings, \nhomemade portable drilling equipment (many kinds have been developed), \nthe making of false teeth, and root canal treatment. There is no reason \nwhy village workers cannot learn all of these skills and practice them at \nlow cost to serve the millions who are unserved today. \n\nThe people must answer to the people's needs. The health of teeth and \ngums, along with general health, will improve only when people take the \nlead in caring for themselves. The challenge for dentists and other health \nprofessionals is to allow and encourage this to happen. \n\n\n\n\n1 \n\n\n\nCHAPTER \n\nYour Own Teeth \nand Gums \n\n\n\nNext time you look in a mirror, look at your teeth and the skin (gums) \naround them. Look in your children's mouths, too. Look at both gums \nand teeth, because the health of one often depends on the health of the \nother. To be strong, teeth need healthy gums. Healthy gums need clean \nteeth. \n\n\n\nWhat can good \nteeth give you? \n\n. GOOD HEALTH \n\n. GOOD LOOKS \n\n. GOOD SPEECH \n\n• GOOD EATING \n\n• GOOD BREATH \n\n\n\n\nAnd when you think of your teeth, think of your gums. Gums are \nimportant for holding each tooth in place. \n\n\n\nYou need strong teeth to eat different kinds of foods. Different foods \nare important for health. Nuts, maize, fruits, and meat are some of the \nbest foods— but they are difficult to bite and chew if your teeth are loose \nand hurting! \n\n\n\n2 \n\n\n\nYou can usually tell if your teeth and gums are healthy or not. Look at \nthe pictures on pages 71 and 72 and compare them with your own mouth. \nIf you find a problem in your mouth, look for its name in Chapter 6 and \nlook for its treatment in Chapter 7. \n\n\n\nMost important: when you are not sure of a \nproblem or how to treat it, talk to an \nexperienced dental worker. \n\n\n\nIf you notice a problem early, often you can stop it from getting worse. \nIt is even better to prevent the problem from starting. You can do this \nif you know how to keep your teeth and gums healthy. \n\n\n\n\n/Birr Hov/ CAN \nI KEEP m \nTEETH AND m \nGUMS HEALTHY? \n\n\n\n\nBY EATIN6 0NLY\\ \n\ngood healthy \nFood and oEANWGr, \n\nYOUR TEETH \nEVERY DAY/ \n\n\n\nLearn to take care of your own teeth and gums before you try to teach \nothers. A good example is one of your best teaching tools. People will \nsee that you are healthy, and they will want to know why. When you tell \npeople ways to care for their teeth, they will believe you if they know \nthat you do these things yourself. First take care of your own teeth and \ngums. Then teach your family what you have learned. They, too, will be \ngood examples for others to see. \n\n\n\n\n\n3 \n\n\n\nEAT ONLY GOOD HEALTHY FOODS \n\nThe best food is food that you grow or raise yourself. Mix different \nkinds of food together and eat several times a day. This helps your body \nas well as your teeth and gums to stay strong and healthy. Traditional \nfood is usually good food. \n\nSweet food, especially the kind you buy from the store, can mix with \ngerms and make cavities— holes in the teeth. Soft food sticks to the teeth \neasily and it, too, can make a coating of germs and food on the teeth that \nstarts an infection in the gums— gum disease. \n\nSoft and sweet food and drinks with a \nlot of sugar are bad for both teeth and gums. \n\n\n\n\n\n\n\n\n\n\nSweet and GOOD \n\n\n\n\nBreast feed to help a child’s teeth \ngrow and stay strong. An older child \ncan drink from a cup. \n\n\n\n\nYES \n\nGOOD FOR TEETH \n\n\n\nDo not give a baby anything to drink \nfrom a bottle. Sweet tea, sugar water \nor fruit juice can easily make holes \nin the child’s teeth. \n\n\n\nREMEMBER: \n\nBREAST \n\nIS \n\nBEST! \n\n\n\n\nNO \n\nBAD FOR TEETH \n\n\n\nEven milk has sugar that can wash over the baby’s teeth and cause cavities when \nit comes from a bottle. \n\n\n\n\n\n\n\n4 \n\n\n\nCLEAN YOUR TEETH EVERY DAY \n\nIf you do not clean properly, the food that is left on your teeth can \nhurt the teeth as well as the gums near them. \n\nHIDING PLACES \n\nBits of food stay longer in grooves and \n'hiding places'. This is where both tooth \nand gum problems start. \n\ngrooves To prevent problems you must take special \non top (.gpg .[Q i^eep these protected places clean. \n\nIt is better to clean your teeth carefully \nt^heTeeth every day than to clean poorly many \n\ntimes a day. \n\nHere are 3 places where problems start. \n\nUse a soft brush to clean your teeth. Buy one from the store (be sure it \nsays soft on the package), or make a brush yourself. To make a brush: \n\n\n\n\n1 . Use a small branch, \nyoung bamboo, strong \ngrass or the skin from \nsugar cane or betel nut. \n\n\n\n\n3. Chew one end to make \nit stringy like a \n\n\n\n\n2. Cut a piece that is still \ngreen and soft. \n\n\n\n\n4. Sharpen the other end so \nit can clean between the \nteeth (see pages 69-70). \n\n\n\n\n\n\n5 \n\n\n\nYou can twist the fiber from inside a coconut husk into a kind of brush. \nFirst rub it and shake away the loose bits. Then use the end to clean your \nteeth. \n\n\n\n\nWhatever kind of brush you use, be sure to clean your back teeth as \nwell as your front teeth. Scrub the tops and sides where the grooves are. \nThen push the hairs between the teeth and scrub (page 67). \n\n\n\nToothpaste is not necessary. \n\nCharcoal or even just water is \nenough. When your teeth are \nclean, rinse away the loose \npieces of food. \n\n\n\n\n\n\n\n\n\n\n6 \n\n\n\nCAVITIES, TOOTHACHES AND ABSCESSES \n\n\n\n'Cavities', are holes in teeth. Cavities are made by the infection called \ntooth decay. If you have a black spot on your tooth, it might be a cavity. \nIf that tooth hurts some of the time, such as when- you eat, drink, or \nbreathe cold air, it probably has a cavity in it. \n\n\n\nYou will get cavities in your teeth if you eat sweet food and then do \nnot clean your teeth. If you see a cavity starting in your mouth or feel a \ntooth hurting you, get help right away. A dental worker knows how to \nfill the cavity so you can keep that tooth. Do this before the pain gets \n\n\n\nworse. \n\n\n\n\nIf you do \nnot fill a cavity, \nit grows bigger. \nIt also grows \ndeeper. \n\n\n\n\nWhen decay touches \nthe nerve inside, \nthe tooth aches, \neven when you try \nto sleep. \n\n\n\n\nWhen infection \nreaches the inside \nof a tooth, it \nis called a tooth \nabscess. \n\n\n\nA tooth with an abscess needs treatment at once, before the infection \ncan go into the bone (page 87). In most cases the tooth must be taken out. \nIf it is not possible to do this right away, you can stop the problem from \ngetting any worse if you follow these steps; \n\n\n\n1. Wash the inside of your mouth with warm \nwater. This removes any bits of food \ncaught inside the cavity. \n\n2. Take aspirin for pain. See page 88 for \namount. \n\n3. Reduce the swelling: \n\n• hold warm water inside your mouth near \nthe bad tooth. \n\n• Wet a cloth with hot water and hold it \nagainst your face. Do not use water hot \nenough to burn yourself! \n\n\n\nA tooth abscess can cause \nswelling like this. \n\n\n\n\n\n\n7 \n\n\n\nSORE BLEEDING GUMS \n\nHealthy gums fit tightly around the teeth. Gums are infected if they \nare loose, sore, and red, and if they bleed when the teeth are cleaned. \nInfection in the gums is called gum disease. \n\nGum disease, like tooth decay, happens when acid touches the teeth \nand gums. This acid is made when sweet and soft foods mix with germs \n\n\n\n\n\nHEALTHY TEETH AND GUMS CAVITIES AND GUM DISEASE \n\nInfection from gum disease can spread into the root fibers and bone (see \npage 40). But you can stop gum disease and prevent it from coming back. \n\nThere are two things to do: clean your teeth better and strengthen your gums. \n\n1. Even if your gums are sore and they bleed, you must still clean the \nteeth beside them. If more food collects on the teeth, the gum \ninfection will get even worse. Get a soft brush (see p. 4) and use it \ngently. This way you will not hurt the gums when you clean. \n\n2. To make your gums stronger and more able to fight the infection: \n\n• Eat more fresh fruits and green leafy vegetables, and fewer soft \nsticky foods from the store. \n\n• Rinse your mouth with warm salt water. Do this every day, even \nafter your gums feel better. \n\n\n\n\n(1 ) Mix some salt with a cup of warm water. (2) Take a \nmouthful and rinse. (3) Spit it out. Repeat until all of the salt \nwater is finished. \n\n\n\n\n\n\nMORE SERIOUS GUM DISEASE \n\n\n\nPainful gums that bleed at the slightest touch need special treatment. \n\nIf you have this problem, ask tor help. A dental worker can explain what \nis happening and what needs to be done. A dental worker can also scrape \nthe teeth and remove the tartar that is poking the gums, making them sore \n\nAt home, you can do some things to help. \n\n1 . Clean your teeth near the gums with a soft brush. Gently push the \nbrush between the tooth and the gum. It may bleed at first, but \n\nas the gums toughen, the bleeding will stop. \n\n2. Make your food soft, so it is easier to chew. Pounded yam and soup \nare good examples. \n\n3. Eat plenty of fresh fruits and vegetables. If it is difficult for you to \nbite into fruit, squeeze it and drink the juice. \n\n4. Start rinsing your mouth with a mixture of hydrogen peroxide and \nwater. You can get hydrogen peroxide from your clinic or your \npharmacy (chemist). \n\nThe strength of hydrogen peroxide is important. Ask for a 3% \n\nsolution, and mix it evenly with water— that is, 1 /2 cup of hydrogen \nperoxide with 1 /2 cup of water. \n\n\n\nWARNING: Read the label to be sure the solution is 3%. A \n\nmixture with more than 3% hydrogen peroxide can burn \nthe mouth. \n\n\n\n\nTake some into your mouth and hold it \nthere for about 2 minutes. Then spit it \nout and repeat. Do this every hour you \nare awake. \n\nUse hydrogen peroxide for only 3 days. \nThen change and start rinsing with salt \nwater (page 7). \n\n\n\nIf you take care, you can keep your teeth for a lifetime. \n\n\n\n\n\n\n\n\n9 \n\n\n\nCHAPTER \n\n\n\n\nTeaching Family and Friends \nIn Your Community \n\n\n\nOld people can remember when there were fewer problems with teeth \nand gums. Children's teeth were stronger and adults kept their teeth \nlonger. \n\nTimes are changing. Today there are more tooth and gum problems than \never before. In many countries, tooth decay and gum disease are two of \nthe fastest growing health problems. \n\nThis unhealthy situation is getting worse, for two reasons: changes in \nthe kind of food people now are eating, and not enough cleaning after \nthey eat. \n\nBEFORE, the food people ate was NOW, more people are buying \ntheir own, grown and prepared by softer and sweeter food from the \nthemselves. store. This kind of food sticks to \n\nthe teeth more easily so it has \nmore time to attack the teeth \n\n\n\n\nEven sugar cane was not as bad as Everyone must be more careful \n\nthe sticky candy children eat today. to clean away soft, sweet food. \n\nThe sugar was bad for the teeth, but But many people do not know \n\nthe fiber in the cane helped rub how. Some, especially children, \n\nthem clean. do not even try. \n\n\n\n\n\n10 \n\n\n\nMany people do not understand that tooth and gum problems are \ncaused by certain kinds of food, and poor cleaning of the teeth. In fact, \nsome have a completely different belief. \n\n\n\n\nDo not attack a belief because it is traditional. Many traditions are more \nhealthy than 'modern' things. Often, instead of telling people that their \nbelief is wrong, you can remind them of a different tradition that is \nhealthy. \n\n\n\nHelp your family and friends to recognize their healthy \ntraditions. Then help them find new ways to use these \nsame traditions for better health. \n\n\n\nI OUR People do not \nUSE TOOTHBRUSHES. \nVIE DO NOT HAVE MONEY \n\\To BUY Such thin&s \nVat the store. \n\n\n\n\n\n\n11 \n\n\n\nBE A GOOD EXAMPLE \n\nOther people like to watch what you do before they try something \ndifferent. First show members of your family and then they will be an \nexample to others in your community. For example: \n\n1 . Instead of buying all your foods from the store, buy fresh fruits and \n\nvegetables from the market. It is even \nbetter to grow food in your own \ngarden. \n\nLearn to use several different kinds of \nfoods in each meal. Mixing foods is a \nhealthy idea. Invite friends to share \nyour meals and see the number of \ndifferent foods you have at each meal. \n\n\n\n\n2. Do not buy fizzy drinks like Coca-Cola or Fanta. \nThey have a lot of added sugar which quickly \nmakes children's teeth rotten. \n\nAlso, do not sweeten your child's milk or tea. \n\nWhen she is young she can learn to enjoy drinks \nthat are not sweet. \n\nClean, cool water, tea with little sugar, milk, or \nwater from a young coconut are best to drink. \nFresh fruits are delicious when you are thirsty. \n\n\n\n\nMost important: do not give your child a feeding bottle, especially \none with a sweet drink inside. (See page 3.) \n\n\n\n\n3. Keep your children's teeth clean. \nYour friends will notice clean \nteeth or teeth that are dirty or \nhave cavities. Remember, clean \nteeth are healthy teeth. \n\nAn older child can clean his own \nteeth if you show him how. \n\nA younger child cannot. He needs \nhelp. Each day someone older \nshould clean his teeth for him \n(page 16). \n\n\n\n\n12 \n\n\n\nWhen you teach, remember that as others learn, \nthey too become teachers. Each person can teach another. \n\n\n\nEncourage people to pass along what you have taught. Mothers can \nteach family and friends. Students can talk at home with brothers, sisters, \nand older family members. \n\n\n\nFROM THE HEALTH CLINIC . . . \n\n\n\n. . .TO THE HOME \n\n\n\n\n/marie, PlEASE HELP \nME CLEAN BA6V‘& \nTEETH AND THEN \nBROTHER’S TEETH, \nWE. WILL PO IT \n\n\n\n\n...TO THE SCHOOL \n\n\n\n. . .TO THE HOME \n\n\n\nUSE A SOFT TOOTHBRUSH.^ \nA SOFT BRUSH IS BEST \n\nBECAUSE IT won’t \nHURT YOUR GUMS. \nTELL YOUR \n\nFAMILY THAT.. \n\n\n\n\n' WISH I HAP \nKNOWN ABOUT \nTHAT before. \n\n\n\n^ROTHER, TRY To BRUSH^\\ \n\n/ YOUR BACK TEETH BETTER.] \nIF YOU DO, THEN they 1 \n\\ WILL STAY STRON& UNTIL J \n\\YOU GROW OLD. \n\n\n\n\nIf all learners become teachers, a simple message can begin in the health clinic or school \nand reach many more people at home. \n\n\n\n\n\n13 \n\n\n\nFINDING THE BEST WAY TO TEACH \n\nDeciding what to teach is important, but just as important is how to \nteach. \n\n\n\nLearning cannot take place when \nyou use words that people do not \nunderstand. They will learn \nsomething only when they see how \nit is related to their lives. \n\n\n\nRemember this when you teach about eating good food and keeping \nteeth clean. Design your own health messages, but be ready to change \nthem if people are not understanding or accepting what you say. \n\nHere are five suggestions for teaching well. \n\n1. Learn First From the People \n\nGet involved in your community's activities. Learn about people's \nproblems, and then offer to help solve them. People will listen to you \nwhen they know that you care about \n\nSit and talk with people. Learn \nabout their customs, traditions \nand beliefs. Respect them. \n\nLearn about their health habits. \n\nImproving health may require \nchanging some habits and \nstrengthening others. \n\nLearn also about tooth decay \nand gum disease in your community. \n\nMake people smile— then look into their mouths. \n\nFind out how many children and adults are having \nproblems with their teeth and gums. Do a survey such \nas the one on p. 1 76. \n\n\n\n\n\n\n\n14 \n\n\n\n2. Build New Ideas Onto Old Ones \n\nPeople find their own ways to stay healthy. Many traditions are good, \nhelpful, and worth keeping. But some are not. \n\nWhen you teach, start with what people already understand and are \ndoing themselves. Then add new ideas. \n\nThis method of teaching is called 'association of ideas'. It helps people \nto understand new ideas because they can compare them with what they \nalready are doing. \n\n\n\nIn this way people can more easily accept, remember, and do what \nyou suggest. \n\nA HEALTHY TRADITION builds NEW IDEAS AND WAYS \n\n\n\n\nA small child cannot find his in the A small child cannot see the \n\nown lice. Mother knows she same way food on his teeth. He needs \n\nmust help him. help with that also. \n\n\n\n\nfood helps people to grow. \n\nDifferent vegetables when in the ^ Eating them several times a \n\nplanted together— like maize same way day makes your teeth and \n\nand yams— help each other gums, as well as your whole \n\nto grow. body, grow stronger. \n\n\n\n\n15 \n\n\n\n3. Keep Your Messages Short and Simple \n\nInstead of partially teaching too many things, it is better to discuss a \nfew things well. After learning what health problems the people feel are \ngreatest, decide what information will help them solve these problems. \nThen think of how to share the information. Try to; \n\n• Use simple words (see page 13). If you must use a big word, take the \ntime to explain it. \n\n• Teach people when they are ready to learn. A sick person, for \nexample, usually wants to know how to prevent his sickness from \nreturning. He will remember what you tell him. \n\n• Repeat the most important message many times. Whenever you teach \nabout staying healthy, remember to emphasize eating good food and \nkeeping teeth clean. Repetition helps people remember. \n\n• Let people see what you mean. See pages 24 to 32 for ways to use \npictures, puppets, and plays. \n\n\n\n4. Teach Wherever People Get Together \n\nKnowing where to teach is sometimes as important as how you teach. \nInstead of asking people to come to a class you have organized, go to \nthem. Look for ways to fit into their way of living. You both will gain \nfrom the experience. They will ask more questions, and you will learn how \nto work with people to solve problems. \n\nTalk with people where they \ngather near their homes. \n\n\n\nTalk to men as they \nsit together and \ndiscuss important \nissues. Also go to \ntheir business and \nfarming meetings. \n\n\n\n\nTeach men and women \nat reading groups. \n\n\n\n\n16 \n\n\n\n5. Teach Something People Can Do Right Away \n\n\n\nIt is good to tell a mother to keep her child's teeth clean, but it is better \nto show her how to do it. She will remember how if she actually watches \nyou clean her child's teeth. \n\nAn even better way for a mother to learn is to let her clean her child's \nteeth while you watch. A person discovers something for herself when she \ndoes it herself. \n\n\n\n\nPick out a child and clean his teeth yourself. Let \nhis mother watch. \n\nUse a soft brush (or for a baby, a clean cloth). \nGently but quickly brush or wipe his teeth. Do the \nbest you can even if he cries. \n\nIf mothers make this into a habit, the child will \nexpect to have his teeth cleaned and will soon \ncooperate— just the way he does to have lice ' \nremoved from his hair. \n\n\n\n\n\nNow let each mother clean her own \nchild's teeth. Teach her to clean on \ntop and on both sides of every \ntooth. \n\n\n\nAsk her to do the same at home \neach day. At the next clinic, look at \nthe children's teeth and see how \nwell the mothers are doing. Give \nfurther help when needed. Always \npraise and encourage those who are \ndoing well. \n\n\n\n\nTeaching Children \nAt School \n\n\n\n17 \n\n\n\nCHAPTER \n\n\n\nChildren want to learn. They want to know more about things that are \nreal to them. Family, friends, and teachers are all important sources of \nnew knowledge for the children. \n\nIt is important to keep alive their desire to learn, so \nthat children can continue to ask questions, discover, \nand learn more for themselves. \n\nWhen children are interested in something, they will work \nhard to learn all they can about it. \n\n\n\nIf you relate your teaching to children's interests and needs, they will \nlearn more easily. New information added to what they already know \nhelps children to understand your lesson better. As a result, they will want \nto learn more because the information is both interesting and worthwhile. \n\nTeaching about teeth and gums is important. You must do it well if \nyou want children to pay attention, learn, and finally act to take care of \ntheir own teeth and gums. \n\nAs school children continue to learn, they can share their new ideas and \ninformation at home with brothers, sisters, mothers, fathers, and grand- \nparents. In this way, the circle of teaching and learning described on page \n12 comes back into the family and is complete. \n\nThis chapter has two parts. Part 1 gives seven guidelines for assuring \nthat learning takes place. Part 2 suggests ways to have fun while learning— \nwith stories, games, and pictures. In Chapter 4 there are nine questions on \nteeth and gums with specific activities for learning how to answer them. \n\n\n\n\n\n18 \n\nPART 1: TEACHING SO THAT \nLEARNING CAN TAKE PLACE \n\nMore children than ever before are \nhaving problems with their teeth and their \ngums. \n\nA tooth that hurts or gums that are sore \ncan affect a student's ability to pay \nattention in school and learn. \n\nTreating the problem makes the child \nfeel better, and that is important. It is \nequally important to prevent the same \nproblem from returning later. \n\nWorking together, teachers and school children \ncan do much to prevent both tooth decay \nand gum disease. \n\nKeeping the mouth healthy involves learning about eating good food \nand keeping teeth clean. Just giving information is not enough, though. To \ntruly learn, children need a chance to find out things for themselves. \n\nForcing a person simply to accept what you say does not work very well. \n\nA student learns not to question. What you \nteach may have no relation to his own \nexperiences and needs. \n\nAs a result, he may end up not doing what \nyou teach— not eating good foods, and \nnot cleaning his teeth. \n\n\n\nLearning happens when a student with a \nquestion or an idea is able to discover more \nabout it himself. \n\nIt also happens when he has a chance to do \nwhatever is necessary to take better care of \nhimself and his family. \n\nHe can learn by doing. Give him a chance to \neat good food and clean his teeth at school. \n\n\n\n\n\n\n\n\n\n\n19 \n\n\n\nLearning about teeth and gums can be fun. When the teaching is real \nand practical, students love to learn. Here are some ideas: \n\nTeaching so that learning can take place \n\n1 . Teach and learn together with your school children. \n\n2. Start with what the students already know. \n\n3. Let students see and then do. \n\n4. Let children help each other. \n\n5. Teach about teeth and gums together with other subjects. \n\n6. Be a good example. \n\n7. Make the community part of your classroom. \n\n\n\n1. Teach and Learn Together with School Children. \n\n\n\n/^PERMANENT iVtCCES&OR LIES' \nAPICAL TO... PA^ attention / \n\nYou neeo to know this for I \nyour TEST'... EACH PRHAARYJ \n\n\n\n\nShare ideas \ninstead of always \ngiving information. \nChildren learn more \nwhen they are \ninvolved. \n\nA lecture transfers \nyour own notes to \nthe children's \nnotebooks without \never passing through \ntheir minds. \n\n\n\nA discussion draws \nout information and \nopinions. \n\nIt helps you to learn \nmore about the \nschool children, \nwhat they already \nknow and believe to \nbe true. \n\n\n\nBut it also allows \nyou to introduce \nimportant \ninformation that is \nrelated to the discussion \n\n\n\nPoes AN'TONt WAVE. A LOOSE TOOTH \nWHT DO VOV think > \n\n\n\n\n\n\n20 \n\n\n\n2. Start with What the Students Already Know. \n\nTo have meaning, learning should be a part of daily living. Talk with \nyour students. Find out what they know about teeth and gums, and what \nquestions they might have. \n\n\n\nAdd information by building upon \nwhat a person already knows. \n\n\n\nDo not use big words. Scientific names and textbook explanations are \nconfusing, and you usually do not need them. Talk about teeth and gums \nusing words that a school child can understand and use later at home. \n\n\n\n\n\nThis way lets the students feel good, \nbecause it makes sense and they know \nsomething about it. \n\n\n\nWhen you can understand new information, you gain confidence and \nyou look forward to learning more. \n\n\n\n\n\n21 \n\n\n\n3. Let Students See and Do. \n\n\n\nStudents learn best when they can take part and find out for themselves \nabout something new. \n\n\n\n\nA lecture about brushing teeth is usually not interesting at all. \n\nLearning is more interesting when students can see how to make a \nbrush and how to clean teeth properly. \n\nIf students can actually make their own brushes and clean their own \nteeth, it is not only interesting but fun. \n\nA student who takes part will not forget. What he learns by doing \nbecomes part of himself. \n\n\n\n\n22 \n\n\n\n4. Let Children Help Each Other.* \n\n\n\nIn most families, older children have important work to do— taking care \nof their younger brothers and sisters. These older children can do much to \nteach the younger ones about care of teeth and gums. For example: \n\n\n\n(1 ) When they feed their younger brothers \nand sisters they can encourage them \nto eat good food, like fruit instead of \ncandy. \n\n(2) They can do a play or puppet show \nabout care of teeth and gums. \n\n(3) They can check the teeth and gums of \nthe younger children and 'score' them \non how healthy they are (see p. 58). \n\n(4) Best of all, they can actually clean the \nteeth of the younger ones, and show \nthem how to clean their own teeth \nwhen they are able. \n\n\n\n\nHere a group of school children \nin Ajoya, Mexico is putting a \nhigh-fluoride paste (see p. 167) \non the teeth of the younger \nchildren. \n\n\n\n5. Teach About Teeth and Gums \nTogether with Other Subjects. \n\nTeeth and gums are part of a bigger health picture. Teach about them \nin class at the same time. \n\nEating good food can be part of a discussion on nutrition, teeth, \nfarming methods, and the politics of who owns the lands. \n\nCleaning the teeth can be part of a \ndiscussion on hygiene, clean water, \nand traditions and customs. \n\nA good way for school children to \nlearn about using numbers is to do a \nsurvey in the community. \n\nThe results will tell the children \nsomething about health problems in \ntheir community. For an example of \na survey of health problems, see page \n\n3-14 of Helping Health Workers Learn. \n\n*For more ideas on how school children can help each other, write to CHI LD-to-child Program, \nInstitute of Child Health, 30 Guilford Street, London WC1 N 1 EH, England. \n\n\n\n\n23 \n\n\n\n6. Be a Good Example. \n\nChildren watch people around them. They pay attention to what you \ndo, as well as to what you say. \n\nBe a good example. \n\nTake care to do \nyourself what you are \nteaching to your \nstudents. \n\nYour family can be \na good example for \nothers. \n\n• Clean your teeth carefully every day. Also, help your children keep \ntheir teeth clean. \n\n• Make a garden near your house and plant a variety of vegetables and \nfruits in it. \n\n• Buy only good, healthy food from the store. Do not buy sweet foods \nand drinks for yourself or your children. \n\n7. Make the Community Part of Your Classroom. \n\nA child's home and his community are really more important to him \nthan his school. Learning will be more interesting for a student if the \nday-to-day needs of his home and his community are part of school \ndiscussion. \n\nLet students find out more \nabout problems at home and in \ntheir community. \n\nFor example: \n\n• How many small children \nhave cavities or red, bleeding \ngums? \n\n• How many stores have \nmostly sweet snack foods \non their shelves? \n\n• Why do the people notgrow \nand eat more local food? \n\nBack in the classroom, students can record what they find. Ask the \nchildren to think of ways to solve the problems they found. If they can \nthink of a program to help solve a health problem, let them go back into \ntheir community and try it. \n\n\n\n\n\n\n24 \n\nPART 2: MAKING LEARNING EXCITING, \nVISUAL, AND FUN \n\nHere are some ideas to help students see what you are teaching, and to \nhave fun while they learn. Students can also show these things to others. \nTeaching others is an excellent way to learn. \n\nTell a story about food or teeth. For example, tell a story about why a \nwild cat's teeth are different in shape from a goat's teeth (page 38). Stories \nare an excellent way to learn, both for the storyteller and for those \nlistening. Leave time at the end to discuss the story and to introduce new \ninformation. See the example of storytelling on pages 1 77-1 79. \n\nMake up a play or drama about good food or clean teeth. Show it later to \nthe community. \n\nThe play should be about looking for an answer to a real problem. If \nthe children invent the play, they will have to think, plan, and solve \nproblems. A play also helps children learn how to talk with and teach \nothers. \n\n\n\nThese school children in Nicaragua are doing a play about cavities. On the left, germs \nand sweet food are combining and trying to make a hole in the ‘tooth’. But a giant \ntoothbrush (right) beats them away! \n\nDo a demonstration using local resources. \n\n\n\nTry, for example, the 'tooth \nin the Coca-Cola' test on \npage 46. \n\n\n\n\n\n\n\n\n\nPuzzles can help school children discover answers for themselves. You can \nmake your own. The best puzzles are with words that the students know \nand can use easily. \n\n\n\n25 \n\n\n\nEXAMPLE (for younger children just learning to read) \n\n\n\n\nAn older child can try to find important words that are more difficult. \n\nVILLAGE \nCO-OP STORE \n\n\n\n\nabscess \n/ sugar \ncavity \n/ sore \ninfection \n\n\n\ncola \n\ntoothache \nsT maize \ngreen leaf \ngum disease \n\n\n\nSpell some of the words diagonally (slanted). It will make the puzzle \nharder. \n\n\n\n\n26 \n\n\n\nYou can use pictures on posters, flip charts, and on flannel-boards. \n\nPictures that school children draw themselves are best. They learn \nsimply by drawing them. Also, school children will draw local people and \nlocal experiences, and the people will understand their pictures better than \nthe ones sent from a central office far away. \n\nPhotographs of local people and events are also good. If there is a \nphotography club in a local secondary school, have them take some \npictures for you. They may even print the photographs larger so that you \ncan use them as posters. \n\nAsk the children to make pictures big enough so that a person can \nstand far away and see them easily. \n\n\n\nLet each child carry her poster home \nto show her family and friends. \n\nHang up other posters in the store, \nchurch, or other places where people \nwill see them. \n\n\n\nPictures can be made to stick to cloth and then used to tell a story. \nCover a board with a piece of flannel cloth or a soft blanket, to make a \n\n\n\nMix some flour and water to make \nglue. Then glue a strip of sandpaper to \nthe back of each picture. The sand- \npaper sticks to the cloth and lets you \nplace the picture where you want on \nthe cloth. \n\nLet the child use her pictures and \ncloth outside of the school, to show \nher story to family and friends. \n\n\n\n*For more ideas on flannel-boards, see pages 1 1-1 5 to 1 1-19 of Helping Health Workers Learn. \n\n\n\nflannel-board.* \n\n\n\n\n\n\n\n27 \n\n\n\nFlip charts are excellent for telling a story with pictures. Often, people \ncan guess what the story is about just from the pictures. When showing \nthe pictures on a flip chart, ask as many questions as you can, to get the \npeople to tell you the story. \n\n\n\n\nThis is part of a flip chart presentation on \nmothers’ and children’s health. Notice the \nrings at the top that hold the flip chart \ntogether. They are made from old \nelectrical cords. \n\n\n\nHere a health worker from \nMozambique is holding a flip chart \nwith pictures about care of teeth \nand gums. There are no words with \nthe pictures. \n\n\n\nBut he can read a short message \nwritten on the back of the page \nbefore. There are also examples of \nquestions to ask. \n\nThis way, anyone \nwho can read can \ntell the 'flip chart \nstory' to others. \n\n\n\nThere is also a \nsmall copy of the \nbig picture on the \nback of the page \nbefore. \n\n\n\n\nFind a way to attach the sheets of heavy paper. Here are two ways: \nwith 2 thin pieces of wood with metal or wire rings \n\n\n\n\n\n\n28 \n\n\n\nFLIP CHARTS-AN EXAMPLE \n\nDental workers in Mozambique created this flip \nchart presentation for teaching in schools. \n\n1 ) Here is a healthy, happy schoolboy. In the \ncircle you see the inside of his mouth. His \nteeth are white and clean. Look at his gums. \nWhat color are they? Are they tight or loose? \nBetween the teeth, are the gums pointed or \nflat? \n\n\n\n2) This is an unhappy, sick boy. What color are \nhis teeth? Not only are they yellow, there are \nblack spots. These are cavities. \n\nWhat color are his gums? Are they pointed? \n\nLoose, red, swollen gums are signs of gum \n\ndisease. \n\nBoth cavities and gum disease can be treated. \n\n3) What happens if tooth and gum \nproblems are not treated? \n\na) The black hole grows bigger on the \ntooth and a sore forms on the gums \nnear the root. The tooth hurts \nwhenever you touch it. \n\nb) The red, loose gums pull away front \nthe tooth. Infection gets to the bone \nand eats it. The tooth loses the bone \nand the gum around it. \n\nThe first problem is a tooth abscess. The second is advanced gum disease. \n\nIf either of these things happens, the tooth must be taken out. \n\n\n\n4) Why does the boy have cavities and gum \ndisease? There are 2 reasons. \n\na) He eats too many sweet foods. \n\nWhat foods do you see here? \n\nWhat other foods hurt the teeth? \n\nb) He does not clean his teeth regularly. \n\nThe germs in his mouth eat sugar from his \nfood and make acid. Acid causes both \ncavities and gum disease. \n\n\n\n\n\n\ne — e \n\n\n\n\n\n\n\n\n\n29 \n\n\n\n5) What foods can the boy eat to keep his teeth \nand gums healthy? What do you see in this \npicture? \n\nNatural foods, with no sugar added, are the \nbest. The foods you grow yourself and local \nfoods from the market are better than sweet \nfoods from the store. \n\n\n\n6) How can we clean our teeth? Carefully is the \nimportant word to remember. Clean your \nteeth at least once a day, carefully brushing \nevery part of every tooth— outside, inside, \nand top. Be very careful to push your brush \nbetween your teeth. That is where the germs \nand food collect to make acid. \n\nIf you do not have a toothbrush, you can \nmake one from a stick. Toothpaste is not \nnecessary. Clean water is enough. \n\nChapter 12 in Helping Health Workers Learn is full of ideas on how to \nmake and use pictures effectively. Once you have a good original, you do \nnot need to be an artist to make a good copy. Here is an easy method that \ncan involve every student. \n\nPlace thin see-through paper over the original drawing. Carefully trace a \ncopy. \n\nNow place the copy on a new sheet of heavy paper. Pressing firmly with \na pencil, retrace all of the lines on the thin copy paper. \n\nRemove the \ntracing paper. \nPressure from the \npencil has made \nlines on the poster \npaper. Redraw \nthem with a \npencil so they \nstand out clearly. \n\nYour copy is now \nready for coloring. \nAnd you can use \nyour copy paper \nagain to make \nanother copy. \n\n\n\n\n\n\n\n\n\n30 \n\n\n\nUse puppet shows to act out the messages \nof eating good food and keeping teeth clean. \n\nStudents can make their own \npuppets to look like people or \nanimals. \n\nUsing puppets, it is often easier ^ \n\nto say things that people them- \nselves cannot. For example, \nthey can talk openly about the \nbad food sold at the village store. \n\n\n\nMr. LyafTy you should \nI feel shame for sellinc^ \nthat kind , \n\\ of food/ \n\n\n\nChildren can make puppets easily from paper bags. They are good for \nshowing teeth because you can make a wide-open mouth. \n\n\n\n\n\n\nOpen and close your \nhand to make it \neat or speak. \n\nTo make a \nbigger puppet, \nattach a \n\ncardboard face\"^ g \nto the bag. ^ \n\n\n\n\nA puppet made from a sock looks \n\nalive. \n\n1. Fit the sock over your hand. \n\n2. Make the mouth by pushing in the \ncloth between your thumb and \nfingers. \n\n3. Add eyes, nose and hair to the \nsock or to a box that fits over it. \n\n\n\nLoosely fill a cloth bag with old cotton or paper. Put the end of a stick \ninside, and tie the bag to it with tape or string. Make a sad or happy face \nto fit the story. Dress the puppet with an old piece of cloth. \n\n\n\n\n\n32 \n\n\n\n\n4) One day later. \n\n(Note how the scene behind the \npuppets changes. It is a flipchart with \npictures to show the different places \nthe puppets 'go'.) \n\n\n\n5) \"I am a poor farmer,\" Pedro's father \ntells Maria. \"I only go to the city two \ntimes a year to sell my crops. I cannot \ntake the boy to the city and pay for \nfillings in his teeth.\" \n\nMaria answers, \"But we can save his \nteeth with a temporary cement filling.\"* \n\n6) \"Then, when you have time and \nmoney, you can go to the city. I know \na dental worker who will put in a \npermanent filling. I trust him. 1 will \nsend a note with you, and it will not \ncost much.\" \n\n\"Goodl\" says the father. \n\n\"Come on, Pedro,\" says Maria, \"I'll \nput some cement in those holesi\" \n\n7) Four months later, Pedro visits the \ndental worker in the city. \"Maria's \ngood fillings saved your teeth,\" he \nsays. \"These permanent fillings will \nlast for years.\" \n\n\"Terrific!\" says Pedro. \n\n8) After the show, the puppets played a \ngame. Throwing a ball into the \naudience, they asked questions like \n\"How do you keep cavities from \nhappening?\" Each child who caught \nthe ball answered the question and \nthrew it back. Then the children in \nthe audience began asking questions \nfor the puppets to answer. \"Why did \nyou get rotten teeth?\" one child asked \nPedro. The puppet looked down and \nsaid, \"Too much candy!\" \n\n\n\nTo learn how to make a temporary filling, see Chapter 10. \n\n\n\n31 \n\n\n\nPUPPET SHOWS-AN EXAMPLE* \n\n\n\n\nAbove, school children in Ajoya, Mexico are holding puppets they made \nthemselves. On the left, you see them in front of the stage and at right, the \nchildren show how they hold the puppets behind the stage. \n\n\n\n\n1 ) They called their puppet show “Rotten \nTeeth— And A Friend's Advice.\" \n\n\n\n2) Pedro, a schoolboy, is sad. His friends \nlooked into his mouth and saw two \nteeth with big holes in them. He tells \nhis brother he wants to walk home \nalone. \n\n\n\n3) On the way, Pedro meets Maria, a \nfriend who is a dental worker. \"I'm \nnot sad because the others are \nlaughing,\" says Pedro. \"I know the \nreal problem. The holes in my teeth \nwill get bigger. My teeth will rot and \nfall out, and maybe my permanent \nteeth coming in will rot, too.\" \n\nMaria thinks she knows what to do. \n\"We will talk to your father,\" she says. \n\n\n\nFor another example of a puppet show, and more suggestions for making puppets, see pages 27-35 \nto 27-39 of Helping Health Workers Learn. \n\n\n\n\n\n33 \n\n\n\nCHAPTER \n\n\n\n\nSchool Activities for Learning \nAbout Teeth and Gums \n\n\n\nWe can help school children in two ways. First, they need treatment \nnow for problems they already have. Second, they need to learn how to \nprevent problems from hurting them (and their families) later. \n\nTreatment and prevention go together. It is a mistake to emphasize only \nprevention and to forget about treatment. In fact, early treatment is the \nfirst step to prevention because it usually meets a person's most strongly \nfelt, immediate need. \n\nAs a community dental worker, you can visit a school and find out \nwhat the felt needs are. Begin with the teacher. Examine for cavities, \nbleeding gums, or other problems. Then look at the students. \n\nChapter 6 tells you how to examine a person. It also helps you decide \nwhat treatment to give, and who should give it. \n\nThen teach how to prevent dental problems. Give the teacher ideas to \nhelp students learn why they have problems, and how to keep the \nproblems from returning. The best way to learn is by doing-through \nactivities, not lectures. This chapter has many suggestions for activities. \n\nThe best health practice is to prevent cavities and gum disease from \neven starting. With these activities, children can do something to guard \ntheir health. \n\n\n\nTeacher, each day \nat school: \n\nSuggest ways for your \nstudents to eat good \nhealthy kinds of food. \n\nAND \n\nGive your students time \nto clean their teeth. \n\n\n\n\n\n\n34 \n\n\n\nA Note To Teachers: \n\nDo not wait for a dental worker. This book, and especially this chapter, \nis written to help you learn and do things yourself. But do ask your dental \nworker to work with you. He probably has suggestions that would fit your \nsituation. After examining the children, he can help you follow their \nprogress. You can then find out how much they are learning and how \nhealthy they are becoming. \n\n\n\nTo begin, talk with your students to find out what they think and \nwhat they already know. What are their traditional beliefs? Some may be \nhelpful, and others may need changing. At first it is best simply to discuss. \n\nAsk the kind of questions that get students talking. Later they will take \npart in discussions more easily. \n\n\n\nAdd new information as you go along, changing some ideas but usually \nbuilding upon what the students already know. \n\n\n\nThis chapter asks nine questions: \n\n1 . Why do we need teeth and gums? \n\n2. Why do some teeth look different? \n\n3. What holds the teeth? \n\n4. How often do teeth grow in? \n\n5. What makes teeth hurt? \n\n6. How do germs make holes in the teeth? \n\n7. What makes the gums feel sore? \n\n8. What does it mean if a tooth is loose? \n\n\n\n\n9. How can we prevent cavities and sore gums? \n\n\n\nFor each question, there is an activity to help. students discover answers \nfor themselves. The questions are not in any particular order, nor are they \nwritten for any particular grade level. Make your own lesson plan, using \nthe main idea to help you. Shorten the lesson and make it easier for \nyounger children. Add more information for older students and let them \ndo more activities. \n\n\n\n35 \n\n\n\nWhy Do We Need Teeth and Gums? \n\nTHE IDEA: \n\nYour teeth and the gums around them help you in many ways. \n\nTeeth are important for: \n\nGood Health. Infection from a \nbad tooth can spread to other parts \nof your body. \n\nGood Looks. Healthy teeth that \nlook good help you feel good. \n\nGood Speech. Your tongue and \nlips touching the teeth help you \nmake many sounds. \n\nGood Eating. Your teeth break \nfood into small pieces so that you \ncan swallow and digest it better. \n\nGood Breath. If you leave food around your teeth, your breath will \nsmell bad. \n\nYour gums are important too. \n\nThey fit tightly around the teeth, and \nhelp to keep them strong. Without strong \ngums, your teeth are of no use. Most old \npeople lose teeth because of bad gums, \nnot bad teeth. \n\n\n\nTHE ACTIVITY: \n\n1 . Draw or cut pictures of people from magazines. Make posters to \nshow that healthy teeth make a person happy, while bad teeth make a \nperson sad. Use the posters for discussion. \n\nHang up a picture of a person the students \nknow and like. Put black on one of her front \nteeth. Talk about it. \n\nOR \n\nLeave the picture for a few days. Then put \nblack on some of her teeth before the \nstudents come to school. See who notices \nfirst. \n\nWhen someone sees the difference, talk about \nhow the person looks, how teeth can be lost, \nhow to prevent that, and what she can do now. \n\n\n\n\n\n\n36 \n\n\n\n\nMake a picture of a person who has lost all of his \nteeth. He looks old. \n\nTalk about how hard it is for him to eat properly \nor speak clearly. \n\n\n\n2. Have the students say words that use teeth to make sounds. \n\n\"v\" and \"f\" — friend, fever — the lower lip \ntouches the top teeth. \n\n\"th\" — the, teeth — the tongue touches the \ntop teeth. \n\n\"s\" — sun — air goes between the teeth. \n\nNow, try saying the same words again, but \ndo not let the tongue or lips touch the \nteeth. \n\n3. Have students draw pictures of good foods we use our teeth to eat. \nThen draw foods that we can eat if we lose our teeth. \n\nNeed Teeth No Teeth Needed \n\n\n\n\n\nMany More! \n\n\n\n\n\nBut NOT \nMuch More! \n\n\n\nTalk about this together. T ry to eat a mango or some maize without \nusing your teeth, or using only your front teeth. \n\n\n\n\n37 \n\n\n\nWhy Do Some Teeth Look Different? \n\nTHE IDEA: \n\n\n\nWe need two different kinds of teeth to help us eat our food. \n\n\n\n\nThe outside of a tooth is the hardest and strongest part of your body. \nWhen a tooth is healthy, it can chew hard food, even bone. The shape of \na tooth allows us to swallow food when the small pieces can slide down its \nsmooth sides. \n\n\n\nSmall bits of food \noften get caught \ninside deep lines, or \ngrooves, in a tooth. \n\nLook for them on the \ntop and the sides of \nback teeth. \n\n\n\n\nFood that is not \ncleaned away from \nthe grooves can make \na cavity (hole) in \nthem. \n\nA tooth with a cavity \nis weak and often \nhurts. \n\n\n\n\n\n\n\n\n38 \n\n\n\nTHE ACTIVITY: \n\n\n\n1 . Ask the students to bring different kinds of food to class. Bring some \nyourself. \n\n(which TEETtr DID YOU USE' \n\nTO EAT THE riANOO? \n\n\n\n\n2. Collect teeth from different animals. Let the students discover from \nthe shape of an animal's teeth the kind of food it usually eats. For \ninstance, a wild cat needs sharp pointed teeth to tear meat, but a goat \n\n\n\n\nMake a poster to show the animal, its teeth, and the kind of food it \nlikes to eat. \n\n3. Have each student take a partner. Let each look at the shape of the \nfront and back teeth in the other's mouth. \n\nTalk about the many different kinds of food we need to stay healthy. \nDiscuss which teeth we use to chew meat, fish, mango, and other good \nfoods in your area. (For most foods, the answer is both front and back \nteeth ! ) \n\n\n\n\n\nWhat Holds the Teeth? \n\nTHE IDEA: \n\n\n\n39 \n\n\n\nWhen you look inside someone's mouth, you see only the top part of \neach tooth. The bottom part, its root, is inside the bone under the gum. \n\n\n\nThe roots of the \ntooth hold it in \nthe bone just \nlike the roots of \na tree hold it \nfirmly in the \nground. \n\n\n\n\nThe roots of the \ntooth do not \nactually touch \nthe bone. Root \n\n\n\nbone \n\n\n\nroot \n\n\n\n\nfibers connect the root and bone, holding the tooth in pi \n\n\n\nace. \n\n\n\nThe gums do not hold the teeth, but healthy gums will keep harmful \ngerms from getting to the bone and root fibers. When the gums are not \nhealthy, they form deep 'pockets' which collect germs. Soon, these germs \nwill reach the root fibers and bone. The bone pulls away from the tooth \nin order to get away from the germs. With no bone to hold it, the tooth is \nlost. This is the most common reason why teeth fall out. \n\n\n\nTHE ACTIVITY: \n\n1. Have the students look for \nan old jaw bone from a dog or \nother animal. Notice that bone \ngoes around every root of every \ntooth and holds it tightly. \n\nBreak away some of the bone \nand look at the roots of the \nteeth. \n\n\n\n\n\nFront teeth need only one root \nbecause they are used for biting. \n\nBack teeth have 2, 3, or even 4 \nroots. That makes them strong \nenough to chew tough meat and \neven break hard bone. \n\n\n\n40 \n\n\n\n2, Show your students how infected gums can cause teeth to fall out. \n\n\n\n\n\nA. When gum disease is beginning, a small red ‘pocket’ forms where the tooth meets \nthe gum. Germs and food collect in the gum and make acid. This makes the gums sore. \nB. As a result, the gum pulls away and the pocket becomes deeper. C. The bone moves \naway from the infection and no longer holds the tooth. \n\nTry to think of other ways to teach how gum disease pushes the bone \naway from the tooth. In Jamaica, dental workers ask, \"What do you do if \nsomeone attacks you with a machete (long knife)?\" \"I run away!\" most \npeople answer. \"Exactly,\" say the dental workers, \"and when you have a \nlot of germs attacking the root of your tooth, the bone 'runs away' and \nleaves the tooth with nothing to hold it.\" \n\nTell a story to show how, when the gum moves away from the top of \nthe tooth, the root and bone are open to attack. For example; \n\n\n\n\nEnrique was sleeping on a cold night when suddenly he had diarrhea. \nStill dreaming, he went outside, and afterward, he forgot to close his pants \ntightly. Suddenly, he saw an ugly monster coming after him! He ran away \nwithout thinking of his pants. Finally he could not run because his pants \nwere around his knees, and the monster caught him. \n\nExplain to the children that when the gums are red near a tooth, they \nare like Enrique's pants— not tight enough around the tooth. When germs \ncome near the tooth, they will go inside and the gums will 'fall down' and \nshow part of the root of the tooth. When this happens, the germs attack \nnot only the top of the tooth, but also the bone and root. \n\n\n\n\n41 \n\n\n\nHow Often Do Teeth Grow In? \n\nTHE IDEA: \n\nA child gets two sets of teeth. The first set, baby teeth, starts to grow \nwhen the child is a baby. The second and last set grows in at school age. \nThey are the permanent teeth. Permanent teeth should last a lifetime. \n\nA child grows his first baby tooth at about 7 \nmonths of age. It is usually a front one. \n\nA baby who is poorly nourished, however, may \nnot grow his first tooth until later. Do not wait for \nthe first tooth before giving him the extra soft food \nhe needs to grow and stay healthy. \n\nThe remaining baby teeth grow in over the next 24 \nmonths. By the time the child is 30 months old, \nthere will be a total of 20 baby teeth in his mouth, \n\n10 on top and 10 on the bottom. \n\nMost permanent teeth form under the baby teeth. When the child is \nbetween 6 and 12 years old, the permanent teeth push against the roots of \nthe baby teeth, making them fall out. Not all of the baby teeth fall out \nat once. One tooth at a time becomes loose, falls out, and then is replaced \nwith a permanent tooth. The new tooth may not grow in immediately. \nSometimes 2 or 3 months pass before the new tooth grows into the space. \n\nIn the 6 years between ages 6 and 12, the 20 permanent teeth replace \nthe 20 baby teeth. In addition, 8 other teeth grow in behind the baby \n\nAt 6 years the four 1st permanent \nmolars start to grow in at the back \nof the mouth. This means an 8-year- \nold child should have 24 teeth, or \nspaces for them. \n\nAt 1 2 years, the four 2nd permanent \nmolars grow in behind the 1st \n\nmolars. This means a 14-year-old \nchild should have 28 teeth, or \nspaces for them. \n\nBetween 16 and 22 years, the four \n3rd permanent molars grow in. This \nmeans that an adult should have a \ntotal of 32 permanent teeth: 16 on \ntop and 16 on the bottom.* \n\n\n\n\n\n*(Note: the third molars often do not grow in correctly. This is a very common cause of tooth \npain. See page 64. \n\n\n\n\n\n42 \n\n\n\nTHE ACTIVITY: \n\nHave the students examine each other.* Help them learn which are \nbaby teeth and which are permanent teeth. Look for the important 1st \npermanent molars at the back. \n\nShow the students \nhow to count the \nteeth and the spaces \nthat are ready for \nnew teeth to grow \nin. \n\nThen have them \ncount their friends' \nteeth, to find out \n\nhow many teeth should be growing in different age groups. Later, they \ncan do this with their brothers and sisters at home. \n\n• Wash your hands. \n\n• Count the teeth. \n\n• Count the spaces where new teeth have not yet grown in. \n\nTOTAL = teeth + spaces \n\n• Find out the person's age. \n\n\n\n\nHave the students first write their totals on the blackboard. Then make \na chart for the children to remember and discuss the results. \n\n\n\n\nHere the children are only counting the teeth. They can also learn to check for cavities and gum \ndisease (see p. 47). \n\n\n\n\n\n43 \n\n\n\nDiscuss the number of teeth children have at different ages. Young \nchildren 6 to 1 2 years old, for example, have 24 teeth; older students, 28 \nteeth; and adults, 32 teeth. \n\n\n\nAt home, students can count brothers' and sisters' teeth to learn how \nmany teeth small children have. Count only the teeth and not the spaces. \n\n\n\n: hi f Tec/A in a. •Smoull C ^\\i lai \n\n\n\nD e is o I \nCbrof^icr) \n\n\nunder 1 yeai- \n\n\n1.-2. years old \n\n\nZ-3 years olci \n\n\n/// \n\n\n\n\n\n\nNqoi&i . \n\n^CSiSto-) \n\n\n\n\ni n j / / / \n\n/Ik \n\nII U ! / 10 \n\n\n\n\nC Ke. n . a. \n \n\n\n0 fv\\o nrki ) \n\nC\\d. j / \n\n/o \n\n\n\n\n\n\nCcoLxSijrJ \n\n\n\n\n\n\nmil mn , \n\n! ! m / \n\nII\"' /do \n\n\n\nAsk the students what other things they saw inside someone else's \nmouth. This is a good time for students to discover important things about \ngood health practices. Encourage them to learn as much as they can from \nwhat they see, and then show them how to use a book like this to answer \ntheir own questions. For example, if students see cavities and red bleeding \ngums, you can start a discussion on tooth decay and gum disease. Use \nsome of the activities on pages 53 to 58. \n\nFor another example, if the students see a baby who has only a few \nteeth, they may have some interesting questions. Show them this book \nand invite them to read pages 61 to 63 to find answers to questions like \nthese: \n\n• Can Chenia, who is six months old and has no teeth, eat soft foods? \nShould she have more than just breast milk? \n\n• When Chenia's teeth grow in, will they give her diarrhea and fever? \n\n• Will a 2-year-old girl get more baby teeth? \n\n• Why do we care for baby teeth, when we only need them for a few \nyears? \n\n\n\n\n\n\n\n\n\n\n\n44 \n\n\n\nWhat Makes Teeth Hurt? \n\nTHE IDEA: \n\n\n\nA tooth will hurt if it is broken, loose, or if it has a cavity. Cavities are \nthe usual cause of toothaches. \n\n\n\nHealthy teeth are alive. \n\n\n\nTwo thin strings enter each tooth. One, the nerve, comes from the brain \nand carries the message of pain. The other is the blood vessel. It comes \nfrom the heart and carries blood to the tooth. \n\n\n\nIf you could peel away the \ngum and look inside the bone, \nyou would see that a nerve \nand a blood vessel go into \neach one of a tooth's roots. \n\nThey give the tooth life \nand feeling. \n\n\n\n\nThe hard cover of the tooth protects the nerve and blood vessel inside \nit. But when tooth decay eats through that cover, the nerve and blood \nvessel are unprotected. A cavity lets food, water and air get closer to the \nnerve, and that can make the tooth hurt. \n\n\n\nThe sugar in food makes tooth decay possible. Sweet food that is also \nsticky is the worst of all because it glues itself to the teeth. Germs inside \nyour mouth use the sugar to grow and to work harder at making cavities. \n\n\n\n\nSee the next section for more discussion of how germs and sugar \ncombine to cause cavities. \n\n\n\n\n\n45 \n\n\n\nA cavity may look small on the outside, but it is much bigger inside. \nDecay spreads more easily in the soft part under the hard cover of the \ntooth. \n\nA tooth with a cavity may hurt, but it usually does not-hurt all the \ntime. This is because the bottom of the cavity is close, but not yet on \nthe nerve inside the tooth. \n\n\n\nFill a small cavity and save a tooth. \n\n\n\nA small cavity that is not treated grows bigger and gets deeper. When \nthe cavity finally touches the nerve, it causes a tooth abscess. Infectiori \nfrom the tooth decay going inside the tooth causes the tooth to ache all \nthe time, even when you try to sleep. \n\nInfection can pass from the tooth to the bone. As it spreads under the \nskin, there will be swelling of your face. \n\n\n\n\nA tooth with an abscess must either be taken out \nor have its nerve treated. \n\n\n\nAn abscessed tooth is dying. When it dies the tooth changes color from \nwhite to dark yellow, grey, or even black. Pus from the end of its root can \npass to the gum, making a sore called a gum bubble. \n\nA tooth is like a light bulb. \n\nWhen the bulb is alive from power inside, it \nis bright and useful. \n\nThe little wires inside the bulb are like the \nnerves inside the tooth. When the bulb burns \nout, it is dark and not useful any more. \n\n\n\n\n\n\n\n\n\nir's mouth. Look for black \nlat are dead, and for sores on \n\n\n\nh. \n\n\n\n\nit outside overnight. \n\n\n\n\n)e the outer cover of the root \na knife. Feel how hard and \n)th it is. \n\nfind out what happens when \ntudents leave a tooth in cola, \nor plain water. \n\n' 3 days scrape each tooth \nagain with a knife. Students \nwill discover that sweet cola \ndrinks make teeth softer anc \n’ darker in color. \n\n\n\n\n\n\n47 \n\n\n\n' 3. Look inside a tooth for the space where the nerve and blood vessel \nused to be. See how close they were to the tooth's hard outer cover. Look \nfor a small hole at the end of the root. That is the place where the nerve \nand blood vessel enter the tooth. \n\nAsk your dental worker to find an old \ntooth with a cavity and grind it for you. \n\nOR \n\n1 . Take a hammer. \n\n2. Gently break open a tooth. \n\n3. Look inside. \n\nSee how much bigger the cavity is on \nthe inside. It spreads under the hard \ncover. \n\nCut through a rotten yam. See how \nthe rotten part spreads under its skin \nin the same way. \n\n4. Do a project in class. \n\n• Count the number of students with cavities. \n\n• Count the number of teeth having cavities. Show the students how \nto look for them on the tops, sides and between the teeth. \n\n• Find out the person's age. \n\n\n\n\nHave the students write on the blackboard what they counted. Then \nmake a chart or graph. \n\nTooth oe^Ay in our scHoou \n\n\n\nnui ^ se -* of sruoeNTS at scHoot- \n\n\n\nnumser or sToomHTs with cavities tZ \n\n^ i,yeAiij lyrnta i /Enn \"iyeMu I o il^env iZyrEXS \n\n■j i>rr iMi'i' iMf/ ml \n\n/<6 ^ mi \n\n\\ number, of cavities we FOUNi)-. JwBb . /I so \n\n\n\nDecide if tooth decay is a serious problem In your school. Ask your \ndental worker to look at your results and to come and treat the \nstudents, and help you prevent the problem from returning. \n\nDo the same with brothers and sisters at home. Find out if tooth \ndecay is a problem with these young children. Tell your dental \nworker what you find. \n\n\n\n\n48 \n\nHow Do Germs Make Holes in the Teeth? \n\nTHE IDEA: \n\nAcid makes holes in the teeth. The acid is made when sweet foods mix \nwith germs in your mouth. \n\nIt is not possible to prevent cavities or gum problems by trying to kill \nall of the germs in your mouth. There are too many— and some germs are \ngood for you. The important thing is to keep the germs from getting \ntogether and making a film or coating on your teeth. \n\nThis film on the teeth is called plaque, but you do not need to use this \nword. Every morning we can all feel a 'furry film' on our teeth. This film \nmust not be allowed to stay on the teeth! It will mix with sugar and make \nacid. Worse, if it stays in a group (or 'colony') for more than 24 hours, it \nwill mix with saliva, harden, and make tartar (see page 50). \n\nThe main reason for cleaning teeth is to break up these colonies so they \ncannot make acid. Also, if you forget to clean your teeth, tartar will form, \nand you will need a dental worker to scrape it off. This is why it is \nimportant to clean your teeth at least every 24 hours, so the tartar can \nnever form on your teeth. \n\n\n\nTHE ACTIVITY: \n\n\n\nHere is a game called \"Scatter!\" that students can play outside. \nYou need: \n\n\n\n\n\n\n\n\n\nFive 'bases' (a tree, rock, or \nthe corner of a house can be \na base) in a half circle, 1 2 \nmeters apart. Each base \nmust have a 'monitor' who \nstays at the base. Note: \nchildren who cannot run \ncan be good monitors. \n\nOne person with a broom. \nThis person is the \n'decolonizer'. \n\nThe Game: \n\n\n\n\nChildren in Jocuixtita, Mexico, beginning a \ngame of “Scatter!.” The 'decolonizer’ is the \ngirl in the center with the broom. \n\n\n\n20 students called \n'colonizers' stand facing the \n\ndecolonizer. When the decolonizer says \"go!\" they try to 'form colonies' \naround the bases before the decolonizer can touch them with the broom. \n\n\n\n\n49 \n\n\n\n\nThe ‘decolonizer' (with broom) has tost the \ngame. The children behind him have formed \na ‘colony’. \n\n\n\n\nHere the decolonizer stops a boy from \ncompleting a chain. \n\n\n\nAfter The Game: \n\nTalk to the students about \ngerms in their mouths and how \nsmall they are. Can anyone see \ngerms? No, but they can feel \nthem and taste them. Ask the \ngroup what their mouths feel \nlike in the morning when they \nwake up. You may get these \nanswers: \n\n• my teeth feel mossy! \n\n• my breath is bad. \n\n• I feel a coating on my teeth, \nbut it goes away when I \nbrush them. \n\n\n\nThe colonizers win if they make \na colony. There are two kinds of \ncolony: (1) 1 5 people touching \none monitor at a base, or (2) a \nchain of 12 people holding \nhands, touching two monitors. \n\nPlay two games: one with \nchildren trying to form the first \nkind of colony, one with the \nsecond kind. These photos are \nfrom the second game. \n\nThe decolonizer tries to stop \nthe others by touching them \nwith the broom. When the \ndecolonizer touches a colonizer \nwith the broom, the colonizer \nmust leave the area for one \nminute. (Give that child a task \nto do— run around the school- \nhouse or lie down and sit up \n30 times.) \n\nThe decolonizer wins if no \ncolonies form in 5 minutes. \n\n\n\n\nTo teach about things too small to see, look at \nthe suggestion on page 11-29 of Helping Health \nWorkers Learn. \n\n\n\nTell the students that this coating on the teeth is a 'colony' of germs. \nThey are always trying to group together on the teeth or in spaces between \nthe teeth— just as the 'colonizers' did in the game! \n\n\n\n\n\n\n50 \n\n\n\nWhat Makes the Gums Feel Sore? \n\nTHE IDEA: \n\nHealthy gums fit tightly around the teeth and help to hold them \nstrongly. Healthy gums also cover and protect the bone under them. \n\nHealthy gums are pink in color, or \n\neven blue or dark yellow in some \npeople. But healthy gums are never \nred. \n\nHealthy gums are pointed between \nthe teeth. This lets food slide away \nand be swallowed. \n\nHealthy gums fold under, making a \nlittle pocket around the tooth. \n\nAs we saw with the last activity (p. 48), when you have 'colonies' of \ngerms on your teeth, they can make acid that makes holes on your teeth. \nThe same coating of germs can make a different acid that makes the gums \nsore. This also happens when food mixes with the coating on your teeth. \nSoft food is the worst kind, because when it mixes with spit it sticks more \nand stays longer on your teeth. Juice from tea, betel nut, and meat color \nthis food, making the tooth look dark. \n\n\n\nHealthy gums become sore because of acid. Also, if the coating on the \nteeth (p. 48) becomes hard, it is called tartar. Tartar can be very sharp \nand hurt the gums. Also, the 'colonies' of germs can make a coating on \ntop of tartar more easily than on a clean tooth. When the colonies are \nnew, they make more acid to cause tooth and gum problems. After 24 \nhours, they harden and make a new layer of tartar. The tartar gets bigger \nand bigger. \n\nSore gums are infected. \n\nInfected gums are red \nand bleed easily. \n\nInfected gums are \nround and swollen \nbetween the teeth. \n\nThey are also loose \ninstead of tight against \nthe teeth. \n\nInfected gums have a deep gum pocket which catches even more food. \n\n\n\nHere is a larger picture of the teeth in the box above: \n\n\n\n\n\n\n\n\n\n51 \n\n\n\nInfection in the gums is called gum disease. It is important to treat gum \ndisease early, before it can spread to the root fibers and the bone. \n\nIf you have sore, bleeding \ngums, you can do much to \ntreat the infection yourself. \n\n1. Clean your teeth with a \nsoft brush gently and more \noften, (see page 69) \n\n2. Eat more fresh fruits and \nvegetables. \n\n3. Rinse your mouth with \nwarm salt water. \n\n4. Clean between your teeth \nwith dental floss or string. \nAt first your gums may \nbleed when you do this. \nBut when the gums are \nstronger the bleeding will \nstop. \n\nTHE ACTIVITY: \n\n1. Have the students look in each other's mouths. \n\nCan they see the coating on the teeth? Usually they \ncannot. They may see food or 'white stuff', but \nthis is not the coating that makes acid. However, if \nsomeone has been, chewing betel nut or eating \nberries, you will see stains on her teeth and the \nstains will be darkest where she has these colonies \nof germs on her teeth. \n\nPut something on the teeth to stain the colonies of germs. T ry using \nfood dye, betel nut or berry juices. Remember: first wash your handsi \nOlder students can rub berries on the teeth of the younger ones. Have \nthem rinse with a little water and spit it out. After this, the colored areas \non the teeth will show where the colonies of germs are forming. Where \nare they? Usually you vvill see the dark colors: \n\n• between the teeth \n\n• in the pits or holes in the teeth \n\n• on the tops (biting surfaces) of the teeth. \n\nThe older students can now show the younger ones the best way to \nclean teeth (see pages 67-70). Let the younger ones see in the mirror if \nthey are getting the colored juice from their teeth. They will learn that it \nis most difficult to get rid of the color between their teeth. Give them \nsome string, dental floss, or even the soft stem from a young palm leaf, \nand show them how to use it between their teeth (p. 70). Remind them to \nbe gentle, or they will hurt their gums. You should clean between your \nteeth every day. \n\n\n\n\n\n\n\n\n\n52 \n\n\n\nWhat Does It Mean if a Tooth is Loose? \n\n\n\nTHE IDEA: \n\n\n\nBaby teeth become loose when children are between 6 and 1 2 years old. \nThis is normal. If a loose baby tooth does not have a cavity, and if the \ngums around it are healthy, there is probably a permanent tooth growing \nunder it. \n\n\n\nBut a tooth might be loose because it is broken or because it is sick \nfrom an abscess or gum disease. Either can destroy the bone around the \n\n\n\n\nWhen bone is lost, the tooth \nbecomes loose. A loose tooth hurts \nand usually must be taken out. \n\nThere is no medicine to make bone \ngrow back around the roots of loose \nteeth. All you can do is stop the \ninfection from getting worse. \n\n\n\nTHE ACTIVITY: \n\n\n\n1. Let the students look into each other's mouth for loose baby teeth. \n\n\n\nLook carefully to see why a tooth is loose. \n\nTouch the gum and bone beside the \nloose tooth. You can feel a bump— it is \nthe new permanent tooth growing. \n\nSave the baby tooth after it has fallen \nout. Look to see how the permanent \ntooth has eaten away its root by pushing \nagainst it. \n\n2. Look for teeth that have cavities or \ngum disease around them. The students \n\n\n\n\ncan do this with each other, and then \nlater at home. (Remember they must \nwash their hands!) \n\nA tooth that has some of its root \nshowing is probably loose. \n\nUsing your fingers or the handles \nof two spoons, rock the tooth back \nand forth gently. See how much it \nmoves, and ask how much it hurts. \n\nTell the person what he can do to \nprevent other teeth from becoming \nloose. (See the next section.) \n\n\n\n\n\n53 \n\n\n\nHow Can We Prevent Cavities and Sore Gums? \n\n\n\nEating good food and carefully cleaning the teeth prevents both tooth \ndecay and gum disease. \n\n\n\nFood from your own garden and local food from the market is best. \n\nThese foods are good for your body, your teeth, and your gums. \n\n\n\n\n\n\n\n\nVegetables, especially Peas and beans, like green \nthose with dark green beans, soybeans, winged \nleaves. beans, and mung beans. \n\n\n\n\nOil, from palm nut \nkernels, ground nuts, \nand coconut. \n\n\n\nFruits, like banana. Fish, meat and eggs. \n\nguava, oranges, and \npapaya. \n\n\n\nClean water, coconut \nwater, and milk are \n\nbest to drink. \n\n\n\n\nSoft foods and sweet foods from \nthe store are not good for you. Soft \nfoods stick to your teeth easily. They \ncan work longer to cause cavities and \ninfected gums, Sweet foods have \nmostly sugar in them, and it is 'factory \nsugar', not the 'natural sugar' that is \nin the foods in the pictures above. \n\nThis kind of sugar is quick to mix with \ngerms and make acid. Remember: \nnatural sugar makes acid slowly; \nfactory sugar makes acid quickly. \n\n■ Children who eat a lot of sugar lose \ntheir appetite for other foods— the \nfoods that help them grow strong, \nstay healthy, and learn well in school. \n\nStore foods are also expensive. You \ncan usually get'better food, and more \nof it for the same money, from your \ngarden or in the market. \n\n\n\n\n54 \n\n\n\nCleaning your teeth carefully every day is another important way to \ntake care of both teeth and gums. However, cleaning teeth is like building \na house. To do a good job, you need to work slowly and carefully. Once a \nday is enough, if you clean your teeth well every day. \n\n\n\n\nBuy a brush from the store, or make one yourself (see p. 4). But be sure \nthe cleaning end of the brush is soft so that it won't hurt the gums. \n\n\n\n\nUse your brush to clean all the teeth, especially the back ones with the \ngrooves. Back teeth are harder to reach and so it is easy not to clean them \nwell enough. Cavities start from sweet food and germs left together inside \nthe grooves. \n\n\n\n1 . Scrub the inside, \noutside, and top \nof each tooth. \n\n2. Push the hairs of \nyour brush between \ntwo teeth. Sweep \nthe food away. \n\n3. Wash your mouth \nwith water, to \nremove any loose \nbits of food. \n\n\n\nSmall children are not able to clean their teeth carefully enough by \nthemselves. They need help. Look at the pictures on the cover and p. 1 6 to \n\nsee how you can do this. Older children can care for younger brothers and \nsisters at home. \n\n\n\n\n\n\n\n55 \n\n\n\nTHE ACTIVITY : \n\nOne of the best ways to teach is by example. \n\n\n\n'^ND 50 AT HOME \nPUT BOTH OWED FISH \nAND OREEN LEAVES \nINTO THE SOUP. MY \n\n/ Jchildren like it very] \n\nYOU WILL TOO/^ \n\n\n\n\nStudents will believe what \ntheir teacher says if they \nknow he eats good food and \ncleans his teeth. \n\nThe reverse is also true. \nLearning is harder when \nstudents know that their \nteacher does not do those \nthings himself. \n\n\n\nStudents can be a good example for their community, too. They can: \n\n* draw pictures of foods that are both good and bad for teeth. Use \nthem to make posters and flannel-board stories. \n\n% make puppets and plays to discuss ways people can become healthier. \n\n\n\nThere are some other ways to make learning meaningful and fun. \n\n\n\n1. Make a garden at school. Divide the ground so that each class has its \nown space to plant a garden. \n\nUse some of the garden's food to prepare a meal for the students, \nperhaps once a week. Students can bring food from home if there is not \nenough ready in the garden. \n\n2. Organize a school lunch program. Each day the students can bring \nsome good food from home. Cooked yams, or maize, nuts, fruit and \nfresh vegetables are all good. Often the students will exchange food \nand talk about the many different foods that can be grown locally. \n\n\n\n56 \n\n\n\n3. Find the best way to clean teeth. Divide the class into groups. They \nwill learn more easily in a small group of 4 to 8 students. \n\nGive all the students something to eat that is sweet, sticky and dark in \ncolor, such as sweet chocolate biscuits. Ask the students to look in each \nother's mouth, to see how easily the biscuit sticks to the teeth. One or \ntwo of the students in a group can then try to clean away the pieces of \nbiscuit, using a different method. \n\n\n\n\nWhen they are finished, the students can look at the teeth to decide if \nthey are clean or not. Put your findings on a chart and talk about what \nyou have learned. \n\n\n\n\n\n\n58 \n\n\n\nHave the students score each other's progress. Do not make it hard to \njudge, or they will not do it. In the example below, the tooth is either \nclean or not clean. \n\n\n\n\nPick 4 teeth, a back tooth \nand a front tooth— two on \ntop and two on the bottom. \n\nUse the same 4 teeth for \neach person. Look for food \non each tooth near the gums. \n\nA clean tooth = 2 points \nA dirty tooth = 0 point \nTotal possible points each \nday is 4 teeth x 2 = 8 points. \n\nIn this example the score is: \nTooth 1 = 2 points \nTooth 2 = 0 point \nTooth 3 = 0 point \nTooth 4 = 2 points \n\nTotal =4 points \n\n\n\nHave each student put his daily score on a chart. At the end of the \nmonth he can see how much he has improved. \n\n\n\n\n\n\nCHAPTER \n\n\n\n59 \n\n\n\nTaking Care of \nTeeth and Gums \n\n\n\nWe can prevent most tooth and gum problems. This chapter gives more \ninformation about how teeth grow in and how to keep teeth and gums \nhealthy. Share this information and you will prevent problems from \nstarting. \n\nBut remember that people are most interested in the problems they \nhave now. Before listening to what you know about prevention, people \nwill want treatment for the problems that are already causing them pain \nand discomfort. \n\n\n\nEarly treatment is a form of prevention. \nIt can prevent a tooth or gum problem \nfrom becoming more serious. \n\n\n\nWhen you treat a person's problem, it shows that you care about him. \nIt also shows that you know what treatment he needs. As his confidence \nin you grows, he will want to learn frorn you about preventing tooth or \ngum problems. \n\n\n\n\nIn order to help a person \nit is important to know \nwhat the problem is and \nwhat is the best treatment. \nBut just as important is \nknowing what you are \nnot able to do, and when \nto seek help. \n\nIn this chapter, you \nwill learn more about \nteeth, gums, and problems \naffecting them, but \nyou must never be too \nproud to get help from \nmore experienced dental \nworkers. \n\n\n\nKNOW YOUR LIMITS. \n\n\n\n\n60 \n\n\n\nTAKING CARE OF BABY TEETH \n\n\n\nA child's baby teeth are being made before birth while the baby is still \ninside the mother's womb. During the last months of pregnancy and the \nfirst few months after the child is born, the baby teeth take their final \nform. Pregnant mothers and young children need good food and good \nhealth in order to have strong baby teeth. \n\nStrong teeth Weak teeth \n\nare white and their have yellow marks that \n\nfront surface is smooth. are pitted and rough. \n\n\n\n\nBaby teeth get marks on them when; 1 ) the pregnant mother is sick or \ndoes not eat good food; 2) the young baby is sick or does not eat good \nfood; or, sometimes, 3) the baby's birth was early or the delivery was \ndifficult. \n\nThe marks are rougher than the rest of \nthe tooth. Food sticks easily to them \nand turns the tooth yellow. \n\nThe marks are also soft. They need to be \ncleaned well every day (p. 61) to prevent \nthem from becoming cavities. A tooth with \na cavity hurts. When children’s teeth \nhurt, they do not want to eat as much. \n\n\n\n\nCavities in baby teeth can make a child's malnutrition worse. Remember \nthis whenever you see a weak, poorly nourished child. When you examine \na child at the health clinic, lift his lip and look at his teeth. Do this as part \nof your routine examination. \n\n\n\n\nYou can fill cavities with cement (Chapter \n10). Cement prevents food and air from \ngoing inside the cavity and hurting the \nchild. \n\nA sore on the gums may be a gum bubble. \n\nIf so, it means the tooth has an abscess \n(page 78). That cavity should not be \nfilled with cement. Instead, the tooth needs \nto be taken out (Chapter 1 1 ) before the \ninfection can get worse. \n\n\n\n\n\n61 \n\n\n\nFor baby teeth to grow strong, mother and baby must stay healthy.* \nHelp her to understand how important this is, A pregnant mother should: \n\n1. Eat enough good kinds of foods, both for herself and her baby \ngrowing inside (page 66; also see Where There Is No Doctor, Chapter \n1 1 , and Helping Health Workers Learn, pages 25'39 to 25-44.) \n\n2. Attend health clinic each month, so the health workers can examine \nher regularly and she can receive important medicines (see Where \nThere Is No Doctor, page 250). \n\n3. Not use the medicine tetracycline, because it can cause the teeth to \nturn dark. You, the health worker, must remember— do not give \ntetracycline to a pregnant woman or to a young child. If she needs \nan antibiotic, use a different one. \n\nFor baby teeth to stay strong, and to prevent marks from turning into \ncavities, mother should: \n\n1 . Continue to breast feed and never feed her child juice or sweet tea \nfrom a bottle. Start adding soft foods, mashed banana or papaya \nwhen the child is 4 months old. \n\n2. Wipe her baby's teeth with a clean cloth after \nthe baby eats. This cleans the baby's teeth, and \nhelps the baby get used to teeth cleaning. Later \nhe will be happy with a brush. \n\nAround 1 year of age, there will be several baby \nteeth. At that time, mother should start using water— \nnot toothpaste— on a soft brush or brushstick. (With \ntoothpaste, you cannot see the child's teeth clearly because of the bubbles \nit makes.) She should scrub the sides and tops of each baby tooth as well \nas she can (page 67). \n\n\n\n\nThe child can also try to clean his own teeth. That should be \nencouraged. However, since he is too young to clean properly, mother (or \nfather, or older brother, sister) must clean his teeth once a day for him. \nContinue helping in this way until the child is old enough to go to school. \n\n\n\n\nYou can make a large brush \nsmaller, to fit more easily into \na young child's mouth. \n\nPull out some of the back hairs, \nor cut them with scissors. \n\n\n\nSee the story about pregnancy and dental care on pages 177-179. \n\n\n\n\n62 \n\n\n\nWhy Baby Teeth Are Important \n\nBaby teeth are just as important to children as permanent teeth are to \nadults. They help a child to eat, talk, and look good. \n\nHowever, many people feel that it is not worth the effort to look after \nbaby teeth. Nor is it worth fixing them. After all, parents think, the \npermanent teeth will take their place. \n\nThis kind of thinking is understandable. The problem is that we are \nforgetting one other useful purpose of baby teeth. Baby teeth keep space \nin the mouth for the permanent teeth to grow in. If there is not enough \nspace, the new teeth will grow in crooked, and cavities grow faster around \n\nUnder each baby tooth a new permanent \ntooth is growing. \n\nAt the same time, extra permanent \nmolars are forming at the back of the \nmouth, inside the bone (page 41 ). \n\nFront baby teeth become loose and fall \nout (usually 6-7 years, but sometimes as \nyoung as 5 years) ahead of back baby \nteeth (10-12 years). This is because the \nfront permanent teeth are formed and \n\nPermanent molars (PM) come in ready to grow in first. \n\nbehind the baby molars (BM). \n\nThe permanent molar (1PM) is often the first of the permanent teeth to \ngrow into the mouth. That happens at 6 years of age. \n\n\n\nThe first permanent molar grows into Slowly but steadily the upper and \nthe mouth by sliding against the lower permanent molars grow until \n\nback of the second baby molar (2BM). they meet and fit tightly together. \n\n\n\n\n\n\n\n63 \n\n\n\nBetween the ages of 6 and 1 1, a child needs healthy baby molars to \nguide the first permanent molars into position and then to hold them \nthere. When the first permanent molars grow into the right place, this is a \ngood sign. It means the other permanent teeth will also grow in properly, \nbecause they will have enough space. \n\nNote: Some people are born without enough space. But most people \nare not born with this problem— they lose the spaces when they \nremove baby teeth instead of fixing them. \n\n\n\nHEALTHY BABY TEETH to make \n\n1PM \n\n\n\n\nhelp \n\nSICK BABY TEETH to make \n\n\n\n4pm \n\n\n\n\nSTRAIGHT PERMANENT TEETH \n\n\n\n\nCROOKED PERMANENT TEETH \n\n\n\n\n10 adult \n\nTell mothers why baby teeth are important. Good food and regular \ncleaning keeps them healthy. They should know that new teeth coming \nin do not cause diarrhea and fever, but that a child may have diarrhea or \nfever at the same time. \n\nIf there is a cavity, fix it so the tooth can be kept in the mouth to do \nits important work (see Chapter 10). \n\n\n\n\n\nTAKING CARE OF MOLAR TEETH \n\n\n\nWe often notice front teeth growing in, but not the back ones. Back \nteeth— molars— are not so obvious. Swelling on the face can be either a \nnew molar growing in or an abscess. So, to help you to decide, look at \nthe tooth for a cavity and at the gums beside it for a gum bubble. \n\n\n\n\nBut if the person is young (16-22 years), it often is not an abscess. The \nthird permanent molar tooth may be growing in at the back of her mouth. \nAs the tooth grows, it cuts through the skin. Just as a dirty cut on a \nperson's hand can get infected, the cut gum around her new tooth also \ncan get infected, causing a swollen face. \n\nSee the red swollen skin on \n\nLook behind her back teeth. top of the new tooth. \n\n\n\n\nIf there is enough space for the tooth, it will grow in by itself It only \nneeds time. Before acting, decide how serious the problem is. \n\nIf there is no swelling and she can open her mouth, explain to her \nwhat is happening and what she can do herself to reduce infection and \ntoughen the gums. The best medicine is to rinse warm salt water over the \nsore area. A good home remedy is to rinse until the tooth grows all the \nway into the mouth. \n\nIf it does appear serious (severe pain, swelling, not able to open the \nmouth), see page 88 for further treatment. \n\n\n\n\n65 \n\n\n\nTAKING CARE OF ALL YOUR TEETH \n\nThis book often repeats an important message: eat good food and clean \nyour teeth. It is repeated because this is the most important thing you \ncan learn from this book. Later chapters will discuss what to do when \nproblems occur, but if you follow these two suggestions, you will almost \nnever have problems with your teeth and gums. This is true because good \nfood keeps your whole body healthy, including your teeth. Also, with no \n'colonies' of germs (page 48) or harmful factory sugar (p. 53) on your \nteeth, your mouth cannot make the acids that cause both tooth and gum \nproblems. So, remember: \n\n\n\n1. Eat Good Food \n\n\n\nAn easy-to-remember rule is the same foods that are good for the body \nare good for the teeth. A healthy body is the best protection against \ninfection. \n\n\n\n\nThe MAIN FOOD is \nat the center of \nevery meal. \n\n\n\nGood nutrition (eating well) means two things: \n\nOne, eat a mixture of different kinds of foods \nevery time you eat. Look at the pictures on page \n53. There are several groups of foods. Every time \nyou eat, try to eat one or two foods from each of \nthe groups. This way, you will get three important \nkinds of food: GROW FOOD (body-building food) \nto give you the protein you need; GLOW FOOD \n(protective food) to give you vitamins and \nminerals; and GO FOOD (concentrated energy \nfood) to give you calories to be active all day. \n\n\n\nTwo, be sure you eat enough food \nto give your body the energy it needs. \n\nThis is even more important than the \nfirst suggestion. We get half or more \nof our energy from our MAIN FOOD. \nIn most parts of the world, people eat \none low-cost energy food with almost \nevery meal. Depending on the area, \nthis MAIN FOOD may be rice, maize, \nmillet, wheat, cassava, potato, bread- \nfruit, or banana. The MAIN FOOD is \nthe central or 'super' food in the local \ndiet. \n\n\n\n\nA spoonful of cooking oil added to a \nchild’s food means he only has to eat \nabout % as much of the local main food \nin order to meet his energy needs. The \nadded oil helps make sure he gets enough \ncalories by the time his belly is full. \n\n\n\n\n66 \n\n\n\nGROW F00D5 \n\n\n\n\n\n\n\n\n©i \n\n\n\n-3 v^~ \n\nS A^/^^^ \n\nsiw /, A ^ ^ \n\n\n\nBe sure \nalways to eat \nGROW FOODS \nand GLOW \nFOODS to get \nthe vitamins \nand protein \nyou need. \n\n\n\nYour energy \nfoods give \nyou the most \nimportant \npart of your \ndiet-calories, \nFlalf or more \nof our \n\ncalories come \nfrom the MAIN \nFOOD, and \nmost of the \nother calories \ncome from GO \nFOODS. \n\n\n\nGLOW FOODS \n\n\n\n\nTHB M/K»M \nFOODS AND \n'GO FOODS' \n6\\VE US THE \nENERfiVTO \nRuN,VJOW<: \nANDPLAV. \n\n\n\n\\NARNING ABOUT 'GO FOODS': Although GO FOOD gives us the energy \nwe need, some GO FOODS are worse than others. Honey, molasses and \nespecially white sugar can be very bad for the teeth, even though they \nhave the calories we need. Fruits, nuts, and oils all give us energy (calories) \nwithout attacking the teeth. \n\n\n\n\n\n2. Clean Your Teeth \n\n\n\nCleaning teeth requires time and care. If you hurry, you will leave food \nand germs behind, and they continue to make cavities and sore gums. \n\nYou may find that different dental workers recommend different ways \nof brushing teeth. Some ways are definitely better, but often they are \nharder to learn. \n\nTeach a method of cleaning that a person can learn and will do at \nhome. Let him start by scrubbing his teeth (and his children's teeth) back \nand forth, or round and round. Encourage him to improve his method \nonly when you think he is ready. \n\nToothpaste is not necessary. Some people use charcoal or salt instead. \nBut it is the brush hairs that do the cleaning, so water on the brush is \nenough. \n\nScrub the outside, inside, and top of each tooth carefully. \n\n\n\n\n\n\n\nWhen you finish, feel the tooth with your tongue to make sure it is \nsmooth and clean. \n\n\n\nFinally, push the hairs of the brush \nbetween the teeth and sweep away any bits \nof food caught there. Do this for both upper \nand lower teeth. \n\nSweep away in the direction the tooth \ngrows: sweep upper teeth down and lower \nteeth up. \n\n\n\n\n\n68 \n\n\n\nExplain how important it is to use a brush with soft hairs. A brush that \nis stiff and hard will hurt the gums, not help them. \n\n\n\n\nYou can make a hard brush softer by \nputting the hairs into hot water for a \nfew minutes. \n\nDo not put the plastic handle into the \nhot water, or it will melt. \n\n\n\n\nIf your store has only hard brushes, tell the storekeeper that hard \ntoothbrushes do not help the people in the community. Ask him to order \nand sell only soft toothbrushes. \n\n\n\nNote: Another important way to reduce cavities is by adding \n\nfluoride to teeth. Fluoride is a substance which, like calcium, \nmakes teeth harder and stronger. \n\nFluoride in drinking water, toothpaste, vitamins, and mouth rinses, \nhelps to prevent cavities. These methods are sometimes expensive. \nPerhaps the most effective and inexpensive method is the weekly \nrinse at school, described on page 167. \n\nFluoride can also be found naturally in food and water. For \nexample, tea leaves and most foods from the sea contain a large \namount of fluoride. \n\nSo, your source of fluoride can be either: \n\n\n\n\n\n\n\n\n69 \n\n\n\nCLEANING BETWEEN THE TEETH IS VERY IMPORTANT \n\nHere are three ways to clean between the teeth: \n\n1. Push the hairs of a toothbrush between the teeth, and sweep the bits \nof food away. \n\n\n\n2. Remove the stem from a palm leaf. Use the thinner end and move it \ngently in and out between the teeth. \n\n\n\n\n3. Use some thin but strong thread or string. String can be the best \nmethod of all— but you must be careful with it. \n\n\n\n\nBuy and use Dental Floss. \n\nGet some thin cotton rope This is a special kind of \n\nused for fishing nets. Unwind OR string for cleaning \n\nand use one strand of it. between the teeth. \n\nBe careful! The string can hurt your gums if you do not use it correctly. \nThe next page shows how to use the string, but the best way to learn how \nto 'floss' your teeth is to have someone show you. Ask a dental worker \nwho has experience. \n\n\n\n\n70 \n\n\n\nWrap the ends of the string around the middle finger of each hand. \n\n\n\n\nUse the thumb and finger to guide the string. Go back and forth to \nslide the string between two teeth. Be careful not to let it snap down and \n\n\n\n\nWith your fingers pull the string against the side of one tooth. Now \nmove the string up and down. Do not pull the string back and forth or \n\nit will cut the gum. \n\n\n\n\nLift the string over the pointed gum and clean the other tooth. \n\n\n\n\nWhen you have cleaned both teeth, release the string from one finger \nand puli it out from between the teeth. Then wrap it around your two \nmiddle fingers once again, and clean between the next two teeth. \n\n\n\nRemember: clean teeth and good food \nwill prevent almost all dental problems. \n\n\n\n\n\n\n71 \n\n\n\nExamination \nand Diagnosis \n\n\n\nCHAPTER ^ \n\n\n\n(AR E THE TE6.TH HEALTHY^ \n\nWhenever you do an examination, \nremember to examine the mouth. (^abej^ierl amv sores \n\nYou can prevent much suffering and serious \nsickness when you notice and treat problems \nearly. Whenever you hold a health clinic, try \nto find out how healthy each person's mouth \nis. \n\nAsk if she is having a problem now, or has \nhad a problem recently. \n\nAlways write down what you find out, so you \nremember what treatment that person needs. \n\n1. Are the teeth healthy? \n\nLook for: \n\n\n\n\nWhen you look inside \nsomeone’s mouth, ask \nyourself three questions. \n\n\n\n\nA New Tooth \n\n\n\n\n2. Black \nSpots \n\n\n\n\n\n\n\n\nQ \n\n\n\n\n\nTell the person what \nis happening and how \nto keep the skin \naround it healthy \n(page 64). \n\nThey may be \ncavities, which \nshould be filled \nwhen they are \nstill small \n(page 45). \n\n\n\nTell the person what \nis happening and how \nto prevent it from \ngetting worse or \naffecting other \nteeth (page 52). \n\n\n\n4. A Dark \nTooth \n\n\n\nA tooth that is dark is dead. \nInfection from its root can \ngo into the bone (p. 45). \nThis can make a sore on the \ngums (p. 72). \n\n\n\n\n\n\n\n72 \n\n\n\n2. Are the gums healthy? \n\n\n\nLook at page 50 and compare the pictures of healthy and unhealthy \ngums. Unhealthy gums often are red and they bleed when you touch them. \n\n\n\nA bubble on the gums below the tooth is a clear sign \nthat the person has an abscess. The abscess may be \nfrom the tooth, or it may be from the gums. To \ndecide, look carefully at both the tooth and the gum \naround it. \n\nA bubble beside a healthy tooth is a sign of infected \ngums. Scale the tooth carefully. See Chapter 8. \n\n\n\n\nA bubble beside a decayed tooth is a sign of a tooth \nabscess. See page 87. \n\nA sore on the gums from a badly decayed tooth \nappears when a gum bubble breaks open and lets out \nthe pus from inside. \n\n\n\n■N. i \n\\' \n\n\n\nt I tt \n\n\n\nGUM BUBBLE \n\n\n\n3. Are there any sores? \n\n\n\nLook for sores under the smooth skin on the inside of the lips and \ncheeks. Look also under the tongue and along its sides. \n\n\n\n\n\n\n\n\n\n^ \\ V \\ \n\n\n\n\n\n\n\\^j\\ d \n\n\n\n\n'M \n\n\n\n\n\n\n\n\n( ) \n\n\n// \n\n\n\\ \n\n\n1 . A sore on the gums \n\n\n2, Sores on the inside \n\n\n3. Sores on the lips \n\n\nmay be from an \n\n\nof the lip or cheek \n\n\nor tongue may be \n\n\ninfected tooth \n\n\nmay be from a virus \n\n\ncancer (p. 1 1 9). \n\n\n(p. 87). \n\n\n(p.98). \n\n\n\n\n\nAfter your examination, tell the person what you have found. If you \nnotice a problem starting, explain what to do to prevent it from getting \nworse. If there are no problems and the mouth is healthy, congratulate \nthe person. \n\n\n\nShare your knowledge— explain things to people. \n\nHelp them learn how they can prevent and \neven manage their own problems with their teeth. \n\n\n\n\n\n\n73 \n\n\n\nWHERE TO EXAMINE \n\nExamine people in a light and bright place. It is dark inside a person's \nmouth, so you need light to see the teeth and gums. \n\nUse the sun. Examine outside, or inside a room facing the window. With \nsunlight alone, you will be able to see most places in the mouth well \nenough. If you cannot, set up a lamp or have someone hold a lamp for \nyou. Reflect the light off a small mouth mirror onto the tooth or gum. \n\nIf you have a low chair, lift up the person's chin so that you do not \nhave to bend over as far when you look into the mouth. An even better \nway is to have the person sit on some books. The person's head can lean \nback on a piece of cloth. \n\nUse an old chair with a strong back. \n\nAttach two flat sticks to the chair. Then tie a \nstrip of clean cloth to the sticks. Tie it strong \nenough to support the head, but loose enough \nto let the head lean back. \n\n\n\nTHE INSTRUMENTS YOU NEED \n\nThree instruments are really enough: \n\n\n\n1 . A wooden tongue blade to hold back the \ncheek, lips, and tongue. \n\n2. A small mirror to let you look more \nclosely at a tooth and the gums around it. \n\n3. A sharp probe to feel for cavities and to \ncheck for tartar under the gum. \n\nIf you have many people to examine, it is helpful to have more than one \nof each instrument. But be sure they are clean. \n\nDirty instruments easily can pass infectipn \nfrom one person to another. After you finish an \nexamination, clean your instruments in soap \nand water and then leave them in a germ-killing \nsolution like the ones described on page 85. \n\n\n\n\n\n\n\nX) \n\n\n\n\n\n\n\n\n\n\n\nA GOOD DIAGNOSIS \n\n\n\nYou are making a diagnosis when you decide what a person's problem \nis and what is causing it. To do this, you need information. You need to \nmake a careful examination to make a good diagnosis. \n\n\n\nLearn all you can about the person's problem; \n\n1. Ask questions about the problem. \n\n2. Look at the person's face. Think about the \nperson's age. \n\n3. Examine the mouth more carefully than before. \n\n4. Touch the place that is sore. \n\n\n\n1. Ask the person about the problem. \n\nGive a sick person a chance to \ndescribe how he is feeling. \n\nListen. Think about what possibly is \nhappening in his mouth. \n\nYou may have an idea what the \nperson has. Now try to find out \nmore by asking questions: \n\n• What is the problem? Ask him to \n\ntalk about the pain, swelling, \nbleeding, or whatever he is feeling. \n\n• Where does it feel that way? See if he can put his finger on the tooth \nor place that is bothering him. \n\n• When do you have the most pain? Find out if it happens all the time \nor only some of the time. \n\n• When did it start? Find out if he has already had this problem before. \nAsk how he took care of it. \n\n• Have you had an accident or injury lately? Infection still inside the \nbone from an old injury in the mouth can make a sore on his face, \nor start swelling. \n\n• Are you having other problems? A head cold or fever can make the \nteeth hurt. \n\n• How old are you? Think about a new tooth coming into the mouth. \n\nAfter you hear the answers to your questions, decide if your original \nidea is the correct diagnosis, if not, try to think of another possibility and \nask more questions. This is the scientific method of making a diagnosis. \nFor a good explanation of scientific method, see Chapter 1 7 of Helping \nHealth Workers Learn. \n\n\n\n\n\n\n75 \n\n\n\nWhen you talk to a woman, find out if she is pregnant. A pregnant \nwoman's gums can easily become infected. The gums may bleed and she \nmay have more tooth decay. But this is not necessary. If a pregnant woman \ntakes extra care of her teeth and gums, she can prevent most dental \nproblems. But if she already has a problem, do not wait for the baby's \nbirth before you help her. You can treat a pregnant woman's mouth \nproblems now. In fact, this may be an important way of protecting her \nbaby as well. See pages 1 77-1 79. \n\n2. Look at the person. \n\nPeople have some problems more often at certain ages. When a person \nfirst comes in to see you, notice his age. Then, before you ask him to open \nhis mouth, look at his face for a sore or swollen area. \n\n\n\n\n\nSWELLING \n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\nCHILD \n\n\nYOUNG PERSON \n\n\nADULT \n\n\nSwelling can come from \n\n\nSwelling can come from \n\n\nSwelling can come from \n\n\n♦ mumps \n\n\n• a new tooth \n\n\n• a tooth abscess \n\n\n• an infection \n\n\ngrowing In \n\n\n(p-87) \n\n\nin the spit \n\n\n(p. 94) \n\n\n• a broken jaw \n\n\ngland (p. 1 1 3) \n\n\n• a tooth abscess \n\n\n(p. 107) \n\n\n• a tooth abscess \n\n\n(p. 87) \n\n\n• a tumor (p. 119) \n\n\n(p. 87) \n\n\n\n\n\n\n\nA SORE \n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\nCHILD \n\n\nYOUNG PERSON \n\n\nADULT \n\n\nA sore can come from \n\n\nA sore can come from \n\n\nA sore can come from \n\n\n• impetigo \n\n\n• fever blisters \n\n\n• a tooth abscess \n\n\n• Vincent’s \n\n\n(p. 98) \n\n\n(p. 87) \n\n\nInfection \n\n\n• a tooth abscess \n\n\n• a bone infection \n\n\n(p. 96) \n\n\n(p. 87) \n\n\n(osteomyelitis) \n\n\n\n\n\n\n76 \n\n\n\n3. Examine inside the mouth. \n\n\n\nRemember what the person said, the person's age, and what you saw. \nNow look more closely at the problem area. \n\n\n\n\nLook at the teeth; \n\n• Is a new one growing in? \n\n• Isa tooth loose? \n\n• Is there a dark (dead) tooth? \n\nLook at ihe gums: \n\n• Are they red? \n\n• Is there any swelling? \n\n• Do they bleed? \n\n• Are the gums eaten away between the teeth? \n\n\n\nLook also for sores on the inside of the cheek or lips, and on the tongue. \n\n\n\n4. Touch the sore place. \n\nTouching is a good way to find out how serious the problem is. This \nwill help you decide which treatment to give. \n\n\n\nPush gently against each tooth in the area of pain to see if a tooth is \nloose. Rock the loose tooth backward and forward between your fingers, \nto see if it hurts when you move it. \n\n\n\n\nUsing the end of \nyour mirror, tap \nagainst several \nteeth, including \nthe one you \nsuspect. \n\nThere is probably \nan abscess on a \ntooth that hurts \nwhen you tap it. \n\n\n\n\nPress against the gums with cotton gauze. Wait a moment, and then \nlook closely to see if they start bleeding. Then use your probe gently to \nfeel under the gum for tartar. Carefully scrape some away. Wait and look \nagain to see if the gums bleed. When gums bleed, it is a sign of gum disease. \n\n\n\n\n\n77 \n\n\n\nLEARN TO TELL SIMILAR PROBLEMS APART \n\n\n\nIf a person comes to you with a toothache or a \nsore or a loose tooth, there are many possible \ncauses for each problem. The first thing you \nnotice— the toothache, sore or loose tooth— is your \nfirst step to a diagnosis. To this you must add more \ninformation before you can point to the most \nprobable cause. \n\nPut together what you have found with what \nyou already know about teeth and gums. You can \nmake a good diagnosis of a problem without \nknowing a special name for it. \n\nUsually it is easy to make a diagnosis. However, \nsometimes you will not be sure, and these are the \ntimes to seek the advice of a more experienced dental worker. Never \npretend to know something you do not. Only treat problems that you \nare sure about and have supplies to treat properly. See Where There Is No \nDoctor, p. w4. \n\n\n\n\nUse the charts beginning here to help you make the diagnosis. For more \npractice using charts to tell problems apart, see Chapter 21 of Helping \nHealth Workers Learn. \n\n\n\nIF THE PERSON AND YOU FIND OUT \n\nHAS THAT \n\n\nHE/SHE MAY \nHAVE \n\n\nSEE \n\nPAGE \n\n\n^ It hurts only after eating ^ \n\nor drinking. There is a cY^ \n\ncavity, but the tooth does /V \n\nnot hurt when you tap it. \n\n\n♦ \n\na cavity \n\n\nf \n\n86 \n\n\nPart of the filling has fallen \nout, or is cracked and ready \nto fall out. Eating and \ndrinking make the tooth hurt. \n\n\na cavity under \nan old filling \n\n\n86 \n\n\nA lUUlMAtJHb The tooth hurts when chewing \n\n^ food. It may hurt when tapped, \\ /L 1 \n\nV but there is no cavity and \n\njf ' ' tooth looks healthy. , / 1 a . \n\n\ntartar between \nthe teeth \n\n\n125 \n\n\n\\ It hurts all the time— even ,>*' i^v~y \n\nI when person tries to sleep. \n\n^ j The tooth hurts when you tap \n\ny/ ^ it and it feels a bit loose. \n\n\nan abscess \n\n\n87 \n\n\nIt hurts when person breathes ^ \n\nin cold air. The tooth was wX\"V~Vy \\ \n\nhit recently. \n\n\na cracked or \nbroken tooth \n\n\n90 \n\n\nHe cannot open his mouth \nproperly. Steady pain and \na bad taste are coming from \nthe back of the mouth. \n\n\na new tooth \ngrowing in \n\n\n94 \n\n\nSeveral top teeth hurt, even \nwhen you tap them. She had \na head cold and can only \nbreathe through her mouth. \n\n\nan infected \nsinus \n\n\n89 \n\n\n\n\n\n78 \n\n\n\nIF THE PERSON AND YOU FIND OUT \n\nHAS THAT \n\n\nHE/SHE MAY \nHAVE \n\n\nSEE \n\nPAGE \n\n\nt + \n\nHe had a toothache recently. f \n\nThe bad tooth hurts when you 1 1 / ^ \n\ntap it. 1 \n\n\na tooth abscess \n\n\nt \n\n87 \n\n\nA . \n\nSWOLLEN FACE She is young, about 18 years \n\nold, and has trouble opening \n\n\na new tooth \ngrowing in \n\n\n94 \n\n\n♦ 1 j He was hit on the face or \n\nif ^ \\j jaw. The bone hurts when \n\nJ/ you touch it. The teeth \n\ndo not fit together properly. \n\n\na broken bone \n\n\n102 \n\n\nThe swelling is under or \nbehind the jaw. It gets \n\nworse when he is hungry \\ ^ \n\nand smells food. \n\n\nan infection \ninside the spit \ngland \n\n\n113 \n\n\nThe swelling has been there \n\nfor a long time. It does • \n\nnot seem to get better. \n\n\na tumor \n\n\n119 \n\n\n\n\n\n\n\n79 \n\n\n\nIF THE PERSON AND YOU FIND OUT \n\nHAS THAT \n\n\nHE/SHE MAY \nHAVE \n\n\nSEE \n\nPAGE \n\n\n♦ ♦ \n\nThe gums are red and swollen. rTT-TTl — 1 \n\nThey bleed when the teeth are \n\ncleaned. ii \n\n\n? \n\ngum disease \nstarting \n\n\n~T‘ \n\n95 \n\n\nA SORE MOUTH Between two teeth the gums \n\n, are sore and swollen, like / aJTI } \n\nINFECTED GUMS a smell tumor. \n\n\nsomething \ncaught under \nthe gum \n\n\n127 \n\n\nQums between the teeth \n\nPVT Y in have died and are no longer /> — r*TT TO \n\npointed. Pus and blood \naround the teeth make the \nmouth smell bad. \n\n\nVincent's \nInfection \n(a more serious \ngum infection) \n\n\n96 \n\n\nThe gums are bright red and V A A \n\nsore, but between the teeth \nthey are still pointed. \n\n\nfever blisters on \nthe gums— from \nHerpes Virus \n\n\n98 \n\n\n\nA sore on the inside of the v \n\ncheek, lips, or under the \n\ntongue, is yellow with the \n\nskin around it bright red. \\3v \n\nFood touching it makes the \n\nsore hurt more. \n\n\na canker sore \n\n\n100 \n\n\nA sore spot around or \n\nunder a denture hurts ' \n\nA SORE MOUTH when you touch it. \n\nfrom a ' \\ ^ \n\nSMALL SORE \n\n\na sharp place on \na denture, or an \nold denture that \nneeds to be \nrefitted \n\n\n100 \n\n\nIn another a i • ^ . u \n\n1 A kind of white cloth seems \n\nto be stuck to the top of \nthe mouth or tongue. It \n/ may stop a baby from sucking. \n\n\nthrush \n\n\n99 \n\n\nThe sore is near the root \nof a bad tooth. \n\n\ngum bubble \n\n\n72 \n\nand \n\n87 \n\n\nThe corners of the mouth v , \n\nare dry. The lips crack \n\nand are sore. r''^' \n\n\nmalnutrition \n\n\n101 \n\n\nSmall painful blisters on \n\nthe lips soon break and \n\nform dry scabs. \n\n\nfever blisters \n—from Herpes \nVirus \n\n\n98 \n\n\nA SORE THAT DOES NOT HEAL PROPERLY MAY BE CANCER (See page 119). \n\n\n\n\n\n\nIF THE PERSON AND YOU FIND OUT \n\nHAS THAT \n\n\nHE/SHE MAY \nHAVE \n\n\nSEE \n\nPAGE \n\n\n» » \n\n■ Inside his mouth, he has v/l \n\na tooth abscess or a ijjp ^3 C — y \n\nbroken tooth near the sore. X k \n\nARCiRF \n\n\n♦ \n\nabscessed tooth \ndraining pus to \nthe outside of \nthe face \n\n\nt \n\n114 \n\n\nON THE FACE \n\nA dark sore is eating through \n\n_ J the cheek. Her gums are badly — /uLli \n\ninfected. A bad smell is coming r^; ^ ^1 \n■& from the dying skin on the face, \\ jf ^.(l \n\nand from inside the mouth. \n\n\na condition called \nA/oma— starting \nfrom Vincent's \nInfection of the \ngums \n\n\n115 \n\n\nA 1 -month-old sore / \n\non the lips is not healing \\ \n\nwith medicine. ^ \n\n\ncancer \n\n\n119 \n\n\n\nHe is young, between 16-24 ^ \n\nyears, with some swelling t ' \n\nbehind his jaw. \n\n\na new tooth \ngrowing in \n\n\n94 \n\n\nTROUBLE \n\nOPENING THE He recsntly had an accident. ' 1 \\P J/l \n\n\na broken jaw- \nprobably in front \nof the ear \n\n\n102 \n\n\nHe had a toothache before \nin a. back tooth with some \n\n\nan abscess In a \nback tooth \n\n\n87 \n\n\n) 1 CAN NOT'^ When she tries to open her \n\n1 OPEN ANY 1 mouth, there is a clicking \n\n1 MORETHAN 1 sound from in front of her \n\nV^THIS.^^ ear. It also hurts in that \n\nplace whenever she tries to \nopen her mouth or chew food. \n\n\npain in the joint \n—where the \njawbone joins \nthe head \n\n\n108 \n\n\nSwallowing is difficult, and oli>,dm^p \nthe jaw grows stiff. Germs V \n\nhave gone into the body from \ndirty instruments or an /// \n\ninfected wound. ^ ^ \n\n\ntetanus \n\n\n112 \n\n\n\nTROUBLE After opening wide to eat or / / \n\nCLOSING THE yawn, his mouth became stuck \n\nMOUTH there. He has many missing )'* \n\nback teeth. \n\n\na dislocated jaw \n\n\n107 \n\n\naccident, and now ) ■ \n\n) ' ' something is stopping the 1 \n\n) ^ -ri^ teeth from coming together. \n\n\na broken jaw \n\n\n102 \n\n\n\n\n\n\n\nTreating Some \nCommon Problems \n\nYou must make a good diagnosis to treat a problem so it finishes and \ndoes not return. Why treat a sore on the face by cleaning it when the sore \nis from pus draining from a tooth with an abscess? You need to know \nthe cause of the sore to give the best kind of treatment. \n\nAfter you make the diagnosis, you must decide whether you or a more \nexperienced dental worker should provide the treatment. \n\nKnow your limits. Do only \nwhat you know how to do. \n\nIn the following pages, we describe the kinds of problems you as a \nhealth worker may see, and we also give the treatment for each problem. \nUse the table below to help you find the right page. \n\nBefore you touch the inside of anyone's mouth, learn how to keep \nclean. See the next 4 pages. \n\n\n\nPART 1: PROBLEMS YOU WILL SEE MOST OFTEN \n\n\n\n\nCavities \n\n\n. page 86 \n\n\nSore gums \n\n\n\n\nlost fiiling \n\n\n. page 86 \n\n\ngum disease starting \n\n\npage 95 \n\n\nbroken filling \n\n\n. page 86 \n\n\nsomething caught under \n\n\n\n\nAbscess \n\n\n. page 87 \n\n\nxY\\e Qum5 (epulis) . . page 95. 127 \n\n\nInfected sinus \n\n\n. page 89 \n\n\nVincent s Infection \n\nfever blusters (from \n\n\npage 96 \n\n\nTooth injury \n\n\n\n\nHerpes virus) \n\n\npage 98 \n\n\n1 . broken tooth \n\n\n. page 90 \n\n\nThrush \n\n\npage 99 \n\n\n2. tooth knocked out .... \nLoose tooth \n\n\n, page 91 \n. page 93 \n\n\nOther sores in the mouth \n\ncanker sores \n\n\npage 100 \n\n\nNew tooth growing in \n\n\n. page 94 \n\n\nfrom a denture \n\n\npage 100 \n\n\nbabies' teething \n\n\n. page 95 \n\n\nat the corners of the mouth . \n\n\npage 101 \n\n\nPART 2: SOME SPECIAL PROBLEMS \n\n\n\n\nBroken bone \n\n\n. page 1 02 \n\n\nTetanus \n\n\npage 1 1 2 \n\n\nDislocated jaw \n\n\n. page 1 07 \n\n\nInfection in the spit gland , . . . \n\n\npage 1 1 3 \n\n\nPain in the joint \n\n\n. page 1 08 \n\n\nSores on the face \n\n\n\n\nSwollen gums and epilepsy . . . \n\n\n. page 1 09 \n\n\nfrom a tooth abscess \n\n\npage 1 14 \n\n\nBleeding from the mouth . . . . \n\n\n. page 110 \n\n\nNoma (cancrum oris), a \n\ncomplication of Vincent's \n\n\n\n\nAfter you take out a tooth \n\n\n\n\ninfection \n\n\npage 1 1 5 \n\n\nswelling of the face . . . . . \n\n\n. page 1 1 0 \n\n\nTumor \n\n\npage 1 1 9 \n\n\npain from the socket . . . . \nbleeding from the socket . . \n\n\n. page 1 1 1 \n. page 1 1 2 \n\n\nCancer \n\n\npage 1 19 \n\n\n\n\n\n\n\n82 \n\n\n\nTHE FIRST RULE FOR TREATMENT: STAY CLEAN! \n\n\n\nNo matter what problem you are treating, be sure that your workplace, \nyour instruments, and you are always clean. For example, prevent \ninfection by always washing your hands before you examine or treat \nsomeone. \n\n\n\nWash your hands in front of the \nperson, in the same room. You \nwill show that you are a careful \nand caring health worker. Also, \nyou will demonstrate just how \nimportant cleanliness really is. \n\n\n\n\nThe mouth is a natural home for germs. They usually do not cause \nproblems because the body is used to them. In fact, many germs are \nhelpful. For example, when we eat, some germs break down chewed food \ninto parts small enough for the body to use. \n\nThere are problems when the number of these ordinary germs increases \ngreatly, or when strange, harmful germs come into a healthy body from \noutside. Fever and swelling follow. It is an infection. \n\nWhen we regularly clean the mouth, the number of germs stays normal. \nYou can teach others to clean teeth and gums, but cleaning is each \nperson's responsibility. \n\nFlowever, dental workers have one serious responsibility. You must \nnot spread germs from a sick person to a healthy person. You must do \neverything you can to make sure your instruments are clean. \n\n\n\n\n83 \n\n\n\n\nGerms hide inside bits of old food, cement, or \nblood on an instrument. There they can continue \nto live, even in boiling water. \n\nThis is why you must be sure to scrub the working \nend of each instrument carefully with soap and \nwater. Rinse, and then look carefully to see that \nit is clean and shiny. \n\n\n\nRemember that 'clean looking' is not necessarily 'clean'. Truly 'clean' \nmeans free of germs. Unless you sterilize, that instrument may still have \ngerms, the kind that cause infection in the next person that it touches. \n\n\n\nSterilizing means killing germs. The best way to sterilize is with heat. \nHigh heat kilts almost all harmful germs— especially those that cause \nhepatitis, tetanus, and mouth infections. Wet heat (steam) is always more \neffective than dry heat from an oven. \n\n\n\nHere is a simple rule to use in deciding \nwhen to sterilize: \n\nBoil any instrument that \nhas touched blood. \n\n\n\nThat means always sterilize with \nsteam all syringes, needles, and \ninstruments you use when scaling \nteeth (Chapter 8) or when taking \nout a tooth (Chapter 11). \n\n\n\n\nInstruments left In boiling water need 30 minutes to become sterile. A \npot with a cover to trap the steam can act faster. The inside becomes \nhotter and 20 minutes is enough. But remember that water can rust metal \ninstruments. To prevent rust: \n\nm Add 5 spoonfuls (20 ml.) of oil to every liter of water you boil. \n\n•• Then lay the hot instruments on a dry, clean (sterile, if possible) \ncloth, so the water can evaporate. \n\nNever put an instrument away while it is wet. \n\n\n\n84 \n\n\n\nSterilizing with steam under pressure is the fastest and surest method. \n\nIt kills harmful germs in 1 5 minutes. You need a strong pot with a tight \nfitting lid. But be sure to make a small hole in the lid so steam can escape \nwhen the pressure becomes too great. \n\nA special pot called a pressure cooker is perfect for this. It even has a \nsafety hole on it to release extra steam. \n\n\n\n1 . Put 2 cups of water and \n2 spoonfuls of oil \ninto the pot. \n\n\n\n\n2. Place the handles together. \nPut on high heat until a \nloud hissing noise begins. \n\n\n\n3. Put on lower heat. Begin \ntiming now. Leave the hissing \npot on the low flame for 1 5 \nminutes. \n\n\n\n\nDO NOT LET \nTHE COOKER \nBOIL DRY! \n\n\n\n4. Cool the pot under water, \nopen, and lay the instruments \non a clean towel to dry. \n\n\n\n\nThe next time you use the pot, \nyou can use the same water that \nwas left inside it. \n\n\n\n\n85 \n\n\n\nSterilizing with heat is not necessary for instruments that do not touch \nblood. For example, after you examine a person or place a temporary \nfilling, you can clean your instruments and then soak them in a solution \nof alcohol or bleach. \n\n\n\nAlcohol solution \n\n1 . Mix in a large container each week: \n\n7 parts alcohol (95%) \nand 3 parts clean water. \n\nKeep the container tightly covered \nto prevent evaporation. \n\n2. Keep a covered pan half filled with \nthis mixture. You will have to add \nsome more of the mixture from the \nlarge container (#1 ) to the pan each \nday. \n\n3. Leave your clean instruments in the \npan, completely covered with the \nliquid, for 30 minutes. \n\n\n\n\n\nBleach (sodium hypochlorite) solution \n\n\n\n\nH. CUP \n\n\n\nFind the cheapest brand name in your area for \nbleach. Examples areJavex, Clorox, Purex, and \nCidex. Make 1 liter of solution with a mixture of \n1/2 cup (100 ml) of bleach and 3 1/2 cups (900 ml) \nof clean water. \n\nBLEACH & WATER \n\n3 + Vi CUPS \n\n\n\nUnfortunately, bleach rusts \nmetal instruments. To reduce \nrust, add 1 large spoonful of \nbaking soda (sodium \nbicarbonate) to the solution, \nand leave your instruments in \nthe solution for only 30 minutes. \n\nWipe each instrument with \nalcohol to remove the film of \nbleach. Then store it dry \ninside a clean cloth or in \nanother covered pan. \n\n\n\n\n\n86 \n\n\n\nPART 1: PROBLEMS YOU WILL SEE MOST OFTEN \nCAVITIES AND LOST OR BROKEN FILLINGS \n\nA cavity can occur in any tooth. A cavity can also start around an old \nfilling, especially if it is dirty. The deeper a cavity gets inside the tooth \nwhere the nerve lives, the more the tooth hurts. \n\nSIGNS: \n\n• pain when drinking water or eating \nsomething sweet \n\n• a hole (or black spot) on the tooth, or \nbetween two teeth \n\n• pain if food gets caught inside the hole \n\n• no pain when you tap the tooth \n\n\n\nTREATMENT (when there is no abscess): \n\nT ry to remove any loose piece of filling with a probe. Then, following \nthe steps in Chapter 10, put in a temporary filling. \n\nNow: \n\n1 . Fill the hole with cement. If you have no cement, put some cotton \ninto the hole to keep food out. \n\n2. Look for cavities or broken fillings in the other teeth. Fill each one \nwith cement before it gets worse and starts to hurt. \n\nSoon (within a few months); \n\n3. Arrange for someone to replace the temporary filling with a \npermanent one. You will need a person who has experience using \na dental drill (see p. 145). \n\nA groove on the neck of a tooth is a more \ndifficult cavity to fill. For the temporary \ncement to hold properly, you need to shape \nthe groove with a drill. To help temporarily, \nyou can paint the groove with fluoride water (page 167). Do this once \neach week until the inside part of the groove is stronger and the tooth \nhurts less. Or, you can paint the inside of the groove with oil of cloves \n(eugenol) to reduce the pain. \n\nTo avoid making the problem worse, (1) do not use a hard toothbrush; \n(2) do not brush back and forth along the gums; and (3) do not chew \nbetel nut and do not hold it against the teeth. \n\n\n\n\n\n\n\n87 \n\n\n\nTOOTH ABSOESS \n\nA cavity that is not filled grows bigger and deeper until it touches the \nnerve. Germs travel inside the tooth's root and start an infection called \n\nan abscess. \n\nPus forms at the end of the root, inside the bone. As the pus increases, \nit causes great pressure. This is why an abscess causes severe pain. \n\nS/GNS: \n\n• pain all the time, even when trying \nto sleep \n\n• tooth often feels longer, and even a \nbit loose \n\n• tooth hurts when it is tapped \n\n• a sore on the gums near where the \nroot ends (gum bubble) \n\n• swelling of the gums around the \ntooth, or swelling of the face on the \nsame side as the bad tooth \n\nTREATMENT: \n\nIf there is no swelling, take out the tooth immediately (unless you are \nable to give root canal treatment). This allows the pus to escape and \nrelieves the pain. See Chapter 1 1 . \n\nIf there is swelling, treat the swelling first. Take out the tooth only \nafter the swelling goes down. This is necessary because an anesthetic (see \nChapter 9) will not work if there is swelling. If the anesthetic works, then \nit is safe to take out the tooth. \n\nTo treat the swelling, give an antibiotic. Penicillin by mouth is best. \n\nUse an injection only when the person is in immediate danger. For \nexample, inject penicillin when the person has a fever or if the swelling \nis pressing against the throat. But remember you can treat most serious \ninfections with simple penicillin by mouth. For the doses for serious \ninfections, look below the box on the next page. If you still think an \ninjection is necessary, look at the section on 'aqueous procaine penicillin' \non page 166. \n\nAdults and children over 25 kg. (60 pounds) of weight should take the \nsame amount of oral penicillin. Children under 25 kg. should take 1/2 as \nmuch. For most infections, penicillin by mouth is taken 13 times; a very \nlarge first dose and 12 smaller doses every 6 hours for 3 days. The person \nshould take all of the penicillin, even if the pain or swelling goes down. \nFor the correct doses, see the next page. \n\n\n\n\n\n88 \n\n\n\nTHE BEST CHOICE \n\n\nSECOND CHOICE \n(for those allergic to penicillin) \n\n\nPenicillin G or V: \n\n1 tablet = 250 mg. \n\nGive enough tablets for 3 days \n\n\nErythromycin: \n\n1 tablet (or capsule) = 250 mg. \n\nGive enough tablets for 3 days \n\n\nFirst Dose (take all at once) \n\n\nFirst Dose (take all at once) \n\n\nAdults 8 tablets \n\nand children over 25 kg. (2000 mg.) \n\nChildren under 25 kg. 4 tablets \n\n(1000 mg.) \n\n\nAdults 4 tablets \n\nand children over 25 kg. (1000 mg.) \n\nChildren under 25 kg. 2 tablets \n\n(500 mg.) \n\n\nThen every 6 hours for 3 days (12 doses) \n\n\nThen every 6 hours for 3 days (12 doses) \n\n\nAdults 2 tablets \n\nand children over 25 kg. (500 mg.) \n\nChildren under 25 kg. 1 tablet \n\n(250 mg.) \n\n\nAdults 2 tablets \n\nand children over 25 kg. (500 mg.) \n\nChildren under 25 kg. 1 tablet \n\n(250 mg.) \n\n\nIMPORTANT: to allow it to best fight \ninfection, take penicillin before eating. \n\n\nIMPORTANT: to avoid upset stomach, \ntake erythromycin with meals. \n\n\n\nFor serious infections, it may be necessary to take the antibiotics for a \nlonger time. Take the same first dose as above, then take 1/2 the first \ndose every 6 hours until the condition begins to improve. Then take the \nsecond, smaller dose every 6 hours until the end of five days, or seven \ndays if it is very serious.* Usually you can take out the tooth 1 or 2 days \nbefore the end of the antibiotic treatment, but the person must continue \nto take all of the tablets, even after you have taken out the tooth. \n\nIf the swelling is 'pointing', open it with a sharp sterile knife to release \nthe pus. Cover the wound with a sterile dressing to keep it clean. If you \nare not able to do that, explain how to reduce the swelling-with heat. \n\nAs often as possible until the swelling goes away: \n\n• soak a cloth in warm water and hold it against the face. \n\n• hold warm water inside the mouth near the swelling. It is not \nnecessary to add salt to the water. \n\nFinally, give the person medicine for pain. A two-day supply will be \nenough, because the penicillin and the heat will reduce the pressure and \nthat will reduce the pain. The best medicines for pain are aspirin/which \ncomes in 300 mg. tablets, and acetaminophen (paracetamol), which \ncomes in 500 mg. tablets. Aspirin is usually cheaper, but acetaminophen \ndoes not cause stomach pain and it is safer than aspirin for children. (To \navoid stomach pain, take aspirin with food, milk, or water.) \n\nTake aspirin or acetaminophen 4 times a day. Every 6 hours, adults \ncan take 2 tablets, children 8 to 12 years take 1 tablet, and children 3 to \n7 take 1/2 tablet. Children 1 to 2 years should only take acetaminophen, \n\n1/4 tablet 4 times a day. See page 165. \n\n*lf the infection does not heai, penicillin may not be the best antibiotic. Take some pus from the \ninfection and have it tested, to see which antibiotic is best. \n\n\n\n\n\n89 \n\n\n\nINFECTED SINUS \n\nA sinus is a hollow place inside the bone. There is a sinus under the \neyes, on each side of the nose. Because the sinus is very close to the roots \nof the top teeth, these teeth may hurt if the sinus becomes infected. \n\n\n\nS/GNS: \n\n* toothache in several top teeth. The \nteeth look healthy, but hurt when \nyou tap them. \n\n* a head cold, and plugged nose. She \ncan only breathe through her mouth. \n\n% hurts when you press against the bone \nunder her eyes. \n\n\n\n\nTREATMENT: \n\nDo not take out any teeth. They will feel better after you treat the sinus \ninfection. \n\n1. Give penicillin for 3 days (page 88). \n\n2. Explain to the person that she should: \n\n• drink lots of water. \n\n•i breathe steam from boiling water— \nto clear her nose. \n\n% hold a warm wet cloth against her \nface, as often as possible. \n\nnot try to blow her nose, or else her \nears will hurt. Wiping the nose is \nbetter. \n\n3. See the person again after 3 days, and \n\n% examine her teeth closely, tapping them to be sure they are strong \nand healthy. \n\n•» if she is not better, get help from a more experienced health worker. \n\n\n\n\n\n\n90 \n\nTOOTH INJURIES \n\n1. Broken tooth \n\nIt is possible to save a broken tooth. It depends on where the tooth \nis broken and whether its nerve is still covered. \n\nSIGNS: \n\n• pain when breathing air or drinking \nwater \n\n• blood from the gums around the tooth \n\n• tooth moves when you touch it \n\nTREATMENT: \n\nTake out the broken tooth if: \n\n• its nerve is not covered. If no one can give special root canal \ntreatment, the tooth must come out. Germs from the spit have \nalready gone inside the tooth and started a small infection. \n\n• its root is broken. To see if it is broken, push gently against the \ntooth as you feel the bone around its roots. The tooth's root \nprobably is broken if the tooth moves but the bone does not. The \nroot probably is not broken if both the tooth and bone move. \nHowever, the bone around the roots may be broken (page 103). \n\nYou can save a broken tooth if the nerve is still covered and the root \nis not broken. To do this, use a file on the sharp edges around the break. \nThis makes them smooth so they do not cut the tongue. Later, an \nexperienced dental worker who has the equipment can cover the broken \npart with a cap or a filling. Until this is possible, tell the person how to \nprotect the tooth: \n\n• Give the tooth a rest. Use other teeth to eat. \n\n• Do not drink things that are very hot or cold, and do not eat spicy \nfood. \n\n• Watch the tooth. See if it changes color (gets darker). Also watch \nthe gums near the root. See if a sore (gum bubble) develops. \n\nA dark tooth and gum bubble are signs that the tooth is dying. Take it \nout, unless you can give special nerve treatment. \n\n\n\n\n\n91 \n\n\n\n2. Tooth knocked out \n\nWhen a tooth is knocked out of the mouth, you should ask two \nquestions: (1 .) Was it a baby tooth? and (2.) How long ago did it happen? \n\n\n\nBaby tooth. There is no reason to try to put a baby tooth back into \nthe socket. Tell the child to bite on some cotton to stop the bleeding. \nThen wait for the permanent tooth to replace it. Warn the mother that \nthe permanent tooth may take more time than usual to grow into the \nmouth. \n\nSimilarly, there is no need for \ntreatment if the baby tooth is pushed \nup under the gum. \n\nThe tooth may grow back into the \nright place later, or it may turn dark \nand die. If you see a darkened tooth or \na gum bubble (p. (72), take out the \nbaby tooth before it hurts the permanent \ntooth that is growing under it. \n\nPermanent tooth. A permanent tooth is worth saving. How long ago \nwas it knocked out? If it was less than 12 hours ago, you can put a \npermanent tooth back into the socket. The sooner you do this the better, \nso do not wait. If you replace the tooth in the first hour, it has a much \nbetter chance of joining with the gum and bone. In order to heal and to \njoin the bone, the tooth must be held firmly. \n\n\n\n\n1. Wash the tooth gently \nwith clean water. There \nshould not be any bits of \ndirt on the root of the \ntooth. \n\nKeep the tooth damp \nwith wet cotton gauze. \n\n\n\nDo not scrape away any \nskin from the root or from \nthe inside of the socket. \n\n\n\n\n\n2. Gently push the tooth up into the \nsocket. As you push it up, use a slight \nturning movement back and forth. \n\nThe biting edge of the loose tooth \nshould be at the same level as the \nteeth beside it. \n\nHold it in place with your fingers for \nabout 5 minutes. \n\n\n\n3. Soften some beeswax and form it \ninto 2 thin rolls. Placed roll near the \ngums on the front side of five teeth: \nthe loose tooth and the two teeth on \neach side of it. Press the wax firmly, \nbut carefully, against these teeth. \n\nDo the same with the second roil of \nwax on the back side of the same \nteeth, again near the gums. \n\nIt is good if the wax on the back side \nis touching the wax on the front \nside. This helps the wax hold the \nteeth more firmly. To do this, you \ncan push the wax between the teeth \nwith the end of your cotton tweezers. \n\n\n\n\n\nKeep the wax in its position for at \nleast 3 weeks. \n\n\n\nTell the person with the injured tooth to return to see you several \ntimes. The tooth may die several months or even several years later (see \npage 45). If that happens, you must take out the tooth, unless you can \ndo root canal treatment. \n\n\n\nIf it is possible, take an X-ray of the tooth 6 months later and then \nagain each year. Look at the X-ray picture of the root to be sure an \ninfection is not eating it away. To do this, compare the root with the \nroots of the teeth beside it. \n\n\n\n\n93 \n\n\n\nLOOSE TOOTH \n\nA tooth may be loose for one of several reasons. Decide the reason \nbefore giving the treatment. \n\n\n\nIF THE TOOTH IS LOOSE BECAUSE \n\n\nTHE BEST TREATMENT: \n\n\nt \n\na new permanent tooth is \ngrowing under it. \n\n\nf \n\n1. tell the mother and child what is \nhappening. \n\n2. pull out the loose baby tooth, if it is \nhurting the child. \n\n\ngum disease or an old abscess \nhas eaten the bone around its \nroots. \n\n\n1. take out the tooth, especially if it \nalso hurts. \n\n2. explain to the person what to do to \nprevent this problem in other teeth. \n(See Chapter 5). \n\n\nits root has been broken. \n\n\ntake out both parts of the tooth. If you \nhave trouble taking out the broken root, \nleave it and try again a week later. \n\n\nthe bone around its root is \ncracked, (The bone moves when \nyou push against the tooth.) \n\n\nDo not take out the tooth. If you do, \n\nthe bone will come out with it. Instead, \nhold the tooth with wires (page 104). \n\n\n\nA tooth may also be loose because \nanother tooth is biting too \nhard against it. \n\nSIGNS: \n\n% you can feel the tooth move \nwhen the upper and lower teeth \nmeet. \n\n• that tooth hurts. \n\nTREATMENT: \n\n\n\n\nYou need to remove a bit of each of the teeth that are biting too hard. \nUse either a dental worker's drill, a small file, or a hard stone. \n\n\n\n1. Smooth the inside edge of the upper tooth. \n\n2. Smooth the outside edge of the lower tooth. \n\n\n\n\n\n94 \n\n\n\nNEW TOOTH GROWING IN \n\n\n\nA new tooth cuts through the gums when it grows into the mouth. \nGerms can easily go under the gums in that place and cause an infection. \nWhen the opposite tooth bites against the sore gum it can make an \ninfection worse. \n\n\n\nSIGNS: \n\n• toothache at the back of the jaw \n\n• mouth cannot open properly \n\n• a bad taste coming from the back of \nthe mouth \n\n• sore throat \n\n• skin over the new tooth is sore and \nhurts when you touch it \n\n• the age of the person is the right age \nfor growing a new molar tooth \n(page 64). \n\n\n\n\nInfection in the gums and \npressure from the new tooth are \npainful. Notice the ‘flap’ \nof skin over the new tooth. \n\n\n\nTREATMENT: \n\nDo not take out a new tooth while there is still infection and pain. Wait \nfor the infection to finish. Then decide if there is room for the tooth to \ngrow in. A dental X-ray can help you make that decision. New molar \nteeth are often difficult to take out. Ask an experienced dental worker to \ntake out the tooth, if it must be done. \n\nWhat you can do \n\nFirst, treat the infection. Then wait for the new tooth to grow more \ninto the mouth. Tell the person what is happening. Tell him what he can \ndo to keep the gums healthy while the tooth grows in: \n\n• Rinse the area with warm salt water (page 7). Make 4 cups each day \nuntil the mouth opens normally again. Then make 1 cup each day \nto prevent the problem from returning. Keep rinsing this way until \nthe tooth grows all the way in. \n\n• Hold a warm wet cloth against the jaw as often as possible each day. \n\n• Take aspirin for pain (page 88). \n\nGive penicillin (page 87) if there is fever, a swelling, or if he is only able \nto open his mouth a little. \n\n\n\n\n95 \n\n\n\nTEETHING \n\nWhen babies and small children first get their teeth, it is called teething. \nThis can make the child unhappy, because his gums are sore. \n\nTeething does not cause fever, head \ncolds, or cough. \n\nBut a child can have any of these \nproblems at the same time as he gets a \nnew tooth. \n\n\n\nTREATMENT: \n\nIf the child has another sickness, do not blame it on teething. Look for \nanother cause and treat it separately. Also, do not cut the gum over the \nnew tooth. Let the tooth grow through the gum by itself. \n\n1. Give acetaminophen or aspirin for pain and fever (page 88). \n\n2. Give the child something hard to bite against. This will help the tooth \n\nto grow through the gums faster. For example, let him chew on a dry \n\nhard biscuit. \n\nGUM DISEASE STARTING \n\nInfection can start in the gums whenever the teeth near them are not \nclean. For example, there may be swelling (called an epulis) between \nonly 2 teeth or between many teeth. In addition, gums that are weak \nfrom poor nutrition are not able to resist the infection. This is why a \npregnant woman must take special care to eat well and clean her teeth \ncarefully. \n\nSIGNS: \n\n• Gums are red instead of pink. \n\n• Gums are loose instead of \ntight against the tooth. \n\n• Between the teeth, gums are \nround instead of pointed. \n\n• Gums bleed when you press \nagainst them, or when you \nscrape away food from under \nthem. \n\n• The person has bad breath \nand a bad taste inside the mouth \n\n\n\n\n\n\n96 \n\n\n\nTREATMENT: \n\nExplain to the person the cause of her gum problem and what she can do \n\nto help herself. \n\n1. Show her how to clean her teeth better near the gums (page 67). \n\n2. Tell her to rinse her mouth with warm salt water (page 7). Make 4 \ncups each day until the bleeding stops. Then make 1 cup each day to \nkeep the gums strong and tough. \n\n3. Tell her to eat fresh fruits and vegetables. Guavas, oranges, pineapples, \npapayas, tomatoes, peas, and green leaves give strength to gums. \n\n4. Gently reach under the gums and remove tartar (or loose piece of \nfishbone) that is caught there (see Chapter 8). \n\n\n\nMORE SERIOUS GUM DISEASE \n\nVincent's Infection of the gums, also called trench mouth, affects both \nadults and children. In its worst form, it can eat a hole through the cheek \nof a weak child (page 115). \n\nA person with Vincent's Infection may not want to eat because his \nteeth hurt when he chews food. That can make a child's malnutrition \nworse. \n\nYou must prevent this problem from starting, especially in a child who \nis weak from sickness. Teach mothers to clean their children's teeth and \nto get their children to rinse their mouths with warm salt water. \n\n\n\nSIGNS: \n\n% gums between the teeth are dying \nand turning gray. \n\n% pus and old blood collect \naround the teeth. \n\n•* burning pain from the gums. \n\n• bleeding from the gums. \n\n• the mouth smells bad. \n\n\n\n\nTREATMENT: \n\nYou will need to see the person over a two-week period. Start some \ntreatment NOW: \n\n1 . If the person is already sick, give penicillin for 3 days (page 88). \n\n\n\n97 \n\n\n\n2. Clean away the pus, old food, and big pieces of tartar. Then: \n\n• Tell the person to rinse his mouth with warm water. \n\n• Wipe his gums with cotton soaked in a 5% solution of hydrogen \nperoxide. Rinse with warm water. For a child, use a weaker solution. \nMix 1 part hydrogen peroxide with 5 parts water and wipe the \nchild's gums with it. \n\n• Scrape away the bigger pieces of tartar. Do not try to remove ail of \nit. You can do that later. Put topical anesthetic on the gums if you \nhave some (first dry the area with cotton so the topical anesthetic \nwill stay longer). Rinse away any loose bits of tartar with warm water. \n\n3. Give Vitamin C (ascorbic acid), 2 tablets a day for 7 days. \n\n(1 tablet = 500 mg.) \n\n4. Teach the person how to care for the gums at home: \n\n• Rinse at home for 3 days with a weak solution of hydrogen peroxide \n(page 8). Try to hold the solution in the mouth for several minutes. \nThe longer the solution touches the gums, the better it is for the \ngums. Rinse once every hour. After 3 days, change to salt water, \n\n4 cups a day. If you have no hydrogen peroxide, rinse with salt \nwater from the beginning. \n\n\n\nFor a young child who is not able to rinse, Mother or \nFather can wipe his gums with the weak solution of \nhydrogen peroxide 4 times a day. \n\nShow parents how to do this. Give them some cotton \ngauze and hydrogen peroxide to take home. \n\n\n\n• Clean the teeth with a soft brush. Parents can clean children's teeth. \nShow them how (page 16), and ask them to do it even if the gums \nbleed. \n\n• Cook food that is soft (like pounded yam) and not spicy (no pepper). \nEat fresh fruits and vegetables that give strength to the gums (page \n96). \n\n• Stop smoking and stop chewing betel nut. \n\nOne week later, scrape away the rest of the tartar from the teeth. Then \nuse the person's own brush and show him how to do a better job of \ncleaning his teeth. \n\n\n\n\n\nFEVER BLISTERS \n\n\n\nHerpes virus causes fever blisters. Herpes virus is a kind of germ. Fever \nblisters are sores that can form either inside the mouth on the gums, or \noutside on the lips. \n\nWhen the sores are inside the mouth, it is a serious problem. It usually \naffects children between 1 and 5 years old. A child with fever blisters in \nhis mouth can become very sick. He will not be able to eat properly. If \nhe does not drink enough fluids, he can become dehydrated (lose his body \nwater). This is dangerous! \n\nSIGNS: \n\n• sore throat \n\n• fever \n\n• crying, stops sucking 2-3 \ndays before sores appear \n\n• spit spills from the mouth \nbecause it hurts to swallow \n\n• painful swelling under the jaw. \n\n• bright red blisters on the gums, \nbut not between the teeth. \n\nBlisters also may be on the roof \nof the mouth. \n\nTREATMENT: \n\nMedicine cannot kill the Herpes virus., The sores will go away by them- \nselves in about 10 days. The treatment is to help the person feel more \ncomfortable and to be sure he gets enough to eat and drink. \n\n1 . Give aspirin or acetaminophen for fever (page 88). \n\n2. Wipe milk or yogurt over the sores to protect them before eating. Wash \nyour hands before touching the inside of someone's mouth! (See page \n82.) Then give food that is soft and not spicy. If he cannot eat, prepare \na special milk-oil drink for him, as on page 105. \n\n3. Give lots of fluids to drink. \n\nSores on the lips usually occur after the age \nof 5. They often appear when the person is \nweak and sick (for example, with diarrhea or \npneumonia.) Usually there is no fever. The \nblisters soon break open and release water. \n\nWhen they dry, a crust forms. The blisters often \nreturn. \n\nThese sores go away in about 1 week. To prevent them from becoming \ninfected, paint the sores with gentian violet, tincture of benzoin, or \npetroleum jelly. If you hold ice against the sores for several minutes each \nday, it may help them heal faster. \n\n\n\n\n\n\n99 \n\n\n\nTHRUSH \n\nThrush is a kind of infection. It often appears when a person is weak \nand poorly nourished, or sick and taking nnedicine like tetracycline or \nampicillin. In a baby, thrush usually appears on the tongue or top of the \nmouth. It can stop the baby from sucking. In an adult, thrush often occurs \nunder a denture. \n\nSIGNS: \n\n• White patches on the tongue, \ncheek, or top of the mouth. \n\nWipe the white area: \n\nIf there is no bleeding it \n\nis old milk. \n\nIf there is bleeding, it \n\nis thrush. \n\n• the child may not want to suck or eat \n\nTREATMENT: \n\nThere is usually something else present which is helping thrush to grow. \nTry to find what it is and deal with it. For example, treat the malnutrition, \nchange or stop the antibiotic medicine, or leave the denture out of the \nmouth for a while. Then: \n\n1 . Put some nystatin creme on top of the white patch with a bit of cotton. \n\nadults: put some on 4 times a day \nchildren 5-12 years: put some on 3 times a day \nchildren up to 5 years old: put some on 2 times a day \n\nShow the mother how she can do this in her child's mouth at home. If \nyou have no nystatin creme, paint gentian violet on the white area. The \nmother should paint the child's mouth 2 times a day. \n\nDo not use penicillin or any other antibiotic unless you need to treat \nsomething different. Thrush can get worse when a person uses an \nantibiotic for a long time. \n\n2. Continue breast feeding. For older persons, make their food soft and \neasy to chew. \n\nIMPORTANT: Sometimes white lines appear on the inside of an adult's \ncheek or on the roof of the mouth. If these lines become sore, they can \nchange into a cancer (page 1 19). To prevent this cancer, ask the person to \n\nstop smoking (especially pipes), stop chewing betel nut, and get dentures \nadjusted if they do not fit properly. \n\n\n\n\n\n100 \n\n\n\nCANKER SORES \n\nA virus can cause canker sores, as with fever blisters. Unlike fever \nblisters, canker sores usually affect adults rather than children. \n\nOne or more sores can appear at any time. These sores hurt, especially \nwhen pieces of food touch them. \n\nSIGNS: \n\n• A sore can appear on the tongue, \nroof of the mouth, or below the \ngums on the smooth skin. \n\n• The sore is white or yellow with the \nskin around it bright red. \n\n• The person may have had a similar \nkind of sore before. It tends to \ncome back. \n\nNote: a sharp edge of a denture rubbing against the gums can make \na similar kind of sore. \n\nTREATMENT: \n\nA canker sore goes away by itself in about 10 days. Medicine does not \nmake that happen any faster. (However, smoothing a denture does help.) \nThe treatment is simple. Tell the person how to feel more comfortable \nwhile waiting for the 10 days to pass: \n\nEat foods that are soft and not likely to hurt the sore. Do not eat food \nwith a lot of pepper. Drink lots of water. Chew food on the other side of \nthe mouth, away from the sore. \n\nA denture which does not \nfit should be remade. \n\nIn the meantime, leave \nthe denture out of the \nmouth for 2-3 days. \n\nAsk the person to rinse \nwith warm salt water, \n\n4 cups each day until \nthe sore is better. \n\nIf the sore continues after 10 days, it may be infected. Give penicillin \n(page 87). \n\nA sore that does not heal after antibiotic treatment may be cancer. \n\nSee a doctor immediately. \n\n\n\n\n\n\n101 \n\n\n\nSORES AT THE CORNERS OF THE MOUTH \n\nTeeth support the lips. When they come together for chewing, the teeth \nstop the person's chin from moving any closer to the nose. \n\nA person without many teeth looks old. A person with a poor fitting \ndenture also looks old. \n\nThe distance from his chin to \nhis nose is shorter than \nnormal. \n\nHe must close his jaw further \nto eat. That causes lines to \nform at the corners of his \nmouth. \n\nPoor health can make lines at \nthe corners of the mouth crack \nand become sore. \n\nA person with missing teeth needs dentures. Dentures will help him \nchew more food and make him look younger. They support his lips and \nopen his mouth more. \n\nNote: Making dentures is not easy. We hope to write a book \nin the future that will tell more about dentures. \n\nA child who has had a fever or measles often has dry lips. The corners \nof her mouth can crack and become sore. \n\nCracks and sores appearing \nat the corners of a child’s \nmouth are signs of dehydration \nand malnutrition. \n\n\n\nThe child needs to eat the kind of foods that give strength, energy, and \nprotection. Feed her beans, milk, eggs, fish, oils, fruits, and green leafy \nvegetables (see page 65). \n\nTREATMENT (when sores occur): \n\n1 . Wash the sores with soap and hot water. \n\n2. Mix 1 part sulfur with 10 parts of petroleum jelly (Vaseline). \n\n3. Smear some on the sores 3-4 times a day. \n\n\n\n\n\n\n\n102 \n\n\n\nPART 2: SOME SPECIAL PROBLEMS \n\nYou will find some problems that are too serious for you to treat. If \nyou can, send the sick person to a more experienced dental worker as soon \nas possible. \n\nSometimes, however, it is better to start some of the treatment yourself. \nEarly treatment can prevent some problems from becoming more serious. \nAlso, if you know what to do when someone returns from the hospital, \nyou can help that person to get well faster. \n\nSometimes, you will find it impossible to get help. Therefore, we will \ndiscuss each of these more serious problems in detail, so you can give as \nmuch help as necessary. \n\nBROKEN BONE \n\nThree main bones form the face and lower jaw. \n\n\n\n\nA bone can break completely, or part of it can crack. In either case, the \nteeth are usually pushed out of position. Look for this as a sign of a \nbroken bone. \n\nS/GNS of a broken bone: \n\n\n\n• The person has had an injury. \n\n• When teeth are closed, some upper \nteeth do not meet lower teeth. \n\n• The person cannot open or close \nthe mouth properly. \n\n• There is bleeding from between \n2 teeth. \n\n• There is swelling or a bruise on \nthe face or jaw. \n\n• There is bleeding into the eye. \n\n\n\n\n\n103 \n\n\n\nSIGNS of a cracked bone around \n\nthe tooth's roots: 0 and the other \n\n• When you move one tooth, the \ntooth beside it also moves. \n\n• When you move the loose tooth, \nthe bone moves with them. \n\n• Blood is coming from under \n\nthe gums. @ PUSH GEntlY their roots \n\nAGAINST one is cracked. \n\nTREATMENT: tooth \n\nWhen a bone is broken or cracked, the treatment is to hold the broken \nparts together so that the parts can rejoin. The usual way to do this is to \nput wires around the teeth. An experienced dental worker should do this. \nThere are two things you can do. First, provide emergency care. Later, \nshow the person how to eat and how to keep his mouth clean. \n\nEmergency care (pages 103-104); \n\n1 . Be sure the person can breathe, \n\n2. Stop the bleeding. \n\n3. Put a bandage on the person's head. \n\n4. Give penicillin to stop infection. \n\n5. Give aspirin for pain. \n\n\n\n1. Be sure the person can breathe. \n\n\n\n\nTOOTH ALSO MOVES \n\n\n\nBECAUSE THE \n\nbone around \n\n\n\n\nLie him on his side \nso that his tongue and \njaw fall forward. \n\n\n\nLater, carry him to the hospital in that position. If he goes in a car, be \nsure he sits with his head forward. His jaw and tongue will be forward and \nhe will breathe more easily. \n\nLook inside the mouth to see if any tooth is broken and very loose. A \nbroken piece of tooth can fall out and block the person's airway, so take \nout the broken part now. You can leave in the root, but if you do, tell \nthe dental workers at the hospital (p. 175). They will remove the root \nwhen they put on the final wires. \n\n2. Stop the bleeding. \n\nWipe away the dried blood from his face and from inside his mouth. \nLook for the place that is bleeding. Sew any deep cuts on his face (see \nWhere There Is No Doctor, p. 86). If you gently press cotton gauze against \nthe bleeding gums, it will usually control the bleeding. \n\n\n\n\n\n104 \n\n\n\nBleeding inside the mouth, from between the broken parts of the bone, \nis more difficult to stop. You must puil the two sides together and hold \nthem in that position. To do this, you need wire that is thin, strong, and \nbends easily. 'Ligature wire' (0.20 gauge) is best. \n\n\n\nPlace a piece of wire around two teeth, one on \neach side of the break. Choose the strongest \ntooth on each side— the ones with the longest \nor the most roots. \n\nTighten the wire around the two strong teeth \nwith pliers or a hemostat. \n\n\n\nAsk the person to close his teeth. Lift up the broken part of the jaw \nand hold it so the lower teeth meet the upper teeth properly. This is the \nnormal way the jawbone holds the teeth. \n\n\n\nNow join the wires. Twist and tighten them \ntogether. This may be painful. You can inject \nlocal anesthetic-see Chapter 8. You must twist \nthe wire tight enough to hold the broken parts \ntogether. \n\n\n\nBend the end of the twisted wire toward the teeth. Now it cannot poke \nthe person's lips or cheek. \n\n3. Put on a head bandage. \n\nGently close the person's jaw so that his teeth come together. Support \nit in this position with a head-and-chin bandage. \n\n\n\n\n\n\nTie the bandage to support the jaw, not to pull it. Do not make it \ntoo tight. It is all right if his mouth stays partly open with the \nteeth slightly apart. \n\nBe sure not to let the bandage choke the person. \n\n\n\n4. Give penicillin by injection (page 166) for 5 days to stop infection \ninside the bone. \n\n5. Give something for pain. Aspirin (p. 88) may be enough. If there is a \nlot of pain and the person cannot sleep, give codeine. The dose for an \nadult is 30 mg. \n\n\n\n\n105 \n\n\n\nSend the person to the hospital as soon as possible. The person must \nhave wires placed on his teeth within a week of the accident. The wires \nmust remain there for 4 to 6 weeks. Every week, the person must return \nto the hospital to have the wires tightened. During this time he cannot \nopen his mouth to chew food or brush his teeth. \n\nCaring for a person who cannot eat properly (see below): \n\n1 . Give him liquids containing food for both strength and energy. \n\n2. Show him how to keep his teeth clean and his gums tough. \n\n1. Give liquid foods for strength and energy. \n\nPrepare food in two ways: (1 ) First, a milk-oil drink to build strength; \nand then (2) a special soup to keep him strong and give him energy. \n\nTo build strength: Milk-oil drink \n\nMix for him each day at your clinic: \n\n• 9 cups of water \n\n• 3 cups of milk powder \n\n• 1 50 ml of peanut oil or coconut milk \n% 1/2 cup of honey or 1 cup of sugar \n\nLeave some near his bed, and keep the rest in a cool place. \n\n\n\nTo keep strength and give energy: Special vegetable soup \n\n\n\nCut into small pieces and cook together in a pot of water: \n\n• 1/2 tin of fish, or a handful of dried fish \n\n• 4 small spoonfuls of peanut oil or palm oil \n• 6 sweet potatoes or small yams \n\n\n\n1 large handful of green leaves \n1 small spoonful of salt \n\n\n\n\n\n\nPour the soup into an empty tin with small holes made in the bottom. \nUse the back of a spoon to press as much of the cooked food as you can \nthrough the holes. The person can suck the soup between the teeth to \nthe throat and then swallow it. Clean the tin and set it in boiling water, \nso you can use it again the next day. \n\n\n\n2. Keep the teeth clean and the gums tough. \n\n\n\nThe person must learn to clean teeth and gums or the gums can quickly \nbecome infected and the mouth will feel sore. So: \n\n•• Scrub both the wires and the teeth with a soft brush after drinking \nsoup. \n\nRinse with warm salt water (page 7), 2 cups every day. \n\n\n\n\n\n106 \n\n\n\nIf the bone around the roots of the teeth is cracked, those teeth will \nbe loose. Do not take the teeth out until the bone is healed. Otherwise, \nbone will come out with the teeth and there will be a big hole in the jaw. \nInstead, support the teeth, in order to hold both sides of the bone steady. \n\n\n\n1 . With your thumb and finger, gently move the \nloose teeth and bone back into normal \nposition. \n\n2. Cut a hypodermic needle and use it as a \nsplint. Make it long enough to fit around two \nstrong teeth on each side of the loose teeth. \n\nCurve the needle so it fits the curve of the \nteeth. To make the sharp ends smooth, use a \nfile or rub the ends against a stone. \n\n3. Tie each tooth to the needle. Use short pieces \nof 0.20 gauge ligature wire (page 104). \n\nPut one end of the wire under the needle. \n\nBring it around the back of one tooth and \nout to the front again over the needle. \n\nUse the end of a small instrument to hold USE A STRONC \ndown the wire at the back of the teeth. Then HCM06TAT OR \ntwist the ends together. Tighten the wire NCEDtE HOLDER \naround each one of the 6 teeth. \n\n4. Cut the ends of the ligature wire. Turn them \ntoward the teeth, so they will not cut the lip. \n\n5. Tighten the wires the next day, and then once each week. But be \ncareful. Only 1/2 a turn usually is needed. More, and the wire will \nbreak. Always twist in the direction a clock moves. With this habit, you \nwill remember which way tightens the wire and which way loosens it. \n\n6. Explain to the person that it takes 4 weeks for the bone to heal. The \nwires must remain on the teeth for this time. T o help the teeth to \nheal, ask the person to: \n\n• give these teeth a rest. Use other teeth for chewing. \n\n• clean both the teeth and the wires with a soft brush. \n\n• rinse with warm salt water, 2 cups every day (p. 8). \n\n• return to have the wires tightened every week. \n\n7. After 4 weeks, cut and remove the wires. Ask the person to watch \nthose teeth. A dark tooth and gum bubble are signs that the tooth is \ndying. Take it out, unless you can give special nerve treatment. \n\n\n\n\n\nBEND the needle \nAROUND THE TOOTH \nSO \\r DOES NOT \n\n\n\n\n\n\n107 \n\n\n\nDISLOCATED JAW \n\nIf a person opens her mouth wide and then is unable to close it, we say \nher jaw is dislocated. It is stuck in the open position. This problem often \nhappens to a person who does not have several of her back teeth. When \nshe opens wide to yawn or shout, the part of her jaw that joins her head \nmoves too far forward inside the joint. It is then unable to return to its \nnormal position. \n\n• She is unable to close her teeth \ntogether. \n\n• She cannot close her lips easily. \n\n• Her lower jaw looks long and \npointed. \n\n• It hurts when you press on the \njoint in front of her ear. \n\n• She cannot speak clearly. \n\n\n\nThe treatment is to try to move the lower jaw back where it belongs. \nThen hold it in that position until the muscles can relax. \n\n1 . Find a way to support the person's head. For example, have the \n■ person sit on the floor with her head against a wall. \n\n2. Kneel in front of her. Put your fingers under her jaw, outside the \nmouth. Put your thumbs beside her last molar tooth on each side. \nDo not put your thumbs on the molars. The person may bite them! \n\nPress down hard with the ends of \nyour thumbs. Force the jaw to move \nquickly down and back into position. \n\nBe sure to press down before you \npress back. \n\nIf the jaw will not move, perhaps the \nmuscles are too tight. A doctor or \ndentist can put the person to sleep, \nwhich will relax the muscles. \n\n3. Support the jaw with a head-and- \nchin bandage for 3 to 4 days \n(page 104). \n\n4. Give aspirin for pain (page 88). \n\n5. Explain the problem to the person and tell her how to care for her \njaw: ( 1 ) eat mostly soft foods for 2 weeks; (2) hold a warm wet \ncloth against the jaw; (3) remember not to open the mouth wide \nanymore. If possible, replace the missing back teeth with dentures \n(page 101 ). \n\n\n\n\n\nS/GNS: \n\n\n\n\nNORMAL DISLOCATED \n\n\n\nTREATMENT: \n\n\n\n\n108 \n\n\n\nPAIN IN THE JOINT \n\nA joint is the place where one bone joins another. The jawbone has \ntwo joints, for it joins the head in front of each ear. \n\nThe mouth opens and closes because: \n\n• muscles pull the jawbone; and \n\n• the jawbone slides against the head \nbone, inside the joints. \n\nPain in these joints may be because: \n\n(1 ) The muscles are tight because the \nthe person is tense or nervous. \n\n(2) The jawbone is fractured in the area \nof the joint. \n\n(3) The teeth do not fit together \nproperly. \n\n\n\n\nTREATMENT: \n\nBefore you' treat, decide what is causing the pain. We will discuss the \nthree causes mentioned above. \n\n1. Tension. \n\nTalk with the person and help, if you can, to find a solution to her \npersonal problems. This can do much to help her and her muscles relax. \n\nIn addition, explain how to care for the sore joint: \n\n(a) Eat only soft foods until it no longer hurts to chew. \n\n(b) Hold a hot, wet cloth against the jaw, to help relax the muscle. Do \nthis as often as possible, but be careful not to burn the skin. \n\n(c) Take aspirin (page 88) to reduce the pain. \n\n2. Fracture. \n\nIf an X-ray shows a fracture, the person needs expert help. A dentist \ncan wire the teeth in a way that will allow the bone to heal. \n\n3. Teeth do not fit together properly. \n\nImagine a line that passes between the two middle upper teeth and the \ntwo middle lower teeth in the person's closed mouth (see the next page). \nWhen the person opens the mouth, this line becomes longer, but it is still \na straight line. If it is not, this condition can, after a long time, cause pain \nin the joint. \n\n\n\n\nThese teeth are normal. The line formed \nwhen the mouth opens. \n\n\n\nWhen you see teeth that do \nnot fit properly: \n\n(a) Warn the person not to open \nhis mouth wide. Suggest, \nfor example, that he take \nhis food in small bites. \n\n(b) Tell the person what can \nbe done to help. Often \n\na dentist can grind the teeth \nin a special way and this \ncan end the pain. \n\n\n\nbetween the two middle teeth does not shift \n\n\n\n\nBecause the line shifts, this means \nthe jaw is also shifting. This \nshift can cause pain in the joint. \n\n\n\nSWOLLEN GUMS AND EPILEPSY \n\n\n\n\nMany persons who suffer from epilepsy \n(see Where There Is No Doctor, page \n78) have a problem with swollen gums. \n\nIn severe cases, the gums are so \nswollen that they cover the teeth. This \nproblem is caused not by epilepsy but by \ndiphenylhydantoin {Dilantin), a drug \nused to control epilepsy. \n\n\n\nWhen you see swollen gums, find out what medicines the person \nis taking. If possible, change to a different drug. If the person must \ncontinue using diphenylhydantoin, explain how to prevent this swelling \nof the gums. Show the person this book, especially pages 67 to 70. \nPersons who take this drug may be able to prevent the swelling by \nbrushing the teeth carefully after each meal, and taking special \ncare to clean between the teeth, (page 69). \n\n\n\n\n110 \n\n\n\nBLOOD IN THE MOUTH \n\n\n\nUse wet cotton gauze to wipe away the old blood fronn inside the \nmouth. Then you can see where it is coming from. Treat the cause of the \nbleeding. \n\n\n\n\n\n\n\n\n\nSEE \n\n\nIF YOU SEE: \n\n\n\n\nTO STOP THE BLEEDING: \n\n\nPAGE \n\n\nt \n\n\n\n\nt \n\n\nT \n\n\na large red clot growing \n\n\n1. \n\n\nRemove the clot with cotton \n\n\n112 \n\n\nout of a socket where you \n\n\n\n\ntweezers. \n\n\n\n\nhave taken out a tooth \n\n\n2. \n\n\nAsk the person to bite on a \npiece of cotton. \n\n\n\n\nsore and bleeding gums \n\n\n1. \n\n\nRinse with a mixture of \n\n\n8 \n\n\nand the mouth smells bad \n\n\n\n\nhydrogen peroxide and water. \n\n\n\n\n(Vincent's infection) \n\n\n2. \n\n\nRemove as much tartar as you can. \n\n\n121 \n\n\na red, bleeding growth inside \n\n\n\n\nTake out the tooth; it has an \n\n\n87 \n\n\nthe cavity in a tooth \n\n\n\n\nabscess. \n\n\n\n\na loose tooth with bleeding \n\n\n\n\nHold the tooth with wires, \n\n\n106 \n\n\ngums around it \n\n\n\n\nor if the root is broken, \ntake out the tooth. \n\n\n151 \n\n\ntorn gums with broken bone \n\n\n1. \n\n\nWith wire, hold the broken \n\n\n104 \n\n\nand bleeding \n\n\n2. \n\n\nparts of the bone together. \nSend the person to an \nexperienced dental worker. \n\n\n\n\n\nPROBLEMS AFTER YOU TAKE OUT A TOOTH \n\n\n\nProblems like swelling, severe pain, and bleeding can occur after you \ntake out a tooth. Tetanus (p. 1 12), a more serious problem, can also occur, \nespecially if your instruments were not clean. \n\n\n\nSwelling of the face \n\nYou can expect some swelling after you \ntake out a tooth. But if the swelling \ncontinues to grow, and it is painful, this \nis not normal. Probably an infection has \nstarted. The treatment is the same as for \na tooth abscess: penicillin for 3 days to \nfight infection, heat to reduce the swelling, \nand aspirin for pain. See page 88 for the \nproper doses. \n\n\n\n\n\n\nIll \n\n\n\nPain from the Socket \n\nThere is always some pain after a tooth is taken out. Aspirin is usually \nenough to help. \n\nHowever, sometimes a severe kind of pain starts inside the tooth's \n'socket' (the wound) 2 to 3 days after you take out the tooth. This \nproblem is called dry socket and it needs special care. \n\n\n\nTREATMENT: \n\n\n\n1 . Place a dressing inside the socket. Change it each day until the pain \nstops. \n\n\n\n\nFirst, clean out the socket. \n\nSquirt warm water inside the socket with \na clean syringe. After the person spits out \nthe water, squirt water inside once more. \nUse a blunt needle so that it does not hurt \nthe gums or bone if it touches them. \n\n\n\n\nSecond, prepare the dressing. \n\nSoak 1-2 small pieces of cotton \nin eugenol (oil of cloves). \nSqueeze each piece so that it \nis damp but not wet. \n\nNote: There may be a local \nmedicine in your area that \nrelieves pain. Use it instead of \neugenol. \n\n\n\n\nThird, place the dressing gently \ninside the socket. \n\nPlace one piece of dressing into \neach root space. Push it down into \nthe root space gently. \n\nCover the socket with plain cotton \ngauze, and send the person home \nbiting against it. He can remove \nthe plain cotton in an hour. The \ndressing should remain inside the \nsocket. \n\n\n\n2. Give aspirin for pain (page 88). \n\n\n\n\n\n112 \n\n\n\nBleeding from the socket \n\nWhen you take out a tooth it leaves a wound, so you can expect some \nblood. However, if the person bites firmly against a piece of cotton, it \nusually controls the bleeding. To help the wound heal (from a clot), tell \nthe person not to rinse with salt water or spit for 1 or 2 days after you \ntake out the tooth. \n\nWhen the first bleeding occurs, put a new piece of cotton on top of \nthe wound and ask the person to close her teeth against it for an hour. \nKeep her there with you, to be sure she continues to bite on the cotton. \n\n(If it is too painful, you may want to inject anesthetic. See Chapter 9.) \nChange the cotton if it becomes soaked with blood. \n\nTREATMENT (if the bleeding continues): \n\n1 . Take her blood pressure (see Helping Health \nWorkers Learn, page 19-13). If it is high, \nyou may need medicine to bring it down. \n\nThat can help slow the bleeding. \n\n2. Look carefully at the wound. If the gum \nis torn or loose, put in a suture (pages 155- \n157), \n\n3. Wrap tea leaves in cotton gauze. Soak the \nbundle in water and then put it on the socket. Have the person bite \nagainst it. Or, have her bite against cotton gauze soaked with cactus juice. \n\nLet the person go home only when the bleeding stops. Give her some \nclean cotton to use in case the bleeding starts again later (see page 157). \n\nTETANUS \n\nThis is a very serious infection. Tetanus germs enter the body when a \nwound, like a wound on the bottom of the foot, gets dirty. Germs can \nalso be carried to the socket when you use a dirty instrument to take out \na tooth. To avoid this, carefully read pages 82 to 85. \n\nSIGNS: \n\n• the jaw becomes stiff and tight \n\n• it is hard to swallow \n\n• the whole body becomes tight, with sudden \nspasms \n\nTREATMENT: \n\nA person with signs of tetanus requires immediate medical help. See \nWhere There Is No Doctor, page 182, if you cannot get help immediately. \n\n\n\n\n\n\n\n113 \n\n\n\nINFECTION INSIDE THE SPIT GLAND \n\nSpit glands are places where the spit is made. They are located in front \nof the ear and under the jaw, on each side of the head, if there is an \ninfection inside a spit gland, the face will become swollen and the area \nwill hurt. \n\nSpit is sent from the gland to the mouth through a thin pipe called a \nduct. Ducts open into the mouth in two places; on the inside of each \ncheek, and under the tongue. \n\nA small stone can often block a duct and cause an infection in the spit \ngland and swelling of the face. You may be able to feel the stone near \nwhere the duct enters the mouth. \n\nS/GNS: \n\n• swelling in the area of the spit gland. \n\n• pain which gets worse when the person is hungry, and when he sees \nor smells food. \n\n• the opening of the duct is red, swollen, and hurts when you touch it. \n\n\n\n\n\nTREATMENT: \n\nReduce the infection and swelling first. Later try to remove the \nstone. \n\n1 . Give penicillin for 3 days (page 88). If the swelling is large and the \ninfection serious, start with short-acting crystalline penicillin (see \np. 166). \n\n2. Give aspirin for pain (page 88). \n\n3. Apply a wet hot cloth to the swelling as often as possible. \n\n4. Give enough soft food to prevent the person from feeling hungry. \nThe pain will be less then. \n\n5. When the person feels better, a dentist or doctor can remove the \nstone that is blocking the duct. \n\n\n\n\n114 \n\n\n\nSORES ON THE FACE \n\nWhenever you see a sore on a person's cheek or under his chin, \nremember there may be a tooth or gum problem. If it is a gum problem, \nit may be Noma. See p. 115. \n\nA bad tooth; \n\nAsk him to open his mouth. \n\nLook for an infected tooth in \nthe area of the sore. \n\nThere may be a large cavity and \nthe tooth may be loose. \n\n\n\nOr the tooth may be darker \nin color than the others. This \nis because it is dead. \n\nThe pus is draining onto the \nskin, so the pressure is reduced \nand the person does not \ncomplain of pain. \n\nTREATMENT: \n\n1 . Take out the tooth (see Chapter 11). \n\n2. Give penicillin for 5 days (see page 88). \n\n3. After the penicillin treatment, check the sore. If it has healed, there \nis no longer infection inside. The treatment is finished. \n\nBut if the sore is still open and you can squeeze out pus, you will need \nthe help of experienced health workers who can: \n\n• test the pus to see if it is resistant to penicillin. The person may \nneed to take a different antibiotic. \n\n• take an X-ray to see if there are dead pieces of bone which are \nkeeping the infection alive. If there are, they must be removed. \n\nIf infected gums (and not a bad tooth) are the cause of a sore on the \ncheek or chin, the problem is more serious. See the next 4 pages. \n\n\n\n\n\n\n115 \n\n\n\nNOMA \n\nWhen a child is sick, a simple gum infection can get out of control and \nspread through the cheek to the face. When that happens the condition is \ncalled Noma or Cancrum Oris. Noma is a complication of Vincent's \nInfection of the gums (page 96). \n\n\n\nYou will usually see noma in children. It will only develop if these 3 \nthings are true: \n\n(1) The child's general resistance is low. Usually, he \nis undernourished and anemic (lacks iron). He \nmay have tuberculosis. \n\nchild has Vincent's Infection. \n\nX . ill (3) The child has recently had a serious illness like \n\nmeasles or malaria. \n\n\n\nThe infection starts in the mouth. \n\nThen it passes to the gums. \n\n1 . Sore mouth with itching gums. \n\n2. Swollen, sore gums. \n\n3. Gums bleed when eating or when \nteeth are cleaned. \n\n4. Bad breath, spits a lot. \n\n\n\n\n\n\n\n\n\n\nThen it reaches the jaw. \n\n5. Loose teeth. \n\n6. Loose pieces of bone around the \nteeth. \n\nFinally, it affects the cheek. \n\n7. Skin is tight with dark red swelling. \n\n8. Black spot on the cheek breaks open, \nleaving a hole into the mouth. \n\n9. A line separates dead tissue from \nhealthy tissue. \n\n\n\n\n\n116 \n\n\n\nTREATMENT: \n\nYou must start treatment for noma immediately in order to prevent the \nhole from getting bigger. The bigger the hole, the tighter the scar that \nforms after you close the hole. A tight scar will prevent the child from \nopening his mouth and chewing the food he needs to grow stronger. \n\n1. Give fluids. \n\nThe child needs to overcome \nboth the lack of body water \n(dehydration) and his lack of \nresistance to disease. \n\nStart giving the Milk-oil drink \ndescribed on p. 1 05. \n\nIf he cannot drink by himself, \nhelp him. Use a spoon or \nsyringe. \n\nPlace the fluid on the inside \nof the healthy cheek and ask \nthe child to swallow. \n\n2. Treat the anemia. \n\n\n\nStart giving iron now. The child should continue taking the tablets or \nmixture for 3 months. \n\n\n\n\n\nFerric Ammonium \nCitrate Mixture \n\n\nFerrous Sulfate \nTablets (200 mg.) \n\n\nover 6 years: \n\n\n1 1/2 ml. (30 drops) daily \n\n\n200 mg. (1 tab) 3 times a day \n\n\n3-6 years: \n\n\n1 ml. (20 drops) daily \n\n\n100 mg. (1/2 tab) 3 times a day \n\n\nunder 3 years: \n\n\n1/2 ml. (10 drops) daily \n\n\n50 mg. (1/4 tab) 3 times a day \n\n\n\nAlso give food rich in iron: meat, fish, eggs, dark green leafy vegetables, \npeas and beans. \n\n\n\nNote: a child may have anemia because he has hookworm. It is wise not \nto wait for a test for hookworm. Begin now giving hookworm medicine such \nas thiabendazole and folic acid (see Where There Is No Doctor, pages 142, \n363, and 376). \n\n\n\n\n\n\n117 \n\n\n\n3. Start antibiotics. \n\nPenicillin is the best antibiotic to use. As the child may not be able to \nswallow pills easily, it is best to start with penicillin injections (page 166). \n\nIf you do not have penicillin, you can give sulfadimidine 4 times a day. \nIt comes in 500 mg. tablets or in syrup that has 500 mg. in 5 ml. To \ndecide how much to give, weigh the child. \n\n\n\nWeight \n\n\nDose (give 4 times a day) \n\n\n5 to 10 kg. \n\n\n1/2 tablet or 1/2 teaspoon of syrup \n\n\n10 to 17 kg. \n\n\n1 tablet or 1 teaspoon of syrup \n\n\n17 to 25 kg. \n\n\n1 1/2 tablet or 1 1/2 teaspoon of syrup \n\n\nover 25 kg. \n\n\n2 tablets or 2 teaspoons of syrup \n\n\n\n4. Treat the other illness that helped noma to develop. \n\nIt is wise to assume that the child has malaria and to begin treating \nwith antimafarial drugs (see \\Nhere There Is No Doctor, pages 357 and \n358). \n\nLook for any other illnesses and treat them, too. \n\n5. Clean the sore. \n\nGently pull away any dead skin with tweezers. Wash the inside of the \nsore with hydrogen peroxide. (Be sure you measure the hydrogen peroxide \ncarefully. See page 8.) Then put in a wet dressing. \n\nThe dressing: \n\n• Soak cotton gauze in salt water. Squeeze out the extra water so that \nit is damp but not wet. \n\n• Put it in the hole and cover it with a dry bandage. \n\n• Every day, remove the bandage, wash the hole with hydrogen \nperoxide, and put in a new dressing. Do this until the hole does not \nsmell anymore and there is no more dark dead skin. \n\n\n\n6. Remove the loose teeth and dead bone. \n\nYou can use a local anesthetic (Chapter 9). Usually there is not much \nbleeding. If gums are loose, join them with a suture (see pages 1 55-1 57). \n\n\n\n\n\n118 \n\n\n\n7. Keep the mouth clean. \n\n• Use a soft brush gently to clean the remaining teeth. Do this 3 times \na day for the child. \n\n•• Wipe the gums with a weak solution of hydrogen peroxide. Use \ncotton gauze that is damp with the solution. Do this every 2 hours \nfor 5 days. \n\n• Then after 5 days, start rinsing with warm salt water 3 cups a day. \n\n8. Get advice on whether surgery is needed. \n\nUnfortunately, the child will probably need surgery, to release the scar. \nWithout this surgery, the child will not be able to open his mouth \nproperly. \n\nSend the child for medical help when the \ninfection is finished and the wound starts to \nclose. \n\nYou may also need a dentist's help at this time. \nThe child's jaws may need to be wired. The \nwires are put on the healthy teeth in a way that \nholds the mouth open while the tight scar is \nforming. When the wires are removed, the child \nwill be able to open and close his mouth to \nchew food. \n\n\n\n\nPREVENTION of Noma: \n\nNoma need not occur. We can prevent it. Always give special attention \nto the mouth of a sick child, to be sure to keep his teeth clean. \n\nWhenever someone is nursing or caring for a sick child, that person \nshould clean the child's teeth as a normal activity. This is especially true \nfor a child who is weak, undernourished, and with little body water \n(dehydration). \n\nSuch a child should always: \n\n(1) have his teeth carefully cleaned each \nday with a soft brush. \n\n(2) rinse his mouth with a warm salt \nwater solution (page 7), 2 times a \nday. \n\n(3) eat fresh fruits and vegetables, \nespecially the kind that have Vitamin \nC— guavas, oranges, pineapples, \npapayas, tomatoes, peas, and dark \ngreen leaves. \n\n\n\n\n119 \n\n\n\nTUMOR \n\nA tumor is a lump that grows under the skin or inside the bone. It \n\n\n\n\nIf the swelling does not get better after 5 days of antibiotics and \nheat treatment (page 88), it may be a tumor. \n\nTREATMENT: \n\nDo not waste any more medicine or any more time. A tumor may be \ncancer. Send for medical help. Surgery is needed to remove a tumor. \n\n\n\nCANCER \n\n\n\n\nAny sore that does not heal may be, \ncancer. The lips and tongue are the \ntwo places in the mouth where \ncancer starts most often. \n\nCancer is deadly. \n\nMedicine cannot help. \n\nIt wastes time to use it. \n\n\n\nCancer can spread quickly to the inside of the person's body where \nyou cannot see it. This can lead to the person's death. \n\n\n\nTREATMENT: \n\nWhenever you treat a sore and it does not get better, send the person \nfor medical help immediately. A doctor can cut out a piece from the sore, \nlook at it under a microscope, and decide if it is cancer. \n\n\n\n121 \n\n\n\nCHAPTER ^ \n\nScaling Teeth \n\n\n\nScaling means 'scraping away . You can scale old food, tartar, or even a \nfish bone caught under the gum. You usually scale teeth to remove tartar. \n\n\n\nWe get tartar when the coating \nof germs on our teeth (p. 48) \nbecomes hard. \n\nGums that press against \ntartar become sore and infected. \n\n\n\nClean teeth keep our gums healthy. Scaling a person's teeth gives \ninfected gums a chance to become normal again. \n\nHowever, gums remain healthy only when we keep the teeth beside \nthem clean. If we are not careful about cleaning our teeth after they are \nscaled, tartar will soon return. Instead of being healthy, the gums will \nbecome sore and infected again. \n\n\n\nScale a person's teeth, but \nalso teach how to keep ceeth clean. \n\nYou must remove something caught under the gums (page 127) before \nit causes more pain and swelling. Remove a piece of fish bone or piece of \nmango string now. \n\nIf the person has a mild gum problem (gums that bleed), wait a week or \nso before scaling. If the person uses this time to clean his teeth better and \nto rinse with warm salt water (page 7), the gums will improve. The \nperson's teeth will be easier for you to scale, and he will learn that he can \ndo much by himself to care for the gums. \n\nUse a mirror to show the person gum infection inside his own mouth. \n\nLater he can see the improvement he has made. He can learn about how \nto keep gums healthy as he follows his own progress. \n\nScale a person's teeth only when he really wants to try to keep them \nclean. If he does not want to clean his teeth, the tartar will soon return. \n\nDo not waste your time scaling the teeth of a person who does not want \nto learn. \n\n\n\n\n\n\n122 \n\n\n\nTHE INSTRUMENTS YOU NEED FOR SCALING \n\nWe scale teeth with special instruments called scalers. There are many \ndifferent kinds of scalers for different teeth, to make scaling easier. It can \nbe a problem to know which ones to buy. \n\nScalers are expensive instruments. For that reason, it is better to order \nonly a few instruments that you can use to clean most teeth. \n\nYou need only 2 double-ended scalers, or 4 single-ended scalers. \n\nFor instance: \n\n1. One with two pointed tips— to remove tartar from the part of the tooth \nnear the gum. \n\nIts proper name is \nIvory C-J scaler. \n\nremove tartar from the part \n\nIts proper name is \nG-7 7 and 12 curette. \n\n\n\n2. Another with two blunt, rounded ends— to \n\nof the tooth under the gum. \n\n\n\n\n\nThe ends of the scaler are the important parts. One end is bent to the \nleft and the other end is bent to the right, so you can reach more easily \naround all sides of the tooth. \n\nThe blade at each end of the scaler is sharp. You must keep the blade \nsharp. A sharp blade can break more of the tartar away than a blunt blade. \n\nYou also need these: \n\n\n\n\nProbe Tweezers Sharpening stone \n\nMirror (explorer) (cotton pliers) (Arkansas stone) \n\n\n\nNote: When you order an instrument, use both its common and proper \nname. Then you have a better chance of receiving the instrument \nyou want. You can also make some of your own instruments. See \npages 1 70-1 72. \n\n\n\nKeep everything in a Scaling Kit. \n\n\n\n\n123 \n\n\n\nHOW TO SCALE TEETH \n\nTartar starts to form inside the gum pocket. There it builds up, because \nthe gums protect it. So you often must feel rather than see the tartar when \nyou scale a tooth. \n\nYou must remove all of the tartar so the gums can heal. New tartar \ngrows faster when there is old tartar left behind for it to build upon. \n\nLay out what you need ahead of time. \n\n/ your instruments; scalers, mirror, probe, tweezers \n■/ sharpening stone \n\n— ^ cotton gauze \n\nYour light must be good enough to see the tooth and gums around it \nclearly. Scaling teeth requires time and practice. Make yourself and the \nperson comfortable. You can sit next to a special chair that lets the person \nlean back (see page 73). \n\n\n\nThe steps in scaling teeth are these (pages 1 23-1 27) : \n\n1 . Explain to the person what you are going to do. \n\n2. Feel under the gum for rough spots (tartar). \n\n3. Place the scaler under the tartar. \n\n4. Pull the scaler against the side of the tooth. \n\n5. Check to be sure the tooth is smooth. \n\n6. Explain what you have done and what the \nperson should now do. \n\n\n\n1. Explain what you are going to do. Tell the person what to expect. There \nwill be some bleeding and possibly some pain. However, you can stop \n\nand rest, or inject local anesthetic, if it is painful. Remember: first wash \nyour hands and your instruments! (See pages 82-85.) \n\n2. Feel under the gum for tartar. Tartar feels like a rough spot on the root \nof the tooth. Since tartar can form anywhere inside the gum pocket, feel \nfor it on all sides of the tooth. \n\nYou can check for tartar two ways. \n\n1. Use your probe. Slide the point up and down along the \nroot surface under the gum. Feel for places that are \nrough. Teeth without tartar are smooth. \n\n2. Use cotton gauze. Twist a corner and press it between \nthe teeth. The gauze lowers the gum and soaks up the \nspit. You can then see more tartar. \n\n\n\n\n\n\n124 \n\n\n\n3. Place the scaler under the tartar. You must learn two important things; \nhow to hold the scaler and how to slide the scaler into the gum pocket. \n\n\n\nHold the scaler \nalmost as you would \nhold a pen. You can \nthen pull it against \nthe tartar with both \npower and control. \n\n\n\n\n\nControl is very important. The \n\nends of the scalers are sharp. \n\nIf you are not careful, the blades \ncan cut the gums. Be gently and do \nnot hurry. Always hold the tip of \nthe scaler on the tooth to avoid \npoking the gums. \n\nRest your 3rd finger against a \ntooth. This will steady your hand \nand let you slide the sharp scaler \nunder the gum with care. \n\n\n\n\n\n\n\n\n\n\n\nFOR AN /aWnS \n\nUPPER \n\n\n\n\n\n\n\n\n\n\nTOOTH J \n\n\n\\ \n\n\nK \\-\\rxy nrc \n\n\n\n\n\n\n\n\n\n\n\n\n\n\n125 \n\n\n\nThe edge of the gum, near the tooth, folds under to form a pocket. This \ngum pocket goes completely around each tooth. The gum pocket can be \nshallow or deep. A deep pocket means there has been an infection for a \nwhile. \n\n\n\n\nTartar starts forming deep \ninside the gum pocket. If \nyou remove tartar that you \ncan see above the gum, it \nis helpful, but not good \nenough. You must remove \nthe rest of the tartar, or \nthe infection will continue. \nIf part of the tartar \nstays on the tooth, the \ninfection will continue. \n\n\n\nFirst, use the pointed-tip Then, go back with your rounded- \n\nscaler to remove the tartar tip scaler and scrape away the \n\n\n\n\nBe careful when you place the rounded end of the scaler inside the gum \n\n\n\n\n1 . Put the sharp face of the \nblade against the tooth. \nSlide it along the tooth \ndown into the gum pocket. \n\n\n\n2. You can feel the edge as it \ngoes over the rough tartar. \nStop when you feel the \nbottom of the gum pocket. \n\n\n\n\n126 \n\n\n\n4. Hold the end tight against the side of the tooth and pull the scaler. T ry \n\nto break free as much tartar as possible at once. It is a bad idea to remove \nthe tartar a bit at a time, because the remaining tartar becomes smooth \nand harder to scrape away. \n\n\n\n\n5. Check to be sure the tooth is smooth. \n\n\n\n\nWith your probe, feel under the gum for \nany place that is still rough. \n\nWhen all the sides of the tooth feel \nsmooth, move to the next tooth. \n\n\n\nDo not hurry. It is more important to take your time and carefully \nremove all the tartar. If the person has a lot of tartar, scale only half the \nmouth now. Do the other half on another day, as soon as the person can \nreturn. \n\n\n\nFinally, make the tooth look clean. Use the sharp edge of either scaler. \nScrape away the dark material on the front and back sides of the tooth. \n\n\n\n\nThe tooth itself has not turned dark. It \nis just a stain. People most often get \nthese stains when they eat meat, drink \ntea or smoke tobacco. \n\nYou can scrape away this old food and \nuncover the white tooth. But remember: \nthe teeth will turn dark again if not \ncleaned carefully every day. \n\n\n\n\n127 \n\n\n\n6. Talk to the person about what you have done and what to expect. The \n\ngums will be sore for the next few days. That is normal. \n\nThen explain to the person what to do to make the gums strong and \ntough again. \n\nA. Clean your teeth better with a soft brush. Reach with the brush into \nthe gum pocket, and behind your front teeth. That is where tartar \ncollects most often (page 67). \n\nB. Clean between your teeth. Use your brush, the stem from a palm \nleaf, or a piece of strong, thin thread (page 69). \n\nC. Rinse your mouth with warm salt water. Start with 4 cups a day, \n\nto make the gums strong. Then use 1 cup a day to keep them strong \n(page 7). \n\nD. Eat local foods that give strength to gums. Fresh fruits like guava \nand oranges, and fresh vegetables with dark green leaves are good \nfor the gums. \n\n\n\nREMOVING SOMETHING FROM UNDER THE GUM \n\n\n\nIf the gum between two teeth is red and swollen, something may be \ncaught inside the gum pocket. Ask what the person has been eating. The \nobject may be a fish bone, mango string, or a sharp piece of tartar. \n\nFirst try to feel the object with your probe. Then remove it using a \n\n\n\n\nO — \n\n\n\n\nTie a knot in a piece of \nthread. Then slide the thread \nbetween 2 teeth (page 69). \nHowever, do not move the \nthread up and down. Instead, \npull it and the knot out \nthe side. The knot can pull \nthe object out with it.* \n\n\n\nIf the gum has grown into a kind of tumor (epulis), an experienced dental worker should cut \nit away. \n\n\n\n\n128 \n\n\n\nKEEP YOUR SCALING INSTRUMENTS \nSHARP AND CLEAN \n\n\n\nA sharp scaler bites into tartar better than a blunt one. Sharpen the \nedge whenever you feel it sliding over the tartar. \n\n\n\n\nFrom time to time, feel the cutting edge to be sure \nit is sharp. \n\nScrape it against your fingernail. If the cutting edge \nis not able to cut your nail, it will not be sharp \nenough to break the tartar free. \n\n\n\nSharpen the cutting edge of the scaler on a fine-grain stone (Arkansas \nstone). Put a few drops of oil or water on the stone first, so the scaler can \nslide against it more easily. \n\nRest your 2nd or 3rd finger against the side of the \nstone. This is for control. \n\nRub the cutting edge against the stone. Move it back \nand forth. \n\nTurn the round scaler as you sharpen it. This helps \nto keep the scaler’s round shape. \n\nScalers must be more than clean— they must be sterile. This is because \nthere may be spots of blood on them. Hepatitis (Where There Is No \nDoctor, page 172) can pass from the blood of one person to the blood of \nanother person. To learn how to sterilize, see pages 83 and 84. \n\nYour mirror, probe, and cotton tweezers do not need sterilization. A \ndisinfectant (see page 85) will clean them. Dry all the instruments with a \ntowel. Then wrap them inside a clean cloth and put them in your scaling \nkit. They are now ready for use whenever you need them again. \n\n\n\n\n\nRemind each person: scaling is not \na cure. Rather it is a way of giving \nher a new start. Only she can give \nherself the care she needs to keep her \ngums healthy. You have removed the \nhard material from her teeth, and if \nshe brushes carefully, the tartar will \nnot return! \n\n\n\n\n129 \n\n\n\nInjecting Inside \nthe Mouth \n\n\n\nCHAPTER \n\n\n\n\nIt is possible to treat a tooth without pain. You do this with an \ninjection of local anesthetic. You must inject near the nerve, so to give \ngood injections, you must know where the nerves are. \n\nInjecting is a skill that develops with experience. The best way to learn \nis not from a book, but from a person who has experience giving injections. \n\nWatch an experienced dental worker give injections. That person \ncan then watch you and show you how to inject carefully and safely. \n\nLocal anesthetic is an injectable medicine. When it touches a nerve, the \ntooth joined to that nerve feels numb or dead for about an hour. This \nusually gives you enough time to take out a strong tooth or to put a \ncement filling into a deep cavity. \n\nWHAT YOU NEED TO INJECT \n\n\n\nThere are two kinds of syringes for injecting local anesthetic inside the \nmouth. One is made of metal and the other is made of glass. The metal \nsyringe uses local anesthetic in a cartridge. The glass syringe uses local \nanesthetic from a bottle. \n\n\n\nMETAL SYRINGE \n\nThis is a dental syringe. It uses special needles, \nand the local anesthetic is sealed inside a \nglass cartridge. You must throw away both \n\n\n\n\nUse a new needle and a new cartridge of local \nanesthetic for each person. \n\n\n\nGLASS SYRINGE \n\nThis kind of syringe is for injections of \nmedicine like penicillin, but you can use it in \nthe mouth. Boil the syringe and needles (p. 84) \nbefore and after each use. When sterile, the \nneedles are ready for another person. \n\n\n\n\nBe careful! Do not touch the needle. \n\n\n\n\n\n\n\n\n\n\n\n130 \n\n\n\nYour choice of which syringe to use depends on the local anesthetic you \ncan get. Order needles to fit your particular kind of syringe. \n\n\n\nMETAL SYRINGE \n\n\nGLASS SYRINGE \n\n\nOrder: \n\n\nOrder: \n\n\n1. syringe: aspirating dental cartridge syringe, \n1 .8 ml. (1 ml=1 cc) \n\n\n1. syringe: standard glass syringe that holds \naround 3 ml (1ml=1cc) \n\n\n2. needles: disposable needles for dental \ncartridge syringe (27 gauge, long) \n\n\n2. needles: 24 gauge, long (40 mm x.56 mm \nor similar) \n\n\nOne box contains 100 needles, each one \ninside a plastic cover \n\n\n3. local anesthetic: 20 ml bottle of lidocaine \n(lignocaine) 2% \n\n\n3. local anesthetic: local anesthetic cartridges \nfor a dental syringe \n\n\nOr, if not available: order 2 ml ampules \nof procaine hydrochloride 1% \n\n\nOne sealed tin contains 50 cartridges \nof lidocaine (lignocaine) 2% \n\n\n\n\n\nNOTE: Lidocaine will keep the teeth numb longer if there is epinephrine \nin it. But this is more expensive, and you should not use it on \npersons with heart problems (see the bottom of the next page). \n\n\n\nWHERE TO INJECT \n\n\n\nYou can deaden a nerve with an injection of local anesthetic: \n\n\n\n1 . near the small nerve branch going inside the root of a tooth. \n\n\n\n2. near the main nerve trunk before it divides into small branches. \n\n\n\n\nSmaller nerves 'branch' off \nfrom the main nerve— much like \nbranches of a tree leave its \nmain trunk. \n\nOne small nerve then goes to \neach root of every tooth. \n\n\n\nInject an upper tooth near its roots. \n\n\n\n\nBone in the upper jaw is soft and \nspongy. \n\nLocal anesthetic placed near the root \nof an upper tooth can go inside the \nbone and reach its nerve easily. \n\nThe same injection also makes the \ngums around that side of the tooth \nnumb. \n\n\n\n\n\n131 \n\n\n\nIt is more difficult to inject the lower teeth. \n\nThe lower jaw bone is thicker. When you inject near the roots of a \nlower tooth, the anesthetic is not able to reach its nerve as easily. \n\n\n\nNote: You can inject lower \nfront teeth in young children, \nor very loose lower front \nteeth in adults, near their roots. \n\nTo make a lower tooth \ncompletely numb, you must \n\nblock the main nerve (a) \nbefore it goes inside the jaw \nbone. \n\n\n\n\nThese two injections also make the gums \naround the teeth numb. \n\n\n\nIf you are treating a back tooth, you must give a second injection for \nnerve (b). See page 134. \n\n\n\nWHEN TO INJECT \n\nInject local anesthetic whenever the treatment you give may hurt the \nperson. If, after you inject, the person says the tooth still hurts, be kind. \nStop and inject again. \n\n\n\nInject local anesthetic slowly and carefully. \n\nYou can then treat a bad tooth and not hurt the person. \n\n\n\nHOW TO INJECT* \n\nFor a good, safe injection, remember these 5 \n\n1. Do not inject local anesthetic into an area \nthat is swollen. This can spread the infection. \n\nAlso, pus inside the swelling stops the local \nanesthetic from working properly. \n\nInstead, treat the swelling first (page 88) and \ntake out the tooth later, s' \n\n2. If the person has a heart problem, do not \ninject more than 2 times in one visit. Also, \nit is best not to use an anesthetic with epinephrine on persons with heart \nproblems. Use lidocaine only, or mepivacaine 3%. \n\n*Local anesthetics are the only injections given in the mouth. To learn about injecting antibiotics, \nsee page 1 66. \n\n\n\n\n\n\n\n\n132 \n\n\n\n3. Before you push the needle under the skin, be sure its pointed end is \nfacing in the correct direction. \n\n\n\n\nThe local anesthetic \nmust come out against \nthe bone, where the \nnerve is. \n\n\n\n\n4. Before you inject the local anesthetic, wait a moment to see if any \nblood enters the syringe. (Note: only an asp/>af//7g' syringe will do this.) \n\n\n\n\nPull back on the plunger. If blood comes inside, \nit means you have poked a blood vessel. \n\nPull the needle part way out and gently move it \nover to a different place. \n\n\n\nIf you inject local anesthetic into the blood vessel, there will be more \nswelling afterward, and the person may faint. If the person faints: \n\n• Lie him on his back. \n\n• Loosen his shirt collar. \n\n• Lift his legs so they are higher than his head. \n\n\n\n5. Be sure your syringe and needles are clean and sterile (see pages 82 to \n85). Do not pass an infection from one person to another by using dirty \nneedles. \n\n\n\nFOR GLASS SYRINGES: \n\nBoil the syringe and needle in water (page 84) \nfor 20 minutes in a covered pot. Although it is \nnot as important, it is also a good practice to \nboil your metal syringe. \n\n\n\nFOR METAL SYRINGES: \n\n• Use a new cartridge for each person who \nneeds an injection. Do not use local anesthetic from a cartridge that \nyou have used on another person. \n\n• Break the disposable needle after using it. Then cover the point with \nits plastic top and throw the needle into the trash. \n\n\n\n\n\n133 \n\n\n\nInjecting the Upper Teeth \n\nInject local anesthetic near the root \nof the tooth you want to treat. \n\nFront teeth have one root. Back teeth \nhave more than one. \n\nFor a tooth to become completely \nnumb, the local anesthetic must \ntouch the small nerve going to each one of its roots. \n\n1. First decide where to inject. \n\nLift the lip or cheek. See the \nline that forms when it joins the \ngum. \n\nThe needle enters at the line \nwhere the lip or cheek meets the \ngum. \n\n2. Push the needle in, aiming at the \nroot of the tooth. Stop when the \nneedle hits bone. Inject about 1 ml. \nof local anesthetic (1/2 of a \ncartridge). \n\nPull the needle part way out and \nmove it over to the next root, \ninject again. \n\nif the tooth is to be taken out, leave 1/4 ml. for the next step. \n\n\n\n\n\n3. If you are taking out a tooth, also inject the gums on the inside. \n\n\n\n\nAsk the person to open \nwide. Inject the remaining \nanesthetic (1/4 ml) directly \nbehind the back tooth that \nmust come out. \n\nOne injection can numb the \ngum behind the 6 front \nteeth. Inject into the lump \nof gum behind the middle \nfront teeth. (Note: This \ninjection hurts! It may help \nto use 'pressure anesthesia'. \nSee p. 1 35.) \n\n\n\n\n4. Wait 5 minutes for the tooth to become numb. \n\n\n\n\n134 \n\n\n\nInjecting the Lower Teeth \n\nWhen you block the nerve, it affects all of the teeth as well as gums on \nthat side. However, it takes practice to do this successfully. Ask an \n\nexperienced dental worker to help you learn how to give this injection \nproperly. \n\nStand in such a way that you can see clearly where you need to inject. \nAsk the person to open wide. \n\n\n\n\n1. First feel for the place to be injected. \n\nPut your thumb beside the last molar tooth. (Wash your hands first! \nSee p. 82.) Feel the jawbone as it turns up towards the head. Rest your \nthumb in the depression there. \n\n\n\n2. Press against the skin with the end of your thumb. \n\n\n\nThe skin forms a 'v' shape. Your needle must go into the 'v'. \n\n\n\n\nHold the syringe on top of tooth \nnumber 4 and aim the needle at the \n'v'. \n\nPush the needle in until it hits the \njawbone, (about 3/4 of the length of \na long needle). Pull back on the \nplunger of the aspirating syringe to \ncheck for blood (page 132). \n\n(3/4 of a cartridge). \n\n\n\nTry to feel your way: If you hit bone too early, pull the needle part way \nout and move it over so that it points more toward the back of the mouth. \nTry again. \n\nIf you do not hit bone, the needle is too far back. Pull it part way out, \nand point it more toward the front. Push it in again. \n\n\n\n\n135 \n\n\n\n3. Give a second injection BESIDE the back teeth. \n\n\n\nIf you are going to fill or remove a back \ntooth, inject beside that tooth, where the cheek \njoins the gum. \n\nInject 1/2 ml of local anesthetic (1/4 of a \ncartridge). \n\nThis injection is not needed for front teeth. \n\nIt is enough to block the main nerve. \n\n4. Wait 5 min\n…[truncated]", "summary": "Where There Is No Dentist by Murray Dickson with an Introduction by David Werner, author of Where There Is No Doctor Compiled by noonya Library of Congress Cataloging in Publication Data Catalog card No. 82-84067 Dickson, Murray Where there is no dentist. Includes index. Palo Alto, CA: Hesperian Foundation ISBN: 0-942364-05-8 First edition, November 1983 Seventh Printing, July 1996 PUBLISHED BY: The Hesperian Foundation P.O. Box 1692 Palo Alto,…", "source_url": "https://archive.org/details/Where_There_is_No_Dentist_Murray_Dickson", "pdf_url": "https://archive.org/details/Where_There_is_No_Dentist_Murray_Dickson", "doc_date": "1983", "case": "hesperian", "sub_case": "Dickson, Murray", "tags": ["hesperian", "tooth", "teeth", "gums", "dental", "gum", "person", "clean", "mouth", "infection", "germs"], "page_count": 0} {"title": "WHERE THERE IS NO DOCTOR - HINDI - DAVID WERNER", "content": "\n\n\nfq 3*33? «PT f qqqr q ## 3R \n\n\nSTFT qf STFcT q>T : \n\nmTi>T Jr st qqt fqqq-g*yqft qf i ?qq qrqq ftqr far farq nwnr q qqr f sffa farq \nqcj ax farq faqq aft qqf ¥t qq'f | | \n\nfc*ft farpr qmrft m f^or qqsft far^r qfr ^rqq % fanr : \n\n?. s^qr % qq Jr qtir q«lr qn ft i qq 3 ^ if qfaq qqr faqqf qfr qrfqqrr \n(q^q.qfarqrTjllqfa rqf faqq SR*! qifaq ^ qff fqq qi TfT t rfl qq |qf qiq % qf% ft | \nqT. . \n\n5 - faqq-^tt ’Ft. qiq qrf 1 qq tt fqqq qrqqri qrfair ^r% Rifa fqtt qcs qqm qT qpqqr \nqrr trt 1 = - \n\n^ fw qr> q ?nr?r q’w ?ft : \n\nq«f tt 2?qqr % ?nf^T if ff q^sf % sfa qjq if ff qqf if *qfgj | \n\nfrtft >ft sptt *ft f??mT?r ^q?r t Tffa : \n\nfiftlT qq% fttqm qrqq % fq, Jqqrqr tf qpn, qrqf.qq qTqqpft A qRT ?nff % fqqq \nJf qRqqt % farq jfa qssTi qrt ft I jfa qeslf % qmq % qR ft qqTwt qjf $tt A qqrwf qrt \nmffaqri f *sft 3TT qqrqf | I \n\n^iw ftqfqti % ffarr qqn; % ffarT ; \n\nqv-qjq if gr^f qf qqmf % qqjf tf. fpfqr AX AAA} qfq if qqR T# | \n\nV J^ 8 *’ sr^Trr qfq Jt qft jjft q? t — fatq qq it srrqfqqs farfa>?qi q*q?qt a^ata \n\nt° *rH tfanr sqfaq tt ^rvra tit q^Rt a*atA y tt qq?q qf 1 \n\nsr^r 3 ^ 1 % T*a% *r ?rc% qft«TK fr^Rgrr % ffarr ; \n\nq>q«r qrq^qt qnnrq ? ? qtT q^rq qrqyqf ?1-Eqrq apf CTH % qf qqr faqsff A HR- \n\nqifqqf qr «nq ? 1 . \n\nWtt tfg^FT gsrR ?TT% % fariT : \n\nfq 3qrqr qT qqf qrq% FqR^ ?qir«q qrqfqt qtr?qr?ff qt qR^R qr^q % fqrr \n\nqq% qftfqqf qft fqr^r qrr 1 qr farqt q«qrqqr ir qrf far q^ ?q jfqqr qfr ?Rqrq qrqf 1 3 q^qf \nqqT qq^qft qrt fqJrq qr^rrq fi qrqqq %a 3?qqr % 35% qR if 5?% q'tq qq % qcsf if 7 r \n? 3 Tf«q Jtqq; ^ fqir q> 5 T*q Jr qrf qmqTqqr gqqq fqqq 1 \n\n\n\n\n\ntfa? \n\nWhere There is No Doctor \n3*r : DONDE NO HAY DOCTOR \n\n\n5r«nr sr^m : \n\nThe Hesperian Foundation \n\nP O. 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TO?T % <3cTTOTTO ?TO??T T>? |> ?TO | I \n\n*f? TO? f%* |q TO? if S 3 % ?TOT f?TOi 5 T^ ^ ?t TT^f ?>t TOft ??? WTWT WTO \n\n^1 ? (^fTOi ?S 5 ) I \n\n\n\n?oo \n\n\nWT? 7T TJT Rffarr afsf)- ^ricfV | % 5R 55T 5 ft I ^rfa^ 7gt 5T 5f ^T'Tfl fa% SIR 7jt \n% ^T ^r T ?. I, ’TTT-’p-TTT f RT ^rf|tr | EfR T~f Tjft % fa it ^ffaRT fait 3ffa 5T% \n\nRT R'Ti-’RTt *Rf TT sffaT '-VJ R ifa it g*3T fall 5Tff C[ I \n\ns(t ^\"t faf 5tfar % Tf% 5R T T TtfrTW^rB 5?W I it 55 55T s|>t |^Fff TT \n\nfa5R | I \n\n2TT ?TR R5 5Rf 55 'fa' 55T #' | 5R5 % \n…[truncated]", "summary": "fq 3*33? «PT f qqqr q ## 3R STFT qf STFcT q>T : mTi>T Jr st qqt fqqq-g*yqft qf i ?qq qrqq ftqr far farq nwnr q qqr f sffa farq qcj ax farq faqq aft qqf ¥t qq'f | | fc*ft farpr qmrft m f^or qqsft far^r qfr ^rqq % fanr : ?. s^qr % qq Jr qtir q«lr qn ft i qq 3 ^ if qfaq qqr faqqf qfr qrfqqrr (q^q.qfarqrTjllqfa rqf faqq SR*! qifaq ^ qff fqq qi TfT t rfl qq |qf qiq % qf% ft | qT. . 5 - faqq-^tt ’Ft. qiq qrf 1 qq tt fqqq qrqqri qrfair ^r% Rifa fqtt qcs qqm qT qpqqr qrr trt 1 = - …", "source_url": "https://archive.org/details/WhereThereIsNoDoctor-Hindi-DavidWerner", "pdf_url": "https://archive.org/details/WhereThereIsNoDoctor-Hindi-DavidWerner", "case": "hesperian", "sub_case": "DAVID WERNER", "tags": ["hesperian", "WHERE THERE IS NO DOCTOR; HINDI; DAVID WERNER"], "page_count": 0} {"title": " Where There is no Dentist", "content": "Where There Is \nNo Dentist \n\nby Murray Dickson \n\nupdated and expanded \n\nwith information about HIV and AIDS \nby Richard Bebermeyer, \n\nMartin Hobdell and Gene Stevenson \n\nIntroduction by David Werner, \nauthor of Where There Is No Doctor \n\n\n\n\n\n\n\nHesperian encourages others to copy, reproduce, or adapt to meet local needs any \nor all parts of this book, including the illustrations, provided that the parts reproduced \nare distributed free or at cost - not for profit. \n\nAny organization or person who wishes to copy, reproduce, or adapt any or all parts \nof this book for commercial purposes must obtain permission from Hesperian. \n\nBefore beginning any translation or adaptation of this book or its contents, please \ncontact Hesperian for suggestions, updated information, and to avoid duplication of \nefforts. Please send us a copy of any materials in which text or illustrations from this \nbook have been used. \n\nCopyright © 1 983, 2006, 201 0 by the Hesperian Foundation. All rights reserved. \n\n\n\nLibrary of Congress \n\nCatalog card No. 82-84067 \nDickson, Murray \n\nWhere there is no dentist. \n\nIncludes index. \n\nBerkeley, CA: Hesperian Foundation \nISBN: 978-0-942364-05-7 \n\nFirst edition, November 1983 \n\n13th printing (updated), September 2010 \n\nPrinted in Canada on acid-free, 100% recycled paper by Transcontinental \n\n\n\nHesperian \n\n1919 Addison St., #304 \nBerkeley, California 94704 \nUSA \n\ntel: 1-510-845-1447 \nfax: 1-510-845-9141 \nbookorders@hesperian.org \nwww.hesperian.org \n\n\n\nWWW \n\n\n\n\nTHANKS \n\n\n\nWhere There Is No Dentist, updated edition, 2010 \n\nThanks from Hesperian \n\nWe continue to be inspired by Murray Dickson and his tireless efforts to \nencourage health and dental promoters and community members to respond \nself-reliantly to their health needs. A few years ago, Murray introduced us to \nRichard Bebermeyer, Martin Hobdell, and Gene Stevenson, whom we thank for \nvolunteering their time to write and develop the manuscript for Chapter 1 2 in \nthis book, \"HIV and Care of the Teeth and Gums.\" That material was originally \npublished in 2002 and distributed as a supplement to the previous edition of \nWhere There Is No Dentist. We also thank Jane Maxwell, who edited the \nsupplement with assistance from Darlena David, Julie Gerk, and Todd Jailer. \n\nHesperian is lucky to be able to draw upon a large pool of people committed \nto grassroots health, and we owe a debt of gratitude for their insightful \ncomments and suggestions to: Jean Arthur, Alma Carolina Blanco Reyes, \nClaire Borket, Roman Carlos, Stephen Cox, Belinda Forbes, Jo Frencken, \nMonica Gandhi, Gene Gowdey, Gerardo Gutierrez, Martin Hobdell, Marie \nKlaipo Patcharin Lekswat, Brian Linde, Theresa Noe, Francina Lozada Nur, \nStephen Moses, Foluso Owotade, Francis Serio, Michael Terry, Garth von \nHagen, and P. Wanzala. \n\nNew illustrations in this edition of the book are by: Silvia Barandier, Sara \nBoore, Heidi Broner, Jose de Jesus Chan, Gil Corral, Regina Faul-Doyle, Anna \nKallis, Susan Klein, Gabriela Nunez, Mona Sfeir, Sarah Wallis, Lihua Wang, and \nMary Ann Zapalac. \n\nEditing and updating of the 2006 edition was coordinated by Kathleen Vickery \nwith assistance from Todd Jailer and Susan McCallister, production by lhaki \nFernandez de Retana and Leana Rosetti, and additional writing by Fiona \nThomson. For the 2010 edition, coordination by Dorothy Tegeler, with support \nfrom Deborah Bickel, Matthew Crimp, Jacob Goolkasian, Shu Ping Guan, Todd \nJailer, Susan McCallister, and Kathleen Tandy. \n\nThanks from Murray Dickson, 1983 \n\nWhere There Is No Dentist is here to fill a need. To many people, it has \nseemed that the existing books about dental care were either too incomplete \nor too complicated. If this book fills that need, it is only because a number of \npeople worked hard to make it happen. To them I owe my sincere thanks. \n\nMuch has happened since that day in Papua New Guinea when David \nWerner's letter arrived. His challenge was simple: \"Since no one else \nhas written a dental manual like this, why don't you?\" With David's \nencouragement and constant support, I was able to take teaching notes and \nproduce a suitable draft that was the basis for this book. To you, David, for \nyour patience in helping me learn, my heartfelt thanks. Thanks also to Trude \nBock and Bill Bower for the home, food, direction, and support, during a short \n\nWWW. nC;'pt.T13.n.or_ \n\n\n\nvisit to The Hesperian Foundation in which the book took a definite turn for the \nbetter. \n\nMichael Blake deserves special mention. As editor of Where There Is No \nDentist, it was he who took the manuscript and nursed it along to completion. \nMichael's commitment to finishing the book was vital, and I sincerely \nappreciate it. \n\nMy thanks go to Maggie Leung for typing the final draft, and to those \ndedicated persons who helped get the book into final form: Annaloy Nickum \n(page design): Hal Lockwood (typesetting and paste-up); Paul Chandler, \n\nSerena Clayton, and Elaine Rossi (proofreading): Pat Bernier (typing); and \nHoward Uno (photostats). \n\nFor their outstanding drawings, I am exceedingly grateful to; June Mehra, \nJanet Elliott de Jacques, Michael Marzolla, Joan Thompson, Mindy Mead, \nArlene Ustin-Cartagena, and Lynn Gordon. My own drawings in the manual \nappear amateurish in comparison. \n\nI want to thank the many persons who reviewed the manuscript and offered \nvaluable suggestions: Ken Cripwell, Bill Bower, Jeff Vore, Aaron Yaschine, \nRosalie Warpeha, Norma Francisco, Mike Muller, Marcia Anderson, Phil \nHaskett, Bert Bali, Tom Coles, Sunil Mehra, and John Rogers. In particular, \nthanks to Chris Lennox who, faced with stressful times in Papua New Guinea, \nfound time to read through two drafts; and to David Morley for his ideas for \nimproving the book and his assistance with its eventual publication. \n\nFor their financial help, I am grateful to the Ella Lyman Cabot Trust, Muttart \nFoundation, the Canadian Organization for Development through Education, \nand the James C. Penney Foundation. \n\nI thank the C.V. Mosby Company and Dr. Kenneth Snawder for permission to \nadapt several drawings from the Handbook of Clinical Pedodontics, and the \nMedical Missionary Association (244 Camden Road, London NW1 9HE, U.K.) \nfor permission to use parts of David Halestrap's book Simple Dental Care. \n\nThis book is based upon several years of practical experience, made possible \nby the Canadian Organization CUSO. For this opportunity, and for CUSO's \nactive interest and involvement in this book, I most gratefully say thanks. \n\nFinally, I want to acknowledge my family's contribution. For weeks on end, \nmy wife, Gerri, faithfully read and discussed with me each part of the book \nas it changed and was rewritten. She did this cheerfully, at a time when she \nwas fully occupied in a graduate study program. For much longer than I had \nanticipated, Gerri and our two boys, Michael and Brennan, had to tolerate my \npreoccupations. \n\nMy parents endured my wanderings and search for answers to human \nproblems with love and a growing sense of understanding. It is my only \ndisappointment that they did not live to see this book in its final form. \n\nWWW nc* penal-. or j \n\n\n\nCONTENTS \n\n\n\nIntroduction by David Werner \n\nPart One; Learning and Teaching about Teeth and Gums \n\nChapter 1 : Your Own Teeth and Gums 1 \n\nEat only good healthy foods 3 Sore bleeding gums 7 \n\nClean your teeth every day 4 More serious gum disease 8 \n\nCavities, toothaches and abscesses B \n\n\n\nChapter 2: Teaching Family and Friends in Your Community \nChapter 3: Teaching Children at School \n\n\n\nChapter 4: School Activities for Learning about Teeth and Gums \n\n\n\nWhy do we need teeth and gums?. \nWhy do some teeth look different? \n\nWhat holds the teeth? \n\nHow often do teeth grow in? \n\nWhat makes teeth hurt? \n\n\n\n37 How do germs make holes in the teeth? \n\n39 What makes the gums feel sore? \n\n41 What does it mean if a tooth is loose? . \n43 How can we prevent cavities and \n\n40 sore gums? \n\n\n\n9 \n\n19 \n\n35 \n\n50 \n\n52 \n\n54 \n\n55 \n\n\n\nChapter 5: Taking Care of Teeth and Gums \n\n\n\n61 \n\n\n\nPart Two: Treating Dental Problems \n\nChapter 6 : Examination and Diagnosis \n\nWhereto examine 75 A good diagnosis \n\nThe instruments you need 75 Learn to tell similar problems apart \n\n\n\nChapter 7: Treating Some Common Problems \n\nThe first rule of treatment: stay clean! 8B Dislocated jaw \n\nProblems you will see most often 92 Pain in the joint \n\nCavities 92 Swollen gums and epilepsy . . \n\nAbscess 93 Blood in the mouth \n\nInfected sinus 95 After you take out a tooth \n\nTooth injuries 96 Swelling of the face \n\nLoose tooth 99 Pain from the socket \n\nNew tooth growing in 100 Bleeding from the socket . . . . \n\nGumdisease 101 Tetanus \n\nFever blisters 104 Infection in the spit (saliva) gland. \n\nThrush 105 Sores on the face \n\nCanker sores 106 Noma \n\nSome special problems 108 Tumor \n\nBroken bone 108 Cancer \n\nWWW. ncspcrK.n.or_ \n\n\n\n73 \n\n76 \n\n80 \n\n85 \n\n113 \n\n114 \n\n115 \n\n116 \n116 \n116 \n\n117 \n\n118 \n118 \n\n119 \n\n120 \n121 \n125 \n125 \n\n\n\n127 \n\n\n\nChapter 8: Scaling Teeth \n\nChapter 9: Injecting Inside the Mouth \n\nChapter 1 0: Cement Fillings \n\nChapter 1 1 : Taking Out a Tooth \n\n\n\nThe instruments you need 154 False teeth \n\nWhere you work is important 156 Problems that can occur \n\nHow to take out the tooth 157 Clean your instruments after you finish \n\nHowto place a suture 161 \n\n\n\nChapter 1 2: HIV and Care of the Teeth and Gums \n\nWhat is HIV? 171 White or yellow patches in the mouth . \n\nHow is HIV spread? 172 Sores of the skin of the mouth \n\nWhogetsHIV? 173 Infection of the gums \n\nHow HIV affects the mouth 173 Cold sores or fever blisters \n\nHow to examine the mouth for Red or purple patches in the mouth . . . \n\nsigns of HIV or AIDS 174 pry q|- painful mouth and throat \n\nDental care for a person with HIV 177 Helping people with HIV in \n\nCommon problems caused by HIV your community \n\nand how to treat them 178 Working for change in your community \n\n\n\nAppendices \n\nGet Rid of Wastes Safely 199 \n\nThe Dental Kit 201 \n\nMedicines 202 \n\nSupplies 205 \n\nInstruments 207 \n\nRecords, Reports, and Surveys 212 \n\nResources 215 \n\nVocabulary 217 \n\nIndex 222 \n\nOther Books from Hesperian 230 \n\n\n\n135 \n\n143 \n\n153 \n\n163 \n\n165 \n\n167 \n\n169 \n\n. 180 \n. 182 \n. 183 \n. 186 \n. 188 \n. 189 \n\n. 190 \n. 191 \n\n\n\nWWW \n\n\n\n\nINTRODUCTION \n\nby David Werner \n\n\n\nA healthy tooth is a living part of the body. It is connected by 'life-lines' of \nblood and nerve to a person's heart and brain. To separate the tooth from the \nbody, or even to interrupt those 'life-lines', means death to the tooth. It also \nmeans pain and Injury to the body, to the person. \n\nLet us look at It another way. The health of the teeth and gums Is related to \nthe health of the whole person, just as the well-being of a person relates to \nthe health of the entire community. \n\nBecause of this, the usual separation between dentistry and general health \ncare Is neither reasonable nor healthy. Basic care of the teeth and gums — \nboth preventive and curative — should be part of the 'know-how' of all primary \nhealth care workers. Ideally, perhaps. Where There Is No Dentist should be \na part of Where There Is No Doctor. Think of It as a companion volume, both \nto Where There Is No Doctor and Helping Health Workers Learn. \n\nMurray Dickson has taken care to write this book in a way that will help the \nreaders see dental care as part of community health and development. The \napproach is what we call 'people centered.' \n\nWhere There Is No Dentist is a book about what people can do for \nthemselves and each other to care for their gums and teeth. It Is written for: \n\n• village and neighborhood health workers who want to learn more \nabout dental care as part of a complete community-based approach to \nhealth: \n\n• school teachers, mothers, fathers, and anyone concerned with \nencouraging dental health in their children and their community: and \n\n• those dentists and dental technicians who are looking for ways to \nshare their skills, to help people become more self-reliant at lower cost. \n\nJust as with the rest of health care, there Is a strong need to \n'deprofessionallze' dentistry — to provide ordinary people and community \nworkers with more skills to prevent and cure problems In the mouth. After \nall, early care Is what makes the dentist's work unnecessary — and this is the \ncare that each person gives to his or her own teeth, or what a mother does \nto protect her children's teeth. \n\n\n\nWWW. iicrpcriaix.or^ \n\n\n\nWhile dental disease is decreasing in richer countries, it is on the increase \nin most poor countries. One reason for this is that people are eating fewer \ntraditional (unrefined) foods and more pre-packaged commercial foods, often \nsweetened with refined sugar. \n\nEven as the need for dental care is growing, there are still far too few \ndentists in poor countries. Most of those few work only in the cities, where \nthey serve mostly those who can afford their expensive services. \n\nPeople in many countries cannot afford to pay for costly professional dental \ncare. Even in rich countries, persons who do not have dental insurance often \ndo not get the attention they need — or go into debt to get it. \n\nTwo things can greatly reduce the cost of adequate dental care; popular \neducation about dental health, and the training of primary health workers \nas dental health promoters. In addition, numbers of community \ndental technicians can be trained — in 2 to 3 months plus a period of \napprenticeship — to care for up to 90% of the people who have problems of \npain and infection. \n\nDentists' training usually includes complicated oral surgery, root canal \nwork, orthodontics (straightening teeth), and other complex skills. Yet most \ndentists rarely do more than pull, drill, and fill teeth — skills that require a \nfraction of the training they have received. The simpler, more common \ndental problems should be the work of community dental technicians who \nare on the front lines (the villages), with secondary help from dentists for \nmore difficult problems. \n\nWould this reduce quality of service? Not necessarily. Studies have shown \nthat dental technicians often can treat problems as well as or better than \nprofessional dentists. In Boston (U.S.A.), for example, a study showed many \nof the basic treatments commonly given by dentists to be done just as well, \nand often better, by dental technicians with much shorter training. \n\nFortunately, in some countries skilled dental technicians have managed to \nbecome the major providers of the most needed dental services. In India, \nthere are still 'street-corner' dental technicians with footpedal drills, who drill \nand fill teeth at remarkably low cost. \n\nIn Elonduras, dental technicians (who learn largely from each other, \nstarting as helpers) have formed their own union. Their political strength \nwas tested when, in the town of Trujillo, a dentist tried to put a technician \nout of business. The local technician had removed an infected root left \nmistakenly by the dentist. The technician had commented on the dentist's \ncarelessness, and the dentist heard about it. The dentist sent a policeman \nwho shut down the technician's office and took away his tools. However, \nthe dental technicians' union look this to court. They argued their rights to \n\n\n\nWWW. ncspcriai-.orj \n\n\n\npractice dentistry, because they are the only persons working in marginal \ncommunities where dentists' prices are too high for the people. The court \ndecided in favor of the technicians, and ordered the dentist to return the \ntechnician's tools and pay him for work lost. \n\nIn other countries dentists and community dental workers work in closer \nharmony. In Guatemala, Ecuador, Papua New Guinea, and Mozambique, \ndental technicians are now recognized by the Ministries of Health. In Papua \nNew Guinea and Ecuador, professional dentists train and supervise them \nto provide dental care to school children. In Ecuador, they work mostly \nas dentist assistants, bringing high quality services to more people while \ndecreasing costs. The 'dental therapists' in Papua New Guinea are trained \nto extract, drill, and fill teeth, as well as to work on prevention of dental \nproblems in school children. \n\nIn Guatemala and Mozambique, dentists from the dental school have trained \nvillage health promoters as dental workers who work with people of all ages. \nTheir training includes community dental health education, cleaning of teeth, \nextractions, and drilling and filling. These health workers are provided with \nthe few basic instruments needed to provide these services. \n\nIn Project Piaxtia Mexico (with which I and the Hesperian Foundation have \nworked for many years), visiting dentists have also helped train village \n'dentics'. They, in turn, now teach basic dental skills to the part-time village \nhealth workers. These village dentics, some of whom have had only 3 \nto 6 years of primary school, now practice — and teach — a wider range of \ndental skills than the average dentist. Their activities include dental health \ncampaigns with school children, community puppet shows about low-cost \ndental self-care, cleaning of teeth, extractions, drilling and filling, and the \nmaking of dentures (false teeth). Several of the dental workers can now do \nroot canal work — a special treatment to remove the central nerve in order to \nsave an infected tooth. One of the village dentics, remembering what he had \nseen a dentist do, taught himself how to do root canals when his girlfriend \nhad an infected front tooth that he did not want to pull. (He had also learned \nto check the tooth from time to time afterward to make sure this treatment \nhad been successful.) \n\nWe still have much to learn about dental health. Dentists need to learn from \nthe knowledge of the local people, as well as the people from the dentists. \n\nWe have learned that villagers with little formal education often can learn \nskills with their hands — such as tooth extractions, puppetry, or surgery — \nmuch faster than university students (who have never learned to use their \nhands for much more than pushing pencils). We also have observed that \nthe best way to learn dentistry is not through school but through practice, \nhelping someone with more experience who is willing to teach. \n\n\n\nWWW. \n\n\n\nne'^pcriaix.or: \n\n\n\nWhere There is No Dentist has 2 parts. The first part (Chapters 1-5) \ndiscusses teaching and learning about preventive care. It begins by \nencouraging the health worker to examine herself and her family. To be a \ngood example is the best way to teach. \n\nThe second part (Chapters 6-1 1 ) talks about diagnosing and treating \ncommon dental problems. It is especially for those who live where they \ncannot reach or afford a dentist. A poor neighborhood in the city can be \nas distant and neglected as a far-off village. This second part is intended \nmainly for health workers who have helped organize people to meet their \nown needs. \n\nMurray Dickson — a Canadian with primary care experience in Northern \nCanada, Nigeria, Papua New Guinea, and Mozambique — has written this \nbook in clear, simple language. He takes care to use popular names instead \nof unfamiliar scientific words. For example, instead of speaking of 'dental \nplaque' the author speaks of the 'coating of germs on the teeth.' Such \nsimple language does not weaken the message. The message is stronger \nbecause everyone understands. \n\nThe author has said: \n\nI am sure some dentists will disagree with parts of this book. \n\nSome points of disagreement may be small, like the failure to \nuse accepted dental terminology. Other ideas, particularly the \nsuggestion that non-dental people can be trained to provide \nmany kinds of treatments, may make some dentists angry. \n\nThe book is meant to be a source for argument and \ndiscussion. This way, it may stimulate others to write the kind \nof manual that is really needed in their countries. \n\nThe people must answer to the people's needs. The health of teeth and \ngums, along with general health, will improve only when people take the \nlead in caring for themselves. The challenge for dentists and other health \nprofessionals is to allow and encourage this to happen. \n\n\n\nw w w. ncspcrisn .org \n\n\n\nCHAPTER \n\n\n\nYour Own Teeth \nand Gums \n\n\n\nNext time you look in a mirror, look at your teeth and the skin (gums) around \nthem. Look in your children's mouths, too. Look at both gums and teeth, \nbecause the health of one often depends on the health of the other. To be \n\nstrong, teeth need healthy gums. Healthy gums need clean teeth. \n\n\n\nWhat can good teeth \ngive you? \n\n. GOOD HEALTH \n. GOOD LOOKS \n• GOOD SPEECH \n. GOOD EATING \n. GOOD BREATH \n\n\n\n\nAnd when you think of your teeth, think of your gums. Gums are \nimportant for holding each tooth in place. \n\nYou need strong teeth to eat different kinds of foods. Different foods are \nimportant for health. Nuts, maize, fruits, and meat are some of the best \nfoods — but they are difficult to bite and chew if your teeth are loose and \nhurtingl \n\n\n\nfw' .. ncspcriaii.org \n\n\n\n1 \n\n\n\n2 Where There Is No Dentist 2010 \n\n\n\nYou can usually tell if your teeth and gums are healthy or not. Look at the \npictures on pages 73 and 74 and compare them with your own mouth. If you \nfind a problem in your mouth, look for its name in Chapter 6 and look for its \ntreatment in Chapter 7. \n\n\n\nMost important: when you are not sure of a problem or \nhow to treat it, talk to an experienced dental worker. \n\n\n\nIf you notice a problem early, often you can stop it from getting worse. It \nis even better to prevent the problem from starting. You can do this if you \nknow how to keep your teeth and gums healthy. \n\n\n\nLearn to take care of your own teeth and gums before you try to teach \nothers. A good example is one of your best teaching tools. People will see \nthat you are healthy, and they will want to know why. When you tell people \nways to care for their teeth, they will believe you if they know that you do \nthese things yourself. First take care of your own teeth and gums. Then \nteach your family what you have learned. They, too, will be good examples \nfor others to see. \n\n\n\n\nWhere There Is No Dentist 2010 3 \n\n\n\nEAT ONLY GOOD HEALTHY FOODS \n\nThe best food is food that you grow or raise yourself. Mix different kinds of \nfood together and eat several times a day. This helps your body as well as \nyour teeth and gums to stay strong and healthy. Traditional food is usually \ngood food. \n\nSweet food, especially the kind you buy from the store, can mix with germs \nand make cavities — holes in the teeth. Soft food sticks to the teeth easily \nand it, too, can make a coating of germs and food on the teeth that starts an \ninfection in the gums — gum disease. \n\n\n\nSoft and sweet food \nand drinks with a lot \nof sugar are bad for \nboth teeth and gums. \n\n\n\n\n\nBreast feed to help a child's teeth \ngrow and stay strong. An older child \ncan drink from a cup. \n\n\n\n\nYES \n\nGOOD FOR TEETH \n\n\n\nDo not give a baby anything to drink \nfrom a bottle. Sweet tea, sugar water \nor fruit juice can easily make holes in \nthe child's teeth. \n\n\n\nREMEMBER: \n\nBREAST \n\nIS \n\nBEST! \n\n\n\n\nNO \n\nBAD FOR TEETH \n\n\n\nEven milk has sugar that can wash over the baby's teeth and cause cavities \nwhen it comes from a bottle. \n\n\n\n.vw' , . ncspcrian.org \n\n\n\n4 Where There Is No Dentist 2010 \n\n\n\nCLEAN YOUR TEETH EVERY DAY \n\nIf you do not clean properly, the food that is left on your teeth can hurt the \nteeth as well as the gums near them. \n\n\n\nHIDING PLACES \n\n\n\n\nHere are 3 places where problems start. \n\n\n\nBits of food Stay longer in \ngrooves and 'hiding places'. \nThis is where both tooth and \ngum problems start. \n\nTo prevent problems you \nmust take special care to \nkeep these protected places \nclean. \n\nIt is better to clean your \nteeth carefully once every \nday than to clean poorly \nmany times a day. \n\n\n\nUse a soft brush to clean your teeth. Buy one from the store (be sure it says \nsoft on the package), or make a brush yourself. To make a brush: \n\n1. Use a small branch of young 2. Cut a piece that is \n\nbamboo, strong grass, or the skin still green and soft, \n\nfrom sugar cane or betel nut. \n\n\n\n\n\n3. Chew one end to make it \nstringy like a brush. \n\n\n\n\n4. Sharpen the other end so \nit can clean between the \nteeth (see pages 71-72). \n\n\n\n\nWhere There Is No Dentist 2010 5 \n\n\n\nYou can twist the fiber from inside a coconut husk into a kind of brush. First \nrub it and shake away the loose bits. Then use the end to clean your teeth. \n\n\n\n\nWhatever kind of brush you use, be sure to clean your back teeth as well as \nyour front teeth. Scrub the tops and sides where the grooves are. Then push \nthe hairs between the teeth and scrub (page 69). \n\n\n\nToothpaste is not necessary \n\nCharcoal or even just water is \nenough. When your teeth are \nclean, rinse away the loose \npieces of food. \n\n\n\n\n;vw' , . hcspcrisn-org \n\n\n\n6 Where There Is No Dentist 2010 \n\n\n\nCAVITIES, TOOTHACHES AND ABSCESSES \n\n'Cavities' are holes in teeth. Cavities are made by the infection called tooth \ndecay. If you have a black spot on your tooth, it might be a cavity. If that \ntooth hurts some of the lime, such as when you eat, drink, or breathe cold \nair, it probably has a cavity in it. \n\nYou will get cavities in your teeth if you eat sweet food and then do not \nclean your teeth. If you see a cavity starting in your mouth or feel a \ntooth hurting you, get help right away. If you do not fill a cavity, it grows \nbigger and deeper. A dental worker knows how to fill the cavity so you can \nkeep that tooth. Do this before the pain gets worse. \n\n\n\n\nEach tooth has roots \nthat hold it in the \njaw bone. Inside \neach root is a nerve, \n(p. 39 to 40 and 45) \n\n\n\n\nWhen decay \ntouches the nerve \ninside the tooth \naches, even when \nyou try to sleep. \n\n\n\n\nWhen infection \nreaches the \ninside of a root, \nit is called a \n\ntooth abscess. \n\n\n\nA tooth with an abscess needs treatment at once, before the infection \ncan go into the bone (page 93). In most cases the tooth must be taken \nout. If it is not possible to do this right away, you can stop the problem from \ngetting any worse if you follow these steps: \n\n\n\n1 . Wash the inside of your mouth with warm \nwater. This removes any bits of food \ncaught inside the cavity. \n\n2 . Take aspirin or acetominophen for pain. \nSee page 95 for amount. \n\n3 . Reduce the swelling: \n\n• hold warm water inside your mouth \nnear the bad tooth. \n\n• Wet a cloth with hot water and \nhold it against your face. Do not \n\nuse water hot enough to burn \nyourself! \n\n\n\n\nA tooth abscess can cause \nswelling like this. \n\n\n\nWhere There Is No Dentist 2010 7 \n\n\n\nSORE BLEEDING GUMS \n\nHealthy gums fit tightly around the teeth. Gums are infected if they are \nloose, sore, and red, and if they bleed when the teeth are cleaned. Infection \nin the gums is called gum disease. \n\nGum disease, like tooth decay, happens when acid touches the teeth and \ngums. This acid is made when sweet and soft foods mix with germs (see \npage 50). \n\n\n\nHEALTHY TEETH AND GUMS CAVITIES AND GUM DISEASE \n\nInfection from gum disease can spread into the root fibers and bone (see \npage 42). But you can stop gum disease and prevent it from coming \nback. There are two things to do: clean your teeth better and strengthen \nyour gums. \n\n1 . Even if your gums are sore and they bleed, you must still clean the \nteeth beside them. If more food collects on the teeth, the gum \ninfection will get even worse. Get a soft brush (see p. 4) and use it \ngently. This way you will not hurt the gums when you clean. \n\n2 . To make your gums stronger and more able to fight the infection: \n\n• Eat more fresh fruits and green leafy vegetables, and fewer soft \nsticky foods from the store. \n\n• Rinse your mouth with warm salt water. Do this every day, even \nafter your gums feel better. \n\n\n\n\n(1 ) Mix some salt with a cup of warm water. (2) Take a mouthful \nand rinse. (3) Spit it out. Repeat until all of the salt water is finished. \n\n\n\n\n\nfw'_. hcspcri^n.org \n\n\n\n8 Where There Is No Dentist 2010 \n\n\n\nMORE SERIOUS GUM DISEASE \n\nPainful gums that bleed at the slightest touch need special treatment. If \nyou have this problem, ask for help. A dental worker can explain what is \nhappening and what needs to be done. A dental worker can also scrape the \nteeth and remove the tartar that is poking the gums, making them sore. \n\nAt home, you can do some things to help. \n\n• Clean your teeth near the gums with a soft brush. Gently push the \nbrush between the tooth and the gum. It may bleed at first, but as the \ngums toughen, the bleeding will stop. \n\n• Make your food soft, so it is easier to chew. Pounded yam and soup \nare good examples. \n\n• Eat plenty of fresh fruits and vegetables. If it is difficult for you to bite \ninto fruit, squeeze it and drink the juice. \n\n• Start rinsing your mouth with a mixture of hydrogen peroxide \nand water. You can get hydrogen peroxide from your clinic or your \npharmacy (chemist). \n\nThe strength of hydrogen peroxide is important. Ask for a 3% \n\nsolution, and mix it evenly with water — that is, V 2 cup of hydrogen \nperoxide with 14 cup of water. \n\n\n\nWARNING: Read the label to be sure the solution \nis 3%. A mixture with more than 3% \nhydrogen peroxide can burn the mouth. \n\n\n\n\nTake some into your mouth and hold it there for \nabout 2 minutes. Then spit it out and repeat. Do \nthis every hour you are awake. \n\nUse hydrogen peroxide for only 3 days. Then \nchange and start rinsing with salt water (page 7). \n\n\n\nIf you take care, you can keep your teeth for a lifetime. \n\n\n\n\nCHAPTER \n\n\n\nTeaching Family and \nFriends in Your Community \n\n\n\nOld people can remember when there were fewer problems with teeth and \ngums. Children's teeth were stronger and adults kept their teeth longer. \n\nTimes are changing. Today there are more tooth and gum problems than \never before. In many countries, tooth decay and gum disease are two of the \nfastest growing health problems. \n\nThis unhealthy situation is getting worse, for two reasons: changes in the \nkind of food people now are eating, and not enough cleaning after they eat. \n\n\n\nBEFORE, the food people ate \nwas their own, grown and \nprepared by themselves. \n\n\n\n\nEven sugar cane was not as bad \nas the sticky candy children eat \ntoday. The sugar was bad for the \nteeth, but the fiber in the cane \nhelped rub them clean. \n\n\n\nNOW, more people are buying \nsofter and sweeter food from \nthe store. This kind of food \nsticks to the teeth more easily \nso it has more time to attack \nthe teeth and gums. \n\n\n\n\nEveryone must be more careful \nto clean away soft, sweet \nfood. But many people do not \nknow how. Some, especially \nchildren, do not even try. \n\n\n\n9 \n\n\n\n10 Where There Is No Dentist 2010 \n\n\n\nMany people do not understand that tooth and gum problems are caused \nby certain kinds of food, and poor cleaning of the teeth. In fact, some have a \ncompletely different belief. \n\n\n\n\nDo not attack a belief because it is traditional. Many traditions are more \nhealthy than 'modern' things. Often, instead of telling people that their belief \nis wrong, you can remind them of a different tradition that is healthy. \n\n\n\nHelp your family and friends to recognize their \nhealthy traditions. Then help them find new ways \nto use these same traditions for better health. \n\n\n\n/OUR PEOPLE DO NOT \n\nI USE toothbrushes. \n[WE DO NOT HAVE MONEY \niTO BUY SUCH THIN&S \nV. AT THE STORE. \n\n\n\n^BUT WE CAN make \n' FOR ourselves many \n^OF THE THIN&S THE \nSTORE SELLS. \n\n\n\n\n\nYES, AND V/E CAN^ \nMAKE OUR OWN \n\nToothbrushes frdm\\ \n\nTHE TWI6- OF A TREE/ I \n\n\n\nWhere There Is No Dentist 2010 11 \n\n\n\nBE A GOOD EXAMPLE \n\nOther people like to watch what you do before they try something different. \nFirst show members of your family and then they will be an example to \nothers in your community. For example: \n\n\n\n1 . Instead of buying all your foods from the store, buy fresh fruits and \n\nvegetables from the market. It is even \nbetter to grow food in your own garden. \n\nLearn to use several different kinds of \nfoods in each meal. Mixing foods is a \nhealthy idea. Invite friends to share your \nmeals and see the number of different \nfoods you have at each meal. \n\n\n\n\n2 . Do not buy fizzy drinks like Coca-Cola or Fanta. \nThey have a lot of added sugar which quickly \nmakes children's teeth rotten. \n\nAlso, do not sweeten your child's milk or tea. \n\nWhen she is young she can learn to enjoy \ndrinks that are not sweet. \n\nClean, cool water, tea with little sugar, milk, or \nwater from a young coconut are best to drink. \nFresh fruits are delicious when you are thirsty. \n\n\n\n\nMost important: do not give your child feeding bottle, \nespecially one with a sweet drink inside. (See page 3.) \n\n\n\n\n3 . Keep your children's teeth clean. \nYour friends will notice clean \nteeth or teeth that are dirty or \nhave cavities. Remember, clean \nteeth are healthy teeth. \n\nAn older child can clean his own \nteeth if you show him how. \n\nA younger child cannot. Fie needs \nhelp. Each day someone older \nshould clean his teeth for him \n(page 18). \n\n\n\n12 Where There Is No Dentist 2010 \n\n\n\nWhen you teach, remember that as others learn, they \ntoo become teachers. Each person can teach another. \n\n\n\nEncourage people to pass along what you have taught. Mothers can teach \nfamily and friends. Students can talk at home with brothers, sisters, and \nolder family members. \n\n\n\nFROM THE HEALTH CLINIC... \n\n\n\n...TO THE HOME \n\n\n\n\nnSASE HELr \nME CtEAN BABY’S \nTEETH AMD THEN \n\nbrother’s teeth. \n\nWE WILL PO IT \nEVERY PAY. \n\n\n\n/ FIRST, I \nMUST CLEAN \nMY OWN \n\nteeth properly, \n\n\n\n\n\nFROM THE SCHOOL... \n\n\n\n...TO THE HOME \n\n\n\n^ROTHER, TRY TO BRUSH^ \n/ YOUR back teeth BETTER, \nj IF YOU DO, THEN THEY \n\\ WILL STAY STRON& UNTIL \n\n\n\n\nIf all learners become teachers, a simple message can begin in the health clinic or \nschool and reach many more people at home. \n\n\n\nWhere There Is No Dentist 2010 13 \n\n\n\nFINDING THE BEST WAY TO TEACH \n\nDeciding what to teach is important, but just as important is how to teach. \n\n\n\n\nLearning cannot take place \nwhen you use words that \npeople do not understand. \nThey will learn something \nonly when they see how it \nis related to their lives. \n\n\n\nRemember this when you teach about eating good food and keeping teeth \nclean. Design your own health messages, but be ready to change them if \npeople are not understanding or accepting what you say. \n\nHere are five suggestions for teaching well. \n\n1. Learn First From the People \n\nGet involved in your community's activities. Learn about people's \nproblems, and then offer to help solve them. People will listen to you \nwhen they know that you care about them and want to help. \n\nSit and talk with people. Learn \nabout their customs, traditions \nand beliefs. Respect them. \n\nLearn about their health habits. \n\nImproving health may require \nchanging some habits and \nstrengthening others. \n\nLearn also about tooth \ndecay and gum disease in \nyour community. \n\n\n\n\n\nMake people smile — then look into their mouths. \n\nFind out how many children and adults are having \nproblems with their teeth and gums. Do a survey \nsuch as the one on p. 214. \n\n\n\n14 Where There Is No Dentist 2010 \n\n\n\n2. Build New Ideas Onto Old Ones \n\nPeople find their own ways to stay healthy. Many traditions are good, \nhelpful, and worth keeping. But some are not. \n\nWhen you teach, start with what people already understand and are \ndoing themselves. Then add new ideas. \n\nThis method of teaching is called 'association of ideas'. It helps people \nto understand new ideas because they can compare them with what \nthey already are doing. \n\nIn this way people can more easily accept, remember, and do what you \nsuggest. \n\n\n\n\nSweeping the compound \nmakes it a clean and \nhealthy place to live. \n\n\n\nin the \nsame \nway \n\n\n\nBrushing the teeth and gums \nkeeps them clean and healthy. \n\n\n\n\n\n\n\nA small child cannot find \nhis own lice. Mother \nknows she must help him. \n\n\n\n\nin the \nsame \nway \n\n\n\nA small child cannot see the \nfood on his teeth. He needs \nhelp with that also. \n\n\n\n\nDifferent vegetables in the \n\nwhen planted together — same \n\nlike maize and yams — \nhelp each other to grow. \n\n\n\n\nEating different kinds of food \nhelps people to grow. Eating \nthem several times a day makes \nyour teeth and gums, as well as \nyour whole body, grow stronger. \n\n\n\nWhere There Is No Dentist 2010 15 \n\n\n\nSTORY TELLING— AN EXAMPLE \n\nPeople everywhere have a tradition of teaching with stories. Many of the \nthings we believe, we learned through stories we heard from parents, \nfriends, and teachers. This is good, except when a story teaches something \nthat isn't truel When a woman gets pregnant, for example, she hears \nmany stories, and she wants to learn whatever she can from these stories. \nUnfortunately, some traditional beliefs about pregnancy are partly \nwrong. An example is the belief that one must always have dental problems \nduring pregnancy. \n\nHere is a story you can tell to help people see that they are partly right about \npregnancy and dental problems, but that there is more to understand. \n\n\n\nA Story: Bertine's teeth \n\nBertine was the dental worker in her village. She was a young woman, but \nthe villagers respected her because she was such a careful worker, and \nbecause she knew how to fill cavities and pull teeth without hurting people. \nShe also spent a lot of time teaching people how to avoid dental problems. \n\"Clean your teeth every dayl \" she often said, at her clinic, at the schools, at \nvillage meetings. \"Eat a mixture of foods, \nespecially a lot of fruits and vegetables! \n\nAvoid candy and sweet, sticky foods! \" \n\nWhen Bertine was 23 years old, she got \nmarried and became pregnant. She also \nbegan to have some tooth problems of \nher own. She saw that her gums were \nbleeding when she cleaned her teeth, \nand she had small cavities in two of her \nteeth. As the dental worker, she was \nembarrassed to have tooth problems, \nbut an older woman told her, \"It's natural \nto lose teeth when you have babies, \n\nBertine. As we say, 'For each child, a \ntooth'.\" \n\nOne day Lucie, a dental worker from a nearby village, came to see her friend \nBertine. Lucie had a young baby, and Bertine asked her a lot of questions \nabout babies and about pregnancy. Then Bertine said, \"Of course. I'm having \nlots of problems with my teeth.\" \"Why do you say 'of course'?\" asked \nLucie. \"Well,\" Bertine replied, \"For each child, a tooth.\" \n\n\"But that's not true! \" Lucie cried. \"You think you are having tooth and gum \nproblems because you are pregnant, but I bet you are having these problems \nfor all the usual reasons.\" \n\n\n\n\n16 Where There Is No Dentist 2010 \n\n\n\n\"The usual reasons?\" asked Bertine. \n\n\"Yes,\" said Lucie. \"How often do you eat now that you are pregnant?\" \n\"Well, a lot more than I used to — I have two persons to feed I \" \"And do you \nstill eat sweet foods sometimes?\" Lucie asked. \"I guess I do,\" said Bertine, \n\"and more sweets than before, because I eat more often.\" \n\n\"How about teeth cleaning?\" asked Lucie. \"Do you clean as often as you did \nbefore you were pregnant?\" \"No,\" Bertine admitted, \"I heard I was going to \nhave tooth problems anyway, and I have been so tired lately.... OhI Do you \nsuppose that these are the only reasons I am having these problems? How \ndo you know so much about this, Lucie?\" \n\n\"Because I had the same problems, Bertine. I learned the truth the hard \nway. I had an infected tooth, and the infection passed to my kidneys. At the \nhealth clinic, they told me it is not necessary to have tooth problems during \npregnancy — and it is even dangerous. I am lucky I did not lose my baby! \n\nThat can happen, you know, when a tooth problem is not treated. We must \nfill your cavities right now.\" \n\n\"You mean I can be treated now, before I have my baby?\" \n\n\"Yes, and you should!\" said Lucie. \"And \nyou can take better care of your teeth. \n\nIt is true that because of the pregnancy, \nyour gums are weaker, and they can get \ninfected. But this means you should take \neven more care than usual to: ( 1 ) clean \nregularly and ( 2 ) eat the right foods. You \nneed to have strength when you are \npregnant. An infection in your mouth does \nnot help that. Because your gums are \nweak, it is also good to ( 3 ) rinse your mouth \nevery day with warm salt water (see page \n7), and if you cannot get fresh fruits and \nvegetables, then ( 4 ) take a tablet of Vitamin \nC every day.\" \n\nLucie then offered to clean Bertine's teeth and to fill her cavities. When she \ntouched Bertine's gums, they bled, and Lucie said, \"They will bleed at first, \nbut after you clean them regularly for a while, they will be stronger. Bleeding \ngums are dangerous to a pregnant woman. The bleeding can increase \nanemia, which is a serious problem.\" \n\n\"If a pregnant woman's tooth has an abscess, is it safe to pull it before she \nhas the baby?\" asked Bertine. \"Yes,\" said Lucie, \"you just must be gentle. \n\nA woman gets tired sitting in a dental chair for a long time, and sometimes \nyou must give some extra anesthetic so she does not feel any pain.\" \n\n\n\n\n\nWhere There Is No Dentist 2010 17 \n\n\n\n3 . Keep Your Messages Short and Simple \n\nInstead of partially teaching too many things, it is better to discuss a \n\nfew things well. After learning what health problems the people feel are \n\ngreatest, decide what information will help them solve these problems. \n\nThen think of how to share the information. Try to: \n\n• Use simple words (see page 13). If you must use a big word, take \nthe time to explain it. \n\n• Teach people when they are ready to learn. A sick person, for \nexample, usually wants to know how to prevent his sickness from \nreturning. He will remember what you tell him. \n\n• Repeat the most important message many times. Whenever you \nteach about staying healthy, remember to emphasize eating good \nfood and keeping teeth clean. Repetition helps people remember. \n\n• Let people see what you mean. See pages 26 to 34 for ways to use \npictures, puppets, and plays. \n\n\n\n4 . Teach Wherever People Get Together \n\nKnowing where to teach is sometimes as important as how you teach. \nInstead of asking people to come to a class you have organized, go to \nthem. Look for ways to fit into their way of living. You both will gain \nfrom the experience. They will ask more questions, and you will learn \nhow to work with people to solve problems. \n\n\n\nTalk with people where they gather near their homes. \n\n\n\nTalk to \nwomen at \nhealth clinics \nand in the \nmarket. Talk \nto men at \nbusiness \nand farming \nmeetings. \n\n\n\n\nTalk to men \n\n\n\nand women \n\n\n\nat church \nmeetings, \nin parents' \n\n\n\ngroups at their \nchildren's \nschool, and \nat community \nmeetings. \n\n\n\nTeach men and women at reading groups. \n\n\n\n18 Where There Is No Dentist 2010 \n\n\n\n5. Teach Something People Can Do Right Away \n\nIt is good to tell a mother to keep her child's teeth clean, but it is \nbetter to show her how to do it. She will remember how if she actually \nwatches you clean her child's teeth. \n\nAn even better way for a mother to learn is to let her clean her child's \nteeth while you watch. A person discovers something for herself \nwhen she does it herself. \n\n\n\n\nPick out a child and clean his teeth yourself. \nLet his mother watch. \n\nUse a soft brush (or for a baby, a clean cloth). \nGently but quickly brush or wipe his teeth. Do \nthe best you can even if he cries. \n\nIf mothers make this into a habit, the child will \nexpect to have his teeth cleaned and will soon \ncooperate — ^just the way he does to bathe or \nto have lice removed from his hair. \n\n\n\n\nNow let each mother clean her \nown child's teeth. Teach her to \nclean on top and on both sides \nof every tooth. \n\n\n\nAsk her to do the same at home \neach day. At the next clinic, look \nat the children's teeth and see \nhow well the mothers are doing. \nGive further help when needed. \nAlways praise and encourage \nthose who are doing well. \n\n\n\nTeaching Children \nat School \n\n\n\nCHAPTER \n\n\n\nChildren want to learn. The want to know more about things that are real \nto them. Family, friends, and teachers are all important sources of new \nknowledge for children. \n\n\n\nIt is important to keep alive their desire to learn, so that \nchildren can continue to ask questions, discover, and \nlearn more for themselves. \n\n\n\nWhen children are interested in something, they \nwill work hard to learn all they can about it. \n\n\n\n\nIf you relate your teaching to children's interests and needs, they will learn \nmore easily. New information added to what they already know helps \nchildren to understand your lesson better. As a result, they will want to learn \nmore because the information is both interesting and worthwhile. \n\nTeaching about teeth and gums is important. You must do it well if you want \nchildren to pay attention, learn, and finally act to take care of their own teeth \nand gums. \n\nAs school children continue to learn, they can share their new ideas \nand information at home with brothers, sisters, mothers, fathers, and \ngrandparents. In this way, the circle of teaching and learning described on \npage 12 comes back into the family and is complete. \n\nThis chapter has two parts. Part 1 gives seven guidelines for assuring that \nlearning takes place. Part 2 suggests ways to have fun while learning — with \nstories, games, and pictures. In Chapter 4 there are nine questions on teeth \nand gums with specific activities for learning how to answer them. \n\n\n\n19 \n\n\n\n20 Where There Is No Dentist 2010 \n\n\n\nPARTI: \n\nTEACHING SO THAT LEARNING CAN TAKE PLACE \n\n\n\nMore children than ever before are having \nproblems with their teeth and their gums. \n\nA tooth that hurts or gums that are \nsore can affect a student's ability to pay \nattention in school and learn. \n\nTreating the problem makes the child feel \nbetter, and that is important. It is equally \nimportant to prevent the same problem \nfrom returning later. \n\n\n\n\nWorking together, teachers and school children can do much \nto prevent both tooth decay and gum disease. \n\n\n\nKeeping the mouth healthy involves learning about eating good food and \nkeeping teeth clean. Just giving information is not enough, though. To truly \nlearn, children need a chance to find out things for themselves. \n\nForcing a person simply to accept what \nyou say does not work very well. \n\nA student learns not to question. What \nyou teach may have no relation to his \nown experiences and needs. \n\nAs a result, he may end up not doing \nwhat you teach — not eating good foods, \nand not cleaning his teeth. \n\n\n\nLearning happens when a student with a \nquestion or an idea is able to discover more \nabout it himself. \n\nIt also happens when he has a chance to do \nwhatever is necessary to take better care of \nhimself and his family. \n\nFie can learn by doing. Give him a chance to \neat good food and clean his teeth at school. \n\n\n\n'WE.UL, I WOULD LIKE To\\ \n^LOOK AT MY BROTHER’S ) \nTEETH FIRST. Tx \n\n\n\n\n\nWhere There Is No Dentist 2010 21 \n\n\n\nLearning about teeth and gums can be fun. When the teaching is real and \npractical, students love to learn. Here are some ideas: \n\nTeaching so that learning can take place \n\n1 . Teach and learn together with your school children. \n\n2 . Start with what the students already know. \n\n3 . Let students see and then do. \n\n4 . Let children help each other. \n\n5 . Teach about teeth and gums together with other subjects. \n\n6 . Be a good example. \n\n7 . Make the community part of your classroom. \n\n\n\n\n\n\n(k PERMANENT SUCCESSOR uES' \n\napjcau to... pm attention ! \n\nYou NEED TO KNOW THIS FOR \nyour TES T'... EACH PRir<\\ARY> \n/’\" /2o \n\n\n\nAsk the students what other things they saw inside someone else's mouth. \nThis is a good time for students to discover important things about good \nhealth practices. Encourage them to learn as much as they can from what \nthey see, and then show them how to use a book like this to answer their \nown questions. For example, if students see cavities and red bleeding gums, \nyou can start a discussion on tooth decay and gum disease. Use some of the \nactivities on pages 55 to 60. \n\nFor another example, if the students see a baby who has only a few teeth, \nthey may have some interesting questions. Show them this book and invite \nthem to read pages 63 to 65 to find answers to questions like these. \n\n• Can Chenia, who is 6 months old and has no teeth, eat soft foods? \nShould she have more than just breast milk? \n\n• When Chenia's teeth grow in, will they give her diarrhea and fever? \n\n• Will a 2-year-old girl get more baby teeth? \n\n• Why do we care for baby teeth, when we only need them for a few \nyears? \n\n\n\n46 Where There Is No Dentist 2010 \n\n\n\nWhat Makes Teeth Hurt? \n\nTHE IDEA: \n\nA tooth will hurt if it is broken, loose, or if it has a cavity. Cavities are the \nusual cause of toothaches. \n\n\n\nHealthy teeth are alive. \n\n\n\nTwo thin strings enter each tooth. One, the nerve, come from the brain and \ncarries the message of pain. The other is the blood vessel. It comes from \nthe heart and carries blood to the tooth. \n\n\n\nIf you could peel away \nthe gum and look inside \nthe bone, you would see \nthat a nerve and a blood \nvessel go into each one \nof a tooth's roots. \n\nThey give the tooth life \nand feeling. \n\n\n\n\nThe hard cover of the tooth protects the nerve and blood vessel inside it. But \nwhen tooth decay eats through that cover, the nerve and blood vessel are \nunprotected. A cavity lets food, water and air get closer to the nerve, and \nthat can make the tooth hurt. \n\nThe sugar in food makes tooth decay possible. Sweet food that is also sticky \nis the worst of all because it glues itself to the teeth. Germs inside your \nmouth use the sugar to grow and to work harder at making cavities. \n\n\n\n\nSee the next section for more discussion of how germs and sugar combine \nto cause cavities. \n\n\n\nWhere There Is No Dentist 2010 47 \n\n\n\nA cavity may look small on the outside, but it is much bigger inside. Decay \nspreads more easily in the soft part under the hard cover of the tooth. \n\nA tooth with a cavity may hurt, but it usually does not hurt all the time. This \nis because the bottom of the cavity is close, but not yet on the nerve inside \nthe tooth. \n\n\n\n\nFill a small cavity and save a tooth. \n\n\n\nA small cavity that is not treated grows bigger and gets deeper. When the \ncavity finally touches the nerve, it causes a tooth abscess. Infection from \nthe tooth decay going inside the tooth causes the tooth to ache all the time, \neven when you try to sleep. \n\nInfection can pass from the tooth to the bone. As it spreads under the skin, \nthere will be swelling of your face. \n\n\n\n\n\nA tooth with an abscess must either be taken out \nor have its nerve treated. \n\n\n\nAn abscessed tooth is dying. When it dies the tooth changes color from \nwhite to dark yellow, grey, or even black. Pus from the end of its root can \npass to the gum, making a sore called a gum bubble. \n\nA tooth is like a light bulb. \n\nWhen the bulb is alive from power inside, it is \nbright and useful. \n\nThe little wires inside the bulb are like the nerves \ninside the tooth. When the bulb burns out, it is dark \nand not useful any more. \n\n\n\n\n48 Where There Is No Dentist 2010 \n\n\n\nACTIVITIES: \n\n1. Have each student look inside a partner's mouth. Look for black \nspots that may be cavities, for dark teeth that are dead, and for sores \non the gums, especially near a bad tooth. \n\n2. Discover how sweet food sticks to teeth. \n\n\n\nCut several different kinds of food with a knife. \n\n\n\nVegetables and meat do not stick to \nthe knife. \n\nSweet foods, like chocolate and \njam buns, do stick to the knife. \n\nThey stick to your teeth the \nsame way. \n\n\n\nPour some cola or juice in a dish, and leave it outside overnight. \n\nAs water is lost, the juice left in the dish \nbecomes sticky. It attracts flies. \n\n\n\n\nThe air you breathe dries the cola and \ncauses a sticky, very sweet coating to \nform on your teeth. It attracts germs. \n\nTry to find some old teeth. Ask the \nstudents to keep their own baby teeth \nwhen they fall out. (Note: in some \ncountries this is not acceptable.) Your \ndental worker can save you some \nteeth that were taken out at the clinic. \n\n\n\n\n\nScrape the outer cover of the root with a knife. Feel how hard and \nsmooth it is. \n\nThen find out what happens \nwhen the students leave a tooth \nin cola, milk, or plain water. \n\nAfter 3 days scrape each tooth \nagain with a knife. Students will \ndiscover that sweet cola drinks \nmake teeth softer and darker \nin color. \n\n\n\n\nWhere There Is No Dentist 2010 49 \n\n\n\n3. Look inside a tooth for the space where the nerve and blood vessel \nused to be. See how close they were to the tooth's hard outer cover. \nLook for a small hole at the end of the root. That is the place where \nthe nerve and blood vessel enter the tooth. \n\n\n\nAsk your dental worker to find an old tooth \nwith a cavity and cut it for you. \n\nOR \n\n• Take a hammer. \n\n• Gently break open a tooth. \n\n• Look inside. \n\nSee how much bigger the cavity is on the \ninside. It spreads under the hard cover. \n\nCut through a rotten yam. See how the \nrotten part spreads under its skin in the \nsame way. \n\n\n\n\n\n\n4. Do a project in class. \n\n• Count the number of students with cavities. \n\n• Count the number of teeth having cavities. Show the students how \nto look for them on the tops, sides and between the teeth. \n\n• Find out the person's age. \n\nFlave the students write on the blackboard what they counted. Then \nmake a chart or graph. \n\n\n\n\n• Decide if tooth decay is a serious problem in your school. Ask your \ndental worker to look at your results and to come and treat the \nstudents, and help you prevent the problem from returning. \n\n• Do the same with brothers and sisters at home. Find out if tooth \ndecay is a problem with these young children. Tell your dental \nworker what you find. \n\n\n\n\n50 Where There Is No Dentist 2010 \n\n\n\nHow Do Germs Make Holes in the Teeth? \n\nTHE IDEA: \n\nAcid makes holes in the teeth. The acid is made when sweet foods mix with \ngerms in your mouth. \n\nIt is not possible to prevent cavities or gum problems by trying to kill all of \nthe germs in your mouth. There are too many — and some germs are good \nfor you. The important thing is to keep the germs from getting together \n\nand making a film or coating on your teeth. \n\nThis film on the teeth is called plaque, but you do not need to use this word. \nEvery morning we can all feel a 'furry film' on our teeth. This film must not \nbe allowed to stay on the teeth I It will mix with sugar and make acid. Worse, \nif it stays in a group (or 'colony') for more than 24 hours, it will mix with \nsaliva, harden, and make tartar (see page 52). \n\nThe main reason for cleaning teeth is to break up these colonies so they \ncannot make acid. Also, if you forget to clean your teeth, tartar will form, and \nyou will need a dental worker to scrape it off. This is why it is important to \nclean your teeth at least every 24 hours, so the tartar can never form on your \nteeth. \n\nTHE ACTIVITY: \n\nHere is a game called \"Scatter!\" that students can play outside. You need: \n\n• Five 'bases' (a tree, rock, or \nthe corner of a house can \nbe a base) in a half circle, \n\n12 meters apart. Each base \nmust have a 'monitor' who \nstays at the base. \n\nNote: children who cannot \nrun can be good monitors. \n\n• One person with a broom. \n\nThis person is the \n'decolonizer'. \n\n\n\n\nChildren in Jocuixtita, Mexico, beginning a \ngame of \"Scatter!\" The 'decolonizer' is the \ngirl in the center with the broom. \n\n\n\nThe Game: \n\n20 students called 'colonizers' stand facing the decolonizer. When the \ndecolonizer says \"go! \" they try to 'form colonies' around the bases \nbefore the decolonizer can touch them with the broom. \n\n\n\nWWW. ncsp£ri3.n.org \n\n\n\n\nWhere There Is No Dentist 2010 51 \n\n\n\n\n\nThe 'decolonizer' (with broom) has lost \nthe game. The children behind him have \nformed a 'colony'. \n\n\n\nThe colonizers win if they make \na colony. There are two kinds of \ncolony: ( 1 ) 15 people touching \none monitor at a base, or ( 2 ) a \nchain of 12 people holding \nhands, touching two monitors. \n\nPlay two games: one with \nchildren trying to form the first \nkind of colony, one with the \nsecond kind. These photos are \nfrom the second game. \n\n\n\nHere the decolonizer stops a boy from \ncompleting a chain. \n\nAfter The Game: \n\nTalk to the students about germs \nin their mouths and how small \nthey are. Can anyone see germs? \nNo, but they can feel them and \ntaste them. Ask the group what \ntheir mouths feel like in the \nmorning when they wake up. You \nmay get these answers: \n\n• My teeth feel mossy. \n\n• My breath is bad. \n\n• I feel a coating on my teeth, \nbut it goes away when I \nbrush them. \n\n\n\nThe decolonizer tries to stop the \nothers by touching them with the \nbroom. When the decolonizer \ntouches a colonizer with the \nbroom, the colonizer must leave \nthe area for one minute. (Give \nthat child a task to do — run \naround the school-house or lie \ndown and sit up 30 times.) \n\nThe decolonizer wins if no \ncolonies form in 5 minutes. \n\n\n\n\nTo teach about things too small to see, look \nat the suggestion on page 1 1 -29 of Helping \nHealth Workers Learn. \n\n\n\nTell the students that this coating on the teeth is a 'colony' of germs. They \nare always trying to group together on the teeth or in spaces between the \nteeth — just as the 'colonizers' did in the game! \n\n\n\n\n52 Where There Is No Dentist 2010 \n\n\n\nWhat Makes the Gums Feel Sore? \n\nTHE IDEA: \n\nHealthy gums fit tightly around the teeth and help to hold them strongly. \nHealthy gums also cover and protect the bone under them. \n\nHealthy gums are pink in color, or \n\neven blue or dark yellow in some people. \n\nBut healthy gums are never red. \n\nHealthy gums are pointed between \nthe teeth. This lets food slide away and \nbe swallowed. \n\nHealthy gums fold under, making a \nlittle pocket around the tooth. \n\nAs we saw with the last activity (p. 50), when you have 'colonies' of germs \non your teeth, they can make acid that makes holes on your teeth. The same \ncoating of germs can make a different acid that makes the gums sore. This \nalso happens when food mixes with the coating on your teeth. Soft food \nis the worst kind, because when it mixes with spit it sticks more and stays \nlonger on your teeth. Juice from tea, betel nut, and meat color this food, \nmaking the tooth look dark. \n\n\n\nHealthy gums become sore because of acid. When the coating on the \nteeth (p. 50) becomes hard, it is called tartar. Tartar can hurt the gums. \nAlso, the 'colonies' of germs can make a coating on top of tartar more \neasily than on a clean tooth. When the colonies are new, they make more \nacid which causes tooth and gum problems. After 24 hours, it hardens \nand makes a new layer of tartar. The tartar gets bigger and bigger. \n\nSore gums are infected. \n\nInfected gums are red \nand bleed easily. \n\nInfected gums are round and \nswollen between the teeth. \n\nThey are also loose instead of \ntight against the teeth. \n\n\n\nHere is a larger picture of the \nteeth in the box above: \n\n\n\n\n\n\n\nInfected gums have a deep gum pocket which catches even more food. \n\n\n\nWhere There Is No Dentist 2010 53 \n\n\n\nInfection in the gums is called gum disease. It is important to treat gum \ndisease early, before it can spread to the root fibers and the bone. \n\n\n\n\n\n\nACTIVITIES: \n\n\n\nIf you have sore, bleeding \ngums, you can do much to \ntreat the infection yourself. \n\n1. Clean your teeth with a soft \nbrush gently and more often \n(see page 71). \n\n2. Eat more fresh fruits and \nvegetables. \n\n3. Rinse your mouth with warm \nsalt water. \n\n4. Clean between your teeth \nwith dental floss or string. At \nfirst your gums may bleed \nwhen you do this. But when \nthe gums are stronger the \nbleeding will stop. \n\n\n\n1. Have the students look in each other's mouths. \n\nCan they see the coating on the teeth? Usually \nthey cannot. They may see food or 'white stuff', \nbut this is not the coating that makes acid. \nHowever, if someone has been chewing betel nut \nor eating berries, you will see stains on her teeth \nand the stains will be darkest where she has \nthese colonies of germs on her teeth. \n\n\n\n\n2. Put something on the teeth to stain the colonies of germs. Try using \nfood dye, betel nut or berry juices. Remember: first wash your hands! \nOlder students can rub berries on the teeth of the younger ones. Have \nthem rinse with a little water and spit it out. After this, the colored areas \non the teeth will show where the colonies of germs are forming. Where \nare they? Usually you will see the dark colors: \n\n• between the teeth \n\n• in the pits or holes in the teeth \n\n• on the tops (biting surfaces) of the teeth. \n\nThe older students can show the younger ones the best way to clean \nteeth (see pages 69-72). Have them use a mirror to see if they are getting \nthe colored juice from their teeth. They will learn that it is most difficult \nto get rid of the color between their teeth. Give them some string, dental \nfloss, or the soft stem from a young palm leaf and show them how to use \nit between their teeth (p. 72). Remind them to be gentle, or they will hurt \ntheir gums. Clean between your teeth every day. \n\n\n\n\n54 Where There Is No Dentist 2010 \n\n\n\nWhat Does It Mean if a Tooth is Loose? \n\nTHE IDEA: \n\nBaby teeth become loose when children are between 6 and 12 years old. \nThis is normal. If a loose baby tooth does not have a cavity, and if the gums \naround it are healthy, there is probably a permanent tooth growing under it. \n\nBut a tooth might be loose because it is broken or because it is sick from an \nabscess or gum disease. Either can destroy the bone around the tooth's roots. \n\n\n\n\nWhen bone is lost, the tooth \nbecomes loose. A loose tooth hurts \nand usually must be taken out. \n\nThere is no medicine to make bone \ngrow back around the roots of \nloose teeth. All you can do is stop \nthe infection from getting worse. \n\n\n\n\nACTIVITIES: \n\n1. Let the students look into each other's mouth for loose baby teeth. \nLook carefully to see why a tooth is loose. \n\n\n\nTouch the gum and bone beside the \nloose tooth. You can feel a bump — it is \nthe new permanent tooth growing. \n\nSave the baby tooth after it has fallen \nout. Look to see how the permanent \ntooth has eaten away its root by \npushing against it. \n\n2. Look for teeth that have cavities or gum \ndisease around them. The students can do \nthis with each other, and then later at home. \n(Remember they must wash their hands! \n\nA tooth that has some of its root showing \nis probably loose. \n\nUsing your fingers or the handles of two \nspoons, rock the tooth back and forth \ngently. See how much it moves, and ask \nhow much it hurts. \n\nTell the person what he can do to \nprevent other teeth from becoming \nloose. (See the next section.) \n\n\n\n\nWhere There Is No Dentist 2010 55 \n\n\n\nHow Can We Prevent Cavities and Sore Gums? \n\n\n\nEating good food and carefully cleaning the teeth prevents both tooth decay \nand gum disease. \n\n\n\nFood from your own garden and local food from the market is best. \n\nThese foods are good for your body, your teeth, and your gums. \n\n\n\n\n\n\nVegetables, especially \nthose with dark green \nleaves. \n\n\n\n\nPeas and beans, like green \nbeans, soybeans, winged \nbeans, and mung beans. \n\n\n\n\nOil, from palm nut \nkernels, ground nuts, \nand coconut. \n\n\n\n4 ^ 00 ^ \n\nFruits, like banana, \nguava, oranges, \nand papaya. \n\n\n\n\nFish, meat and eggs. \n\n\n\nClean water, coconut \nwater, and milk are best \nto drink. \n\n\n\n\nSoft foods and sweet foods from the store \nare not good for you. Soft foods stick to your \nteeth easily. They can work longer to cause \ncavities and infected gums. Sweet foods have \nmostly sugar in them, and it is 'factory sugar', \nnot the 'natural sugar' that is in the foods in \nthe pictures above. \n\nThis kind of sugar is quick to mix with germs \nand make acid. Remember: natural sugar \nmakes acid slowly: factory sugar makes acid \nquickly. \n\nChildren who eat a lot of sugar lose their \nappetite for other foods — the foods that help \nthem grow strong, stay healthy, and learn well \nin school. \n\nStore foods are also expensive. You can \nusually get better food, and more of it for \nthe same money, from your garden or in the \nmarket. \n\n\n\n\n56 Where There Is No Dentist 2010 \n\n\n\nCleaning your teeth carefully every day is another important way to take care \nof both teeth and gums. However, cleaning teeth is like building a house. \nTo do a good job, you need to work slowly and carefully. Once a day is \nenough, if you clean your teeth well every day. \n\n\n\n\nBuy a brush from the store, or make one yourself (see p. 4). But be sure the \ncleaning end of the brush is soft so that it won't hurt the gums. \n\n\n\n\nUse your brush to clean all the teeth, especially the back ones with the \ngrooves. Back teeth are harder to reach and so it is easy not to clean them \nwell enough. Cavities start from sweet food and germs left together inside \nthe grooves. \n\n\n\n\n1 . \n\n\n\n2 . \n\n\n\n3 . \n\n\n\nScrub the inside, \noutside, and top of \neach tooth. \n\nPush the hairs of \nyour brush between \ntwo teeth. Sweep \nthe food away. \n\nWash your mouth \nwith water, to \nremove any loose \nbits of food. \n\n\n\n\n\nSmall children are not able to clean their teeth carefully enough by \nthemselves. They need help. Look at the pictures on the cover and p.18 to \n\nsee how you can do this. Older children can care for younger brothers \nand sisters at home. \n\n\n\n\nWhere There Is No Dentist 2010 57 \n\n\n\nACTIVITIES; \n\nOne of the best ways to teach is by example. \n\n\n\n\n^ND SO AT HOME \nPUT BOTH OWED FJSM \\ \nAnd &REEN LEAVES \\ \n\n\n\nINTO THE SOUP. MY \\ \n\n\n\nJCHluDREN UKE »T VERY) \n\\MUCH. YOU VNILL TOOlJ \n\n\n\nStudents will believe what their teacher says if they know he eats good food \nand cleans his teeth. \n\nThe reverse is also true. Learning is harder when students know that their \nteacher does not do those things himself. \n\nStudents can be a good example for their community, too. They can: \n\n• draw pictures of foods that are both good and bad for teeth. Use them \nto make posters and flannel-board stories. \n\n• make puppets and plays to discuss ways people can become healthier. \nThere are some other ways to make learning meaningful and fun. \n\n1. Make a garden at school. Divide the ground so that each class has its \nown space to plant a garden. \n\nUse some of the garden's food to prepare a meal for the students, \nperhaps once a week. Students can bring food from home if there is \nnot enough ready in the garden. \n\n2. Organize a school lunch program. Each day the students can bring \nsome good food from home. Cooked yams, or maize, nuts, fruit and \nfresh vegetables are all good. Often the students will exchange food \nand talk about the many different foods that can be grown locally. \n\n\n\n\n58 Where There Is No Dentist 2010 \n\n\n\n3. Find the best way to clean teeth. Divide the class into groups. They will \nlearn more easily in a small group of 4 to 8 students. \n\nGive all the students something to eat that is sweet, sticky and dark in \ncolor, such as sweet chocolate biscuits. Ask the students to look in each \nother's mouth, to see how easily the biscuit sticks to the teeth. One or \ntwo of the students in a group can then try to clean away the pieces of \nbiscuit, using a different method. \n\n\n\n\nWhen they are finished, the students can look at the teeth to decide if \nthey are clean or not. Put your findings on a chart and talk about what you \nhave learned. \n\n\n\n\nf^ARIE Dto \nNOT CLEAN \n\n\n\nLAURA RINSED \nONLV WITH WATER \n\n\n\nVINCENT ATE \nA CARROT \n\n\n\nSARA BRUSHED \nAND RINSED \n\n\n\nWhere There Is No Dentist 2010 59 \n\n\n\n4. Make cleaning part of a daily health activity. Older students can \nlook after younger students. They can first check their hair for lice, then \nsores for infection, and teeth for old food or germs. (To see the coating \nof germs on the teeth, try the activity on page 53.) One partner can \npoint out to the other where washing and brushing can be done better. \n\n\n\n\nCLEANLINESS CAN BEGIN AT SCHOOL \n\nAt school, students can wash their hands before lunch and brush their \nteeth afterward. Encourage them to keep a piece of soap and a toothbrush \nor brushstick (p. 4). One day a week, the whole class can treat their teeth \nwith fluoride (p. 205) to prevent cavities. \n\n\n\n\nThe student \ncan keep the \nbrush at her \nown desk... \n\n\n\n... or on a \nrack at the \nback of the \nroom. \n\n\n\n\n60 Where There Is No Dentist 2010 \n\n\n\nHave the students score each other's progress. Do not make it hard to \njudge, or they will not do it. In the example below, the tooth is either clean \nor net clean. \n\n\n\nI \n\n\n\n\nSCORING TEETH \n\nPick 4 teeth, a back tooth and \na front tooth — two on top and \ntwo on the bottom. \n\nUse the same 4 teeth for each \nperson. Look for food on each \ntooth near the gums. \n\nA clean tooth = 2 points. \n\nA dirty tooth = 0 points. \n\nTotal possible points each day \nis 4 teeth x 2 = 8 points. \n\nIn this example the score is: \nTooth 1 = 2 points \nTooth 2 = 0 points \nTooth 3 = 0 points \nTooth 4 = 2 points \nTotal = 4 points \n\n\n\nHave each student put his daily score on a chart. At the end of the month he \ncan see how much he has improved. \n\n\n\n\nCHAPTER \n\n\n\nTaking Care of \nTeeth and Gums \n\n\n\nWe can prevent most tooth and gum problems. This chapter gives more \ninformation about how teeth grow in and how to keep teeth and gums \nhealthy. Share this information and you will prevent problems from starting. \n\nBut remember that people are most interested in the problems they have \nnow. Before listening to what you know about prevention, people will \nwant treatment for the problems that are already causing them pain and \ndiscomfort. \n\n\n\nEarly treatment is a form of prevention. \nIt can prevent a tooth or gum problem \nfrom becoming more serious. \n\n\n\nWhen you treat a person's problem, it shows that you care about him. It \nalso shows that you know what treatment he needs. As his confidence in \nyou grows, he will want to learn from you about preventing tooth or gum \nproblems. \n\n\n\nIn order to help a person it is \nimportant to know what the \nproblem is and what is the \nbest treatment. But just as \nimportant is knowing what \nyou are not able to do, and \nwhen to seek help. \n\nIn this chapter, you will learn \nmore about teeth, gums, and \nproblems affecting them, \nbut you must never be too \nproud to get help from more \nexperienced dental workers. \n\n\n\n\nKnow your limits. \n\n\n\n61 \n\n\n\n62 Where There Is No Dentist 2010 \n\n\n\nTAKING CARE OF BABY TEETH \n\nA child's baby teeth are being made before birth while the baby is still inside \nthe mother's womb. During the last months of pregnancy and the first few \nmonths after the child is born, the baby teeth take their final form. Pregnant \nmothers and young children need good food and good health in order \nto have strong baby teeth. \n\n\n\nStrong teeth \n\nare white and their \nfront surface is smooth. \n\n\n\n\nWeak teeth \n\nhave yellow marks that \nare pitted and rough. \n\n\n\n\nBaby teeth get marks on them when: 1 ) the pregnant mother is sick or does \nnot eat good food; 2 ) the young baby is sick or does not eat good food; or, \nsometimes, 3 ) the baby's birth was early or the delivery was difficult. \n\n\n\nThe marks are rougher than the rest of the tooth. Food \nsticks easily to them and turns the tooth yellow. \n\nThe marks are also soft. They need to be cleaned well \nevery day (p. 63) to prevent them from becoming \ncavities. A tooth with a cavity hurts. When children's \nteeth hurt, they do not want to eat as much. \n\n\n\n\nCavities in baby teeth can make a child's malnutrition worse. \n\nRemember this whenever you see a weak, poorly nourished child. When \nyou examine a child at the health clinic, lift his lip and look at his teeth. Do \n\nthis as part of your routine examination. \n\n\n\n\nYou can fill cavities with cement (Chapter 10). \nCement prevents food and air from going inside \nthe cavity and hurting the child. \n\nA sore on the gums may be a gum bubble. If so, \nit means the tooth has an abscess (page 81). \nThat cavity should not be filled with cement. \nInstead, the tooth needs to be taken out \n(Chapter 1 1 ) before the infection can get worse. \n\n\n\n\nWhere There Is No Dentist 2010 63 \n\n\n\nFor baby teeth to grow strong, mother and baby must stay healthy.* Help \nher to understand how important this is. A pregnant mother should: \n\n• Eat enough good kinds of foods, both for herself and her baby growing \ninside (page 68; also see Where There Is No Doctor, Chapter 1 1 , and \nHelping Health Workers Learn, pages 25-39 to 25-44.) \n\n• Attend health clinic each month, so the health workers can examine her \nregularly and she can receive important medicines (see Where There \nIs No Doctor, page 250). \n\n• Not use the medicine tetracycline, because it can cause the teeth \nto turn dark. You, the health worker, must remember — do not give \ntetracycline to a pregnant woman or to a young child. If she needs \nan antibiotic, use a different one. \n\nFor baby teeth to stay strong, and to prevent marks from turning into \ncavities, mother should: \n\n• Continue to breast feed and never feed her \nchild juice or sweet tea from a bottle. Start \nadding soft foods, such as mashed banana or \npapaya, when the child is 6 months old. \n\n• Wipe her baby's teeth with a clean cloth after \nthe baby eats. This cleans the baby's teeth, \nand helps the baby get used to teeth cleaning. \n\nLater he will be happy with a brush. \n\nAround 1 year of age, there will be several baby teeth. At that time, mother \nshould start using water — not toothpaste — on a soft brush or brushstick. \n(With toothpaste, you cannot see the child's teeth clearly because of the \nbubbles it makes.) She should scrub the sides and tops of each baby tooth \nas well as she can (page 69). \n\nThe child can also try to clean his own teeth. That should be encouraged. \nHowever, since he is too young to clean properly, mother (or father, or older \nbrother, sister) must clean his teeth once a day for him. Continue helping in \nthis way until the child is old enough to go to school. \n\nYou can make a large brush smaller, \nto fit more easily into a young \nchild's mouth. \n\n\n\nPul I out some of the back hairs, or \ncut them out with scissors. Do not \ncut the hairs in half, because the \ntops are often rounded or softer, and \nthat is better for the gums. \n\n\n\n\n\nSee the story about pregnancy and dental care on pages 15-16. \n\n\n\n64 Where There Is No Dentist 2010 \n\n\n\nWhy Baby Teeth Are Important \n\nBaby teeth are just as important to children as permanent teeth are to adults. \nThey help a child to eat, talk, and look good. \n\n\n\nHowever, many people feel that It is not worth the effort to look after baby \nteeth. Nor is it worth fixing them. After all, parents think, the permanent teeth \nwill take their place. \n\n\n\nThis kind of thinking is understandable. The problem is that we are forgetting \none other useful purpose of baby teeth. Baby teeth keep space in the mouth \nfor the permanent teeth to grow in. If there is not enough space, the new \nteeth will grow in crooked, and cavities grow faster around crooked teeth. \n\n\n\n\nUnder each baby tooth a new \npermanent tooth is growing. \n\nAt the same time, extra \npermanent molars are forming \nat the back of the mouth, \ninside the bone (page 43). \n\nFront baby teeth become \nloose and fall out (usually \n6-7 years, but sometimes as \nyoung as 5 years) ahead of \nback baby teeth (1 0-1 2 years). \nThis is because the front \npermanent teeth are formed \nand ready to grow in first. \n\n\n\nThe permanent molar (1 PM) is often the first of the permanent teeth to grow \ninto the mouth. That happens at 6 years of age. \n\n\n\n\nThe first permanent molar grows into \nthe mouth by sliding against the back \nof the second baby molar (2BM). \n\n\n\nSlowly but steadily the upper and \nlower permanent molars grow until \nthey meet and fit tightly together. \n\n\n\nWhere There Is No Dentist 2010 65 \n\n\n\nBetween the ages of 6 and 1 1 , a child needs healthy baby molars to guide \nthe first permanent molars into position and then to hold them there. When \nthe first permanent molars grow into the right place, this is a good sign. It \nmeans the other permanent teeth will also grow in properly, because they \nwill have enough space. \n\nNote: Some people are born without enough space. But most people are \nnot born with this problem — they lose the spaces when they remove \nbaby teeth instead of fixing them. \n\n\n\nHEALTHY BABY TEETH , — ►STRAIGHT PERMANENT TEETH \n\nto make \n\n\n\n\n\nSICK BABY TEETH ^ — ► CROOKED PERMANENT TEETH \n\nto make \n\n\n\n4m 2 bw \n\n\n\n\n1 0 years \n\n\n\n\nTell mothers why baby teeth are important. Good food and regular cleaning \nkeep them healthy. They should know that new teeth coming in do not \ncause diarrhea and fever, but that a child may have diarrhea or fever at the \nsame time. \n\n\n\nIf there is a cavity, fix it so the tooth can be kept in the mouth to do its \nimportant work (see Chapter 1 0). \n\n\n\n66 Where There Is No Dentist 2010 \n\n\n\nTAKING CARE OF MOLAR TEETH \n\nWe often notice front teeth growing in, but not the back ones. Back teeth \nmolars are not so obvious. Swelling on the face can be either a new molar \ngrowing in or an abscess. So, to help you to decide, look at the tooth for a \ncavity and at the gums beside it for a gum bubble. \n\n\n\n\nBut if the person is young (16-22 years), it often is not an abscess. The third \npermanent molar tooth may be growing in at the back of her mouth. As the \ntooth grows, it cuts through the skin. Just as a dirty cut on a person's hand \ncan get infected, the cut gum around her new tooth also can get infected, \ncausing a swollen face. \n\n\n\nSee the red swollen skin on \n\nLook behind her back teeth. top of the new tooth. \n\n\n\n\nIf there is enough space for the tooth, it will grow in by itself. It only needs \ntime. Before acting, decide how serious the problem is. \n\nIf there is no swelling and she can open her mouth, explain to her what is \nhappening and what she can do herself to reduce infection and toughen the \ngums. The best medicine is to rinse warm salt water over the sore area. \n\nA good home remedy is to rinse until the tooth grows all the way into the \nmouth. \n\nIf it does appear serious (severe pain, swelling, not able to open the mouth), \nsee page 94 for further treatment. \n\n\n\nWhere There Is No Dentist 2010 67 \n\n\n\nTAKING CARE OF ALL YOUR TEETH \n\nThis book often repeats an important message: eat good food and clean \nyour teeth. It is repeated because this is the most important thing you \ncan learn from this book. Later chapters will discuss what to do when \nproblems occur, but if you follow these two suggestions, you will almost \nnever have problems with your teeth and gums. This is true because good \nfood keeps your whole body healthy, including your teeth. Also, with no \n'colonies' of germs (page 50) or harmful factory sugar (page 55) on your \nteeth, your mouth cannot make the acids that cause both tooth and gum \nproblems. So, remember: \n\n1. Eat Good Food \n\nAn easy-to-remember rule is the same foods that are good for the \nbody are good for the teeth. A healthy body is the best protection \nagainst infection. \n\n\n\n)d nutrition (eating well) means 2 things: \n\nEat a mixture of different kinds of foods \nevery time you eat. Look at the pictures \non page 55. There are several groups of \nfoods. Every time you eat, try to eat one or \ntwo foods from each of the groups. This \nway, you will get 3 important kinds of food: \ngrow food (body-building food) to give you \nthe protein you need; glow food (protective \nfood) to give you vitamins and minerals: and \ngo food (concentrated energy food) to give \nyou calories to be active all day. \n\n2) Be sure you eat enough \nfood to give your body the \nenergy it needs. This is even \nmore important than the first \nsuggestion. We get half or \nmore of our energy from our \nmain food. In most parts of the \nworld, people eat one low-cost \nenergy food with almost every \nmeal. Depending on the area, \nthis main food may be rice, \nmaize, millet, wheat, cassava, \npotato, breadfruit, or banana. \n\nThe main food is the central or \n'super' food in the local diet. \n\n\n\n\nA spoonful of cooking oil \nadded to a child's food \nmeans he only has to eat \nabout % as much of the \nlocal main food in order to \nmeet his energy needs. The \nadded oil helps make sure \nhe gets enough calories by \nthe time his belly is full. \n\n\n\n\nThe MAIN FOOD is at \nthe center of every meal. \n\n\n\n68 Where There Is No Dentist 2010 \n\n\n\n\nBe sure always \nto eat grow \nfoods and \nglow foods \nto get the \nvitamins and \nprotein you \nneed. \n\n\n\nYour energy \nfoods give \nyou the most \nimportant \npart of your \ndiet — calories. \nHalf or more \nof our \n\ncalories come \nfrom the main \nfood, and most \nof the other \ncalories come \nfrom go foods. \n\n\n\nWARNING ABOUT GO FOODS: Although go foods give us the energy \nwe need, some go foods are worse than others. Honey, molasses, and \nespecially white sugar can be very bad for the teeth, even though they \nhave the calories we need. Fruits, nuts, and oils all give us energy (calories) \nwithout attacking the teeth. \n\n\n\n\n\nWhere There Is No Dentist 2010 69 \n\n\n\n2. Clean Your Teeth \n\nCleaning teeth requires time and care. If you hurry, you will leave food \nand germs behind, and they continue to make cavities and sore gums. \n\nYou may find that different dental workers recommend different ways \nof brushing teeth. Some ways are definitely better, but often they are \nharder to learn. \n\nTeach a method of cleaning that a person can learn and will do at home. \nLet him start by scrubbing his teeth (and his children's teeth) back and \nforth, or round and round. Encourage him to improve his method only \nwhen you think he is ready. \n\nToothpaste is not necessary. Some people use charcoal or salt \ninstead. But it is the brush hairs that do the cleaning, so water on the \nbrush is enough. \n\nScrub the outside, inside, and top of each tooth carefully. \n\n\n\n\nWhen you finish, feel the tooth with your tongue to make sure it is \nsmooth and clean. \n\n\n\nFinally, push the hairs of the brush \nbetween the teeth and sweep away \nany bits of food caught there. Do \nthis for both upper and lower teeth. \n\nSweep away in the direction the \ntooth grows: sweep upper teeth \ndown and lower teeth up. \n\n\n\n\n\n70 Where There Is No Dentist 2010 \n\n\n\nExplain how important it is to use a brush with soft hairs. A brush that is stiff \nand hard will hurt the gums, not help them. \n\n\n\n\nYou can make a hard brush softer \nby putting the hairs into hot water \nfor a few minutes. \n\nDo not put the plastic handle into \nthe hot water, or it will melt. \n\n\n\n\nIf your store has only hard brushes, tell the store keeper that hard \ntoothbrushes do not help the people in the community. Ask him to order and \nsell only soft toothbrushes. \n\n\n\nNote: Another important way to reduce cavities is by adding \nfluoride to teeth. Fluoride is a substance which, like \ncalcium, makes teeth harder and stronger. \n\nFluoride in drinking water, toothpaste, salt, vitamins, and mouth \nrinses helps to prevent cavities. These methods are sometimes \nexpensive. But treating teeth once a week with fluoride toothpaste \nis effective and inexpensive. See page 205. \n\nFluoride can also be found naturally in food and water. For \nexample, tea leaves and most foods from the sea contain a large \namount of fluoride. \n\nSo, your source of fluoride can be either: \n\n\n\n\n\nWhere There Is No Dentist 2010 71 \n\n\n\nCLEANING BETWEEN THE TEETH IS VERY IMPORTANT \n\nHere are three ways to clean between the teeth: \n\n1 . Push the hairs of a toothbrush between the teeth, and sweep the bits \nof food away. \n\n2 . Remove the stem from a palm leaf. Use the thinner end and move it \ngently in and out between the teeth. \n\n\n\n\n3 . Use some thin but strong thread or string. String can be the best \nmethod of all — but you must be careful with it. \n\n\n\n\nand use one strand of it. \n\n\n\n\nBuy and use dental floss.This \nis a special kind of string for \ncleaning between the teeth. \n\n\n\nBe careful! The string can hurt your gums if you do not use it correctly. \nThe next page shows how to use the string, but the best way to learn \nhow to 'floss' your teeth is to have someone show you. Ask a \n\ndental worker who has experience. \n\n\n\n72 Where There Is No Dentist 2010 \n\n\n\nWrap the ends of the \nstring around the middle \nfinger of each hand. \n\n\n\n\nUse the thumb and finger to guide the string. Go back and forth to slide the \nstring between two teeth. Be careful not to let it snap down and hurt the gums. \n\n\n\n\nWith your fingers pull the \nstring against the side of one \ntooth. Now move the string \nup and down. Do not pull \nthe string back and forth or \nit will cut the gum. \n\n\n\n\n\nLift the string over the pointed \ngum and clean the other tooth. \n\n\n\n\n\nWhen you have cleaned both teeth, release the string from one finger and \npull it out from between the teeth. Then wrap it around your two middle \nfingers once again, and clean between the next two teeth. \n\n\n\nRemember: clean teeth and good food \nwill prevent almost all dental problems. \n\n\n\nExamination \nand Diagnosis \n\n\n\nCHAPTER ^ \n\n\n\nWhenever you do an \nexamination, remember \nto examine the mouth. \n\nYou can prevent much suffering \nand serious sickness when \nyou notice and treat problems early. \nWhenever you hold a health clinic, try \nto find out how healthy each person's \nmouth is. \n\n\n\nAsk if she is having a problem now, or \nhas had a problem recently. \n\nAlways write down what you find out, \nso you remember what treatment that \nperson needs. \n\n\n\n(are the T£ETH healthy ? ) , \n\n(are THE GUIAS HEALTHY Y) 0 \n\n(are there Akiv sores?) O \n\n\n\n\nWhen you look inside someone's \nmouth, ask yourself these questions. \n\n\n\n1. Are the teeth healthy? Look for: \n\n\n\n\nTell the person what is \nhappening and how to \nkeep the skin around it \nhealthy (page 66). \n\n\n\nThey may be cavities \nwhich should be \nfilled when they are \nstill small (page 47). \n\n\n\n4. A Dark \nTooth \n\n\n\nTell the person what is \nhappening and how to prevent \nit from getting worse or \naffecting other teeth (page 54). \n\n\n\nA tooth that is dark is dead and infection \nfrom its root can go into the bone (page 47). \nThis can make a sore on the gums (page 74). \n\n\n\n73 \n\n\n\n74 Where There Is No Dentist 2010 \n\n\n\n2. Are the gums healthy? \n\nLook at page 52 and compare the pictures of healthy and unhealthy gums. \n\nUnhealthy gums often are red and they bleed when you touch them. \n\nA bubble on the gums below the \ntooth is a clear sign that the person \nhas an abscess. The abscess may be \nfrom the tooth, or it may be from the \ngums. To decide, look carefully at \nboth the tooth and the gum around it. \n\nA bubble beside a healthy tooth is a sign \nof infected gums. Scale the tooth carefully. \n\nSee Chapter 8. \n\nA bubble beside a decayed tooth is a sign \nof a tooth abscess. (See page 93.) \n\nA sore on the gums from a badly decayed \ntooth appears when a gum bubble breaks \nopen and lets out the pus from inside. \n\n\n\nN 1 , \n\nV ' /; \n\n\n\n\n\n\nGUM BUBBLE \n\n\n\n\n3. Are there any sores? \n\n\n\nLook for sores under the smooth skin on the inside of the lips and \ncheeks. Look also under the tongue and along its sides. \n\n\n\nA \\ \n\n\n\n\n\n\nV \\ \n\n\nU-) y \n\n\n\n\n\n\n7 ^ \n\n\n\n\n1. A sore on the \n\n\n2. Sores on the inside \n\n\n3. Sores on the \n\n\ngums may be \n\n\nof the lip or cheek \n\n\nlips or tongue \n\n\nfrom an infected \n\n\nmay be from a \n\n\nmay may be \n\n\ntooth (p. 93). \n\n\nvirus (p. 104). \n\n\ncancer (p. 125). \n\n\n\nAfter your examination, tell the person what you have found. If you notice \na problem starting, explain what to do to prevent it from getting worse. If \nthere are no problems and the mouth is healthy, congratulate the person. \n\n\n\nShare your knowledge — explain things to people. \nHelp them learn how they can prevent and even \nmanage their own problems with their teeth. \n\n\n\nWWW. \n\n\n\n\nWhere There Is No Dentist 2010 75 \n\n\n\nWHERE TO EXAMINE \n\nExamine people in a light and bright place. It is dark inside a person's mouth, \nso you need light to see the teeth and gums. \n\n\n\nUse the sun. Examine outside, or inside a room facing the window. With \nsunlight alone, you will be able to see most places in the mouth well \nenough. If you cannot, set up a lamp or have someone hold a lamp for you. \nReflect the light off a small mouth mirror onto the tooth or gum. \n\n\n\nIf you have a low chair, lift up the \nperson's chin so that you do not have to \nbend over as far when you look into the \nmouth. An even better way is to have the \nperson sit on some books. The person's \nhead can lean back on a piece of cloth. \n\nUse an old chair with a strong back. \n\nAttach two flat sticks to the chair. Then \ntie a strip of clean cloth to the sticks. Tie \nit strong enough to support the head, but \nloose enough to let the head lean back. \n\n\n\n\nTHE INSTRUMENTS YOU NEED \n\nThree instruments are really enough: \n\n\n\n\n\n\n\n\n\n\n\n\n\n\n1 . A wooden tongue blade to hold back \nthe cheek, lips, and tongue. \n\n2 . A small mirror to let you look more \nclosely at a tooth and the gums \naround it. \n\n3 . A sharp probe to feel for cavities \nand to check for tartar under the \ngum. \n\n\n\nIf you have many people to examine, it is helpful to have more than one of \neach instrument. But be sure they are clean. \n\n\n\nDirty instruments easily can pass infection \nfrom one person to another. After you finish \nan examination, clean your instruments in soap \nand water and then leave them in a germ-killing \nsolution like the ones described on page 89. \n\n\n\n\n76 Where There Is No Dentist 2010 \n\n\n\nA GOOD DIAGNOSIS \n\nYou are making a diagnosis when you decide what a person's problem is \nand what is causing it. To do this, you need information. You need to make \na careful examination to make a good diagnosis. \n\n\n\nLearn all you can about the person's problem: \n\n1. Ask questions about the problem. \n\n2. Look at the person's face. Think about the person's age. \n\n3. Examine the mouth more carefully than before. \n\n4. Touch the place that is sore. \n\n\n\n1. Ask the person about the problem. \n\nGive a sick person a chance to \ndescribe how he is feeling. \n\nListen. Think about what possibly is \nhappening in his mouth. \n\nYou may have an idea about what \nthe person has. Now try to find out \nmore by asking questions: \n\n• What is the problem? Ask him \n\nto talk about the pain, swelling, \nbleeding, or whatever he is feeling. \n\n• Where does it feel that way? See if he can put his finger on the tooth \nor place that is bothering him. \n\n• When do you have the most pain? Find out if it happens all the time \nor only some of the time (for example, when he drinks something very \ncold). \n\n• When did it start? Find out if he has already had this problem before. \nAsk how he took care of it. \n\n• Have you had an accident or injury lately? Infection still inside the \nbone from an old injury in the mouth can make a sore on his face, or \nstart swelling. \n\n• Are you having other problems? A head cold or fever can make the \nteeth hurt. \n\n• How old are you? Think about a new tooth coming into the mouth. \n\nAfter you hear the answers to your questions, decide if your original idea \nis the correct diagnosis. If not, try to think of another possibility and ask \nmore questions. This is the scientific method of making a diagnosis. \nFora good explanation of scientific method, see Chapter 17 of Helping \nHealth Workers Learn. \n\n\n\n\nWWW. \n\n\n\nncsperian.org \n\n\n\nWhere There Is No Dentist 201 0 77 \n\n\n\nWhen you talk to a woman, find \nout if she is pregnant. A pregnant \nwoman's gums can easily become \ninfected. The gums may bleed and \nshe may have more tooth decay. \n\nBut this does not have to happen. \n\nIf a pregnant woman takes extra \ncare of her teeth and gums, she can \nprevent most dental problems. But \nif she already has a problem, do not \nwait for the baby's birth before you \nhelp her. You can treat a pregnant \nwoman's mouth problems now. In \nfact, this may be an important way of \nprotecting her baby as well (see pages \n15 to 16). \n\n\n\n\nTrain midwives to examine \nwomen's mouths. When \nthey send women to you for \ndental care, they can give \nyou helpful information \nabout the women's health. \n\n\n\nCaring for a pregnant woman — a guide for dental workers \n\n1 . Ask her how many months she has been \npregnant and find out if she has high blood \npressure. Any person with blood pressure over \n1 50/1 00 may bleed excessively after extraction \nTo get this information, encourage all women \nto have regular check-ups with a midwife or a \ntrained health worker who has equipment for \nmeasuring blood pressure. \n\n2 . Do not take X-rays of teeth unless absolutely \nnecessary. X-rays are dangerous to the unborn \nbaby inside. Before an X-ray, always cover the \nmother's chest, belly, and thighs with an apron \nlined with lead. \n\n3 . Do not give her tetracycline or doxycycline while she is pregnant \nor breastfeeding. \n\n4 . Always give a careful and complete mouth examination. Tell her \nwhat treatment she needs and how to prevent tooth problems. \n\n5 . Be gentle. Show the woman that you care, that you want her to \nbe comfortable, and that you can treat her without hurting her. \n\n\n\n\n78 Where There Is No Dentist 2010 \n\n\n\n2. Look at the person. \n\nPeople have some problems more often at certain ages. When a person \nfirst comes in to see you, notice his age. Then, before you ask him to \nopen his mouth, look at his face for a sore or swollen area. \n\n\n\n\n\nSWELLING \n\n\n\n\n\n\nJ|\\) \n\n\n\n\n\n\n\n\n\n\n\n\n\n\nCHILD \n\n\nYOUNG PERSON \n\n\nADULT \n\n\nSwelling can come from: \n\n\nSwelling can come from: \n\n\nSwelling can come from: \n\n\n• mumps \n\n\n• a new tooth growing \n\n\n• a tooth abscess (p. 93) \n\n\n• an infection in the spit \n\n\nin (p. 100) \n\n\n• a broken jaw (p. 1 1 3) \n\n\ngland (p. 1 19) \n\n\n• a tooth abscess (p. 93) \n\n\n• a tumor (p. 125) \n\n\n• a tooth abscess (p. 93) \n\n\n\n\n\n\nWWW. ncspcns^n.org \n\n\n\nWhere There Is No Dentist 2010 79 \n\n\n\n3. Examine inside the mouth. \n\n\n\nRemember what the person said, the person's age, and what you saw. \nNow look more closely at the problem area. \n\n\n\n\nLook at the teeth: \n\n• Is a new one growing in? \n\n• Is a tooth loose? \n\n• Is there a dark (dead) tooth? \n\nLook at the gums: \n\n• Are they red? \n\n• Is there any swelling? \n\n• Do they bleed? \n\n• Are the gums eaten away \nbetween the teeth? \n\n\n\nLook also for sores on the inside of the cheek or lips, and on the tongue. \n\n\n\n4. Touch the sore place. \n\nTouching is a good way to find out how serious the problem is. This will \nhelp you decide which treatment to give. \n\n\n\nPush gently against each tooth in the area of pain to see if a tooth is \nloose. Rock the loose tooth backward and forward between your fingers, \nto see if it hurts when you move it. \n\n\n\nUsing the end of your mirror, tap against \nseveral teeth, including the one you suspect. \n\n\n\nThere is probably \nan abscess on a \ntooth that hurts \nwhen you tap it. \n\n\n\nI MUST TAKE OUT \nYOUR TOOTH. IT \nHAS AN abscess. \n\n\n\n\n' T«.p_ \n\n\n\n\nPress against the gums with cotton gauze. Wait a moment, and then look \nclosely to see if they start bleeding. Then use your probe gently to feel \nunder the gum for tartar. Carefully scrape some away. Wait and look again \n\nto see if the gums bleed. When gums bleed, it is a sign of gum disease. \n\n\n\n80 Where There Is No Dentist 201 0 \n\n\n\nLEARN TO TELL SIMILAR PROBLEMS APART \n\nIf a person comes to you with a toothache or a sore \nor a loose tooth, there are many possible causes for \neach problem. The first thing you notice — the \ntoothache, sore or loose tooth — is your first step \nto a diagnosis. To this you must add more information \nbefore you can point to the most probable cause. \n\nPut together what you have found with what \nyou already know about teeth and gums. You \ncan make a good diagnosis of a problem without \nknowing a special name for it. \n\nUsually it is easy to make a diagnosis. However, \nsometimes you will not be sure, and these are the \ntimes to seek the advice of a more experienced dental \nworker. Never pretend to know something you do not. Only treat \nproblems that you are sure about and have supplies to treat properly. \nSee Where There Is No Doctor, p. w4. \n\n\n\n\nUse the charts beginning here to help you make the diagnosis. For more \npractice using charts to tell problems apart, see Chapter 21 of Helping \nHealth Workers Learn. \n\n\n\nIF THE PERSON AND YOU FIND OUT \n\nHAS THAT \n\n\nHE/SHE \nMAY HAVE \n\n\nSEE \n\nPAGE \n\n\n^ It hurts only after eating or V ^/'WTTT \n\ndrinking. There is a cavity, but the \ntooth does not hurt when you tap it. Uy T \n\n\n\n\ni \n\na cavity \n\n\ni \n\n92 \n\n\nPart of the filling has fallen out, or is \\/C^£r\\n \n\ncracked and ready to fall out. Eating \nand drinking make the tooth hurt. \n\n\na cavity \nunder an \nold filling \n\n\n92 \n\n\nA TOOTHACHE tooth hurts when chewing food. \n\nIt may hurt when tapped, but there is 1 X \n\nno cavity and the tooth looks healthy. \n\n\n\n\ntartar \nbetween \nthe teeth \n\n\n131 \n\n\nIt hurts all the time — even when /QO \n\n) person tries to sleep. The tooth \n\n/\"^N W *^7 hurts when you tap it and it feels a \n\nX bit loose. tfww \n\n\nan abscess \n\n\n93 \n\n\n/ ^ It hurts when person breathes in cold \n\nair. The tooth was hit recently. \\ // Y Y V \\ \n\n\na cracked \nor broken \ntooth \n\n\n96 \n\n\nHe cannot open his mouth properly. \nSteady pain and a bad taste are \ncoming, from the back of the mouth. \n\n\n\n\na new tooth \ngrowing in \n\n\n100 \n\n\nSeveral top teeth hurt, even when \n\nyou tap them. She had a head cold \n\nand can only breathe through her v*'^^ \n\nmouth. ^ ^ \n\n\nj \n\n\nan infected \nsinus \n\n\n95 \n\n\n\nWWW. \n\n\n\n\nWhere There Is No Dentist 2010 81 \n\n\n\nIF THE PERSON AND YOU FIND OUT \n\nHAS THAT \n\n\nHE/SHE MAY \nHAVE \n\n\nSEE \n\nPAGE \n\n\nHe had a toothache recently. \n\nThe bad tooth hurts when (/ ^ \n\nyou tap it. IvVJS \n\n\n▼ \n\na tooth \nabscess \n\n\ni \n\n93 \n\n\nSWOLLEN FACE She is young, about 1 8 years \n\n^ old, and has trouble opening \n\n\na new tooth \ngrowing in \n\n\n100 \n\n\nJ •)) He was hit on the face or jaw. \n\n(A 4^ 1/ The bone hurts when you \n\ntouch it. The teeth do not fit \ntogether properly. \n\n\na broken bone \n\n\n108 \n\n\nThe swelling is under or \nbehind the jaw. It gets worse \nwhen he is hungry and smells \n\n\nan infection \ninside the spit \ngland \n\n\n119 \n\n\nThe swelling has been there for \na long time. It does not seem to C\\y^^ \n\nget better. \n\n\na tumor \n\n\n125 \n\n\n\nFood and tartar are attached >o-v \n\nto the tooth. The gums VipJirKJ, \n\naround it are loose and \nswollen. ^ \n\n\ninfection \ninside the root \nfibers — from \ngum disease \n\n\n101 \n\n\nThere was pain in the tooth \nbefore, but it does not hurt \nso much anymore. It has a \ncavity and there may be a \nsore on the gums near it. \n\n\ninfection in the \nbone — from \nan old tooth \nabscess \n\n\n99 \n\nand \n\n93 \n\n\n-I \n\nLOOSE TOOTH ^ . u Li \n\nThe tooth was hit V \n\n^ some time ago. V/f \n\n\na root broken \nunder the gum \n\n\n96 \n\n\nWhen the loose tooth \n\n^ moves, the bone around it \n\nand the tooth beside it also \n\nBONE BROKEN \nUNDER THE \n\n\na broken bone \naround the \ntooth's roots \n\nOR \n\ninfection inside \nthe bone from \nVincent's \nInfection \n\n\n108 \n\nto \n\n112 \n\n102 \n\nand \n\n121 \n\n\nWhen you ask the person to \nslowly close his teeth, one ( i icLJL/) \n\ntooth hits another, before the ^Y\\)Sk ]\\ \nother teeth come together. \n\n\na tooth is out \nof position and \nbiting too hard \naganist another \n\n\n99 \n\n\n\n82 \n\n\n\nWhere There Is No Dentist 2010 \n\n\n\nIF THE PERSON \nHAS \n\n\nAND YOU FIND OUT \nTHAT \n\n\nHE/SHE \nMAY HAVE \n\n\nSEE \n\nPAGE \n\n\nt \n\n\nt \n\nThe gums are red and \nswollen. They bleed when the \nteeth are cleaned. \n\n\nTS?oa \n\n\nt \n\ngum disease \nstarting \n\n\n1 \n\n101 \n\n\nA SORE MOUTH \nfrom \n\nINFECTED GUMS \n\n\nBetween two teeth the gums \nare sore and swollen, like a \nsmall tumor. \n\n\n\n\nsomething \ncaught under \nthe gum \n\n\n133 \n\n\n\n\nThe gums between the teeth \nhave died and are no longer \n\n\nAXLCn \n\n\nVincent's \nInfection {a \nmore serous \ngum Infection) \n\n\n\n\n\n\npointed. Pus and blood around \nthe teeth make the mouth \nsmell bad. \n\n\n\n\n102 \n\n\n\n\nThe gums are bright red and \nsore, but between the teeth \nthey are still pointed. \n\n\n\n\nfever blisters \non the gums — \nfrom Herpes \nVirus \n\n\n104 \n\n\n\nA sore on the inside of the . \n\ncheek, lips, or under the \ntongue, is yellow with the \nskin around it bright red. \n\nFood touching it makes the \nsore hurt more. \n\n\na canker sore \n\n\n106 \n\n\nA sore spot around or under \n\nor a denture hurts when you ' \n\nA SORE MOUTH touch it. ^ \n\nfrom a / \\ \\ \n\nSMALL SORE \n\n\na sharp place \non a denture, \nor an old \ndenture that \nneeds to be \nrefitted \n\n\n106 \n\n\nin another \n\nplaj-e A kind of white cloth seems \n\nto be stuck to the top of the \nmouth or tongue. It may \nstop a baby from sucking. \n\nV / \n\n\nthrush \n\n\n105 \n\n\nThe sore is near the root of \na bad tooth. \n\n\ngum bubble \n\n\n74 \n\nand \n\n93 \n\n\nThe corners of the mouth \\ y \n\nare dry. The lips crack and \n\nare sore. ' \n\n\nmalnutrition \n\n\n107 \n\n\nSmall painful blisters on the C— \n\nlips soon break and form dry ^^ 0 ’. \n\nscabs. \n\n\nfever blisters — \nfrom Herpes \nVirus \n\n\n104 \n\n\nA SORE THAT DOES NOT HEAL PROPERLY MAY BE CANCER (See page 125). \n\n\n\n.-'llfliki UrL \nWWW. ncspcri3n.org \n\n\n\nWhere There Is No Dentist 201 0 83 \n\n\n\nIF THE PERSON AND YOU FIND OUT \n\nHAS THAT \n\n\nHE/SHE MAY \nHAVE \n\n\nSEE \n\nPAGE \n\n\nInside his mouth, he has a l \n\ntooth abscess or a broken \n\ntooth near the sore. ^ \n\nA Q*^RF \n\n\nabscessed tooth \ndraining pus to \nthe outside of \nthe face \n\n\nt \n\n120 \n\n\nON THE FACE \n\nA dark sore is eating through \nthe cheek. Her gums are \\| \n\nbadly infected. A bad smell is ^ jijf \n\nA~^ coming from the dying skin on T \n\nfhe face, and from inside the \n\n\na condition \ncalled Noma — \nstarting from \nVincent's \nInfection of the \ngums \n\n\n121 \n\n\nA 1 -month-old sore on the lips \\ j \n\nis not healing with medicine. \n\n\ncancer \n\n\n125 \n\n\n\nHe is young, between \n\n1 6-24 years, with some 4* S' \n\nswelling behind his jaw. \n\n\na new tooth \ngrowing in \n\n\n100 \n\n\nTROUBLE OJ \n\nOPENING THE He recently had an accident. ' \n\nMOI^H \n\n\na broken jaw — \nprobably in \nfront of the ear \n\n\n108 \n\n\n4^'^' \\ ^}/j ^ toothache before \n\nin a back tooth with some \n\n\nan abscess in a \nback tooth \n\n\n93 \n\n\n) iCAWNOT^ When she tries to open \n\n[open ANY j her mouth, there is clicking \n\n\\ 1 sound from in front of her \n\n1 ^ huns io thst place \n\nwhenever she tries to open \nher mouth or chew food. ' ^ \n\n\npain in the \njoint — where \nthe jawbone \njoins the head \n\n\n114 \n\n\nSwallowing is difficult and ^ \n\nthe jaw grows stiff. Germs v ~^/ \n\nhave gone into the body / \n\nfrom dirty instruments or an y / \ninfected wound. \n\n\ntetanus \n\n\n118 \n\n\n\nTROUBLE After opening wide to eat \n\nCLOSING THE or yawn, his mouth became \n\nMOUTH stuck there. He was many \n\nmissing back teeth. \n\n\n\n\na dislocated \njaw \n\n\n113 \n\n\naccident and now . \n\n1 \\/'<^ something is stopping the J \n\n^ teeth from coming together. \n\n\n1 \n\n\na broken jaw \n\n\n108 \n\n\n\nWhere There Is No Dentist 201 0 \n\n\n\nWWW. \n\n\n\nhesperian \n\n\n\n■ org \n\n\n\nTreating Some \nCommon Problems \n\n\n\nCHAPTER \n\n\n\n7 \n\n\n\nYou must make a good diagnosis to treat a problem so it goes away and \ndoes not return. Why treat a sore on the face by cleaning it when the sore \nis from pus draining from a tooth with an abscess? You need to know the \ncause of the sore to give the best kind of treatment. \n\nAfter you make the diagnosis, you must decide whether you or a more \nexperienced dental worker should provide the treatment. \n\n\n\nIn the following pages, we describe the kinds of problems you as a health \nworker may see, and we also give the treatment for each problem. \n\nBefore you touch the inside of anyone's mouth, learn how to keep \nclean. The next 6 pages explain how you can prevent infections by washing \nyour hands, wearing gloves, and sterilizing your instruments. \n\nGerms in the mouth \n\nThe mouth is a natural home for germs. They usually do not cause problems \nbecause the body is used to them. In fact, many germs are helpful. For \nexample, when we eat, some germs break down chewed food into parts \nsmall enough for the body to use. \n\nThere are problems when the number of these ordinary germs increases \ngreatly, or when strange, harmful germs come into a healthy body from \noutside. Fever and swelling follow. It is an infection. \n\nWhen we regularly clean the mouth, the number of germs stays normal. \n\nYou can teach others to clean teeth and gums, but cleaning is each person's \nresponsibility. \n\nFlowever, dental workers have one serious responsibility. You must not \nspread germs from a sick person to a healthy person. You must do \neverything you can to make sure your instruments are clean. An instrument \nwith blood on it can spread hepatitis (a serious liver disease) or FIIV, which \ncauses AIDS. \n\n\n\nKnow your limits. Do only \nwhat you know how to do. \n\n\n\nncspcrian.or” \n\n\n\n\n\n\nWWW. \n\n\n\n86 Where There Is No Dentist 2010 \n\n\n\nTHE FIRST RULE FOR TREATMENT: STAY CLEAN! \n\nNo matter what problem you are treating, be sure that your workplace, your \ninstruments, and you are always clean. For example, prevent infection by \nalways washing your hands before you examine or treat someone. \n\nWash your hands in front of the person, in the same room. You will show \nthat you are a careful and caring health worker. Also, you will demonstrate \njust how important cleanliness really is. \n\n\n\n\nWear gloves \n\nLatex or plastic gloves protect the people you \ntouch from germs that may be stuck under your \nfingernails or on your skin, even after you wash \nyour hands. They also protect you from getting \ninfections. Wear clean gloves whenever you \ntouch someone's mouth or any blood. \n\nIf you are filling or removing a tooth, or if you are touching any \ninstruments that have been sterilized, you must wear sterile gloves. \n\nIf you do not have gloves, use plastic bags that \nhave been washed in disinfectant soap instead. \nBags are harder to use than gloves, but they are \nbetter than nothing. \n\n\n\nTjjlpl \n\n\n\n\nWhere There Is No Dentist 2010 87 \n\n\n\n\nGerms hide inside bits of old food, cement, or \nblood on an instrument. There they can continue \nto live, even in boiling water. \n\nThis is why you must be sure to scrub the working \nend of each instrument carefully with soap and \nwater. Rinse, and then look carefully to see that it \nis clean and shiny. \n\n\n\nRemember that 'clean looking' is not necessarily 'clean'. Truly 'clean' means \nfree of germs. Unless you sterilize, that instrument may still have germs, \nthe kind that cause infection in the next person that it touches. \n\nSterilizing means killing germs. The best way to sterilize is with heat. High \nheat kills almost all harmful germs — especially those that cause hepatitis, \ntetanus, and mouth infections. Wet heat (steam) is always more effective \nthan dry heat from an oven. \n\nHere is a simple rule to use in \ndeciding when to sterilize: \n\nBoil or sterilize with steam \nany instrument that has \ntouched blood. \n\n\n\nThat means always sterilize \nall syringes, needles, and \ninstruments you use when \nscaling teeth (Chapter 8) \nor when taking out a tooth \n(Chapter 1 1). \n\nInstruments left in boiling water need 30 minutes to become sterile. A pot \nwith a cover to trap the steam can act faster. The inside becomes hotter and \n20 minutes is enough. But remember that water can rust metal instruments. \nTo prevent rust: \n\n• Add 5 spoonfuls (20 ml) of oil to every liter of water you boil. \n\n• Then lay the hot instruments on a dry, clean (sterile, if possible) cloth, \nso the water can evaporate. \n\nNever put an instrument away while it is wet. \n\n\n\n\nWWW. nCSpCriUll .org \n\n\n\n88 Where There Is No Dentist 2010 \n\n\n\nSterilizing with steam under pressure is the fastest and surest method. It \nkills harmful germs in 1 5 minutes. You need a strong pot with a tight fitting \nlid. But be sure to make a small hole in the lid so steam can escape \nwhen the pressure becomes too great. \n\nA special pot called a pressure cooker is perfect for this. It even has a safety \nhole on it to release extra steam. \n\n\n\n1 . Put 2 cups of water and \n2 spoonfuls of cooking \noil into the pot. \n\n\n\n\n2 . Place the handles together. \nPut on high heat until a loud \nhissing noise begins. \n\n\n\n\n3 . Put on lower heat. Begin \ntiming now. Leave the hissing \npot on the low flame for \n1 5 minutes. \n\n\n\n\nDO NOT LET \nTHE COOKER \nBOIL DRY! \n\n\n\n4 . Cool the pot under water, open, \nand lay the instruments on a \nclean towel to dry. \n\n\n\n\nThe next time you use the pot, \nyou can use the same water that \nwas left inside it. \n\n\n\nWhere There Is No Dentist 2010 89 \n\n\n\nSterilizing with heat is not necessary for instruments that do not touch \nblood. For example, after you examine a person or place a temporary filling, \nyou can clean your instruments and then soak them in a solution of alcohol \nor bleach. \n\n\n\nAlcohol solution \n\n1. Mix in a large container each week: \n7 parts alcohol (95%) with 3 parts \nclean water. Keep the container \ntightly covered to prevent \nevaporation. \n\n2. Keep a covered pan half filled with \nthis mixture. You will have to add \nsome more of the mixture from the \nlarge container to the pan each day. \n\n3. Leave your clean instruments in the \npan, completely covered with the \nliquid, for 30 minutes. \n\n\n\n\n\n\ntight fitting \nlid \n\n\n\n\nBleach solution (sodium hypocholorite) \n\nFind the cheapest brand name in your area for bleach. \nExamples are Javex, Clorox, Purex, and Cidex. Make \n1 liter of solution with a mixture of 14 cup \n(125 ml) of bleach and 314 cups (875 ml) \nof clean water. \n\n\n\n\n\nBLEACH & WATER \n\n\n\nV2 CUP \n\n\n\n\n\n\n3+ V 2 CUPS \n\n\n\nUnfortunately, bleach rusts metal \ninstruments. To reduce rust, \nadd 1 large spoonful of baking \nsoda (sodium bicarbonate) to \nthe solution, and leave your \ninstruments in the solution for only \n30 minutes. \n\nWipe each instrument with alcohol \nto remove the film of bleach. Then \nstore it dry inside a clean cloth or in \nanother covered pan. \n\n\n\n\nChange the solution each week. \n\n\n\n90 Where There Is No Dentist 2010 \n\n\n\nKeep your sterile instruments together in a clean place. \n\nWrap them in a clean cloth OR Leave them in disinfectant \n\n(p. 89) \n\n\n\n\nMark with tape the names \nof the instruments inside. \n\n\n\n\nBefore you use any instrument \nagain, wash it with clean water — to \nremove the taste of the disinfectant. \n\n\n\nGerms living in dirty cotton can easily go inside the socket and start an \ninfection. It is important, therefore, to keep the cut pieces in a container that \nis clean and has a cover. Use clean tweezers to remove the cotton gauze \nwhen you need some. \n\n\n\n\nAlso, keep your room and work area clean. Sweep or mop the floor one or \ntwo times a day, and wipe down the chair and tables after every patient. \n\n\n\nStaying clean is a part of staying healthy. \n\n\n\nWhere There Is No Dentist 2010 91 \n\n\n\nNEEDLES \n\n\n\nMany people get sick with serious illnesses like hepatitis or HIV from using \nunsterilized needles. \n\nReusable syringes and disposable syringes \n\nReusable syringes can be used again and again. Reusable syringes make \nless waste and can save money, but they must be washed very carefully and \nsterilized after every use. \n\nUse each disposable needle only one time and then throw it away in a box \nlike the one on pages 199-200. If you must reuse a needle, replace the cap \nvery carefully and put the needle in a safe place (such as a pan full of bleach \nsolution) until you are ready to clean and sterilize it (p. 138). \n\n\n\nHOW TO WASH AND STERILIZE A SYRINGE AND \nNEEDLE FOR REUSE: \n\n\n\n1 . Put on a pair of heavy gloves \nto protect your hands from \ngerms and from sticking \nyourself with the needle. \n\n\n\n\nli \n\n\n\n2 . Draw 5% bleach solution (see page 89) up \nthrough the needle into the syringe barrel. \n\n\n\n\n3 . Squirt out the bleach solution. |f \n\n\n\n4 . Repeat several times. Rinse everything \nseveral times with clean water. \n\n\n\n5 . Take the syringe and needle apart and boil or \nsteam them. (See page 138.) \n\n\n\nNever reuse a needle or syringe without \ncleaning and sterilizing it first. \n\n\n\n\n\n\n\n92 Where There Is No Dentist 2010 \n\n\n\nPARTI \n\nPROBLEMS YOU WILL SEE MOST OFTEN \n\n\n\nCAVITIES AND LOST OR BROKEN FILLINGS \n\nA cavity can occur in any tooth. A cavity can also start around an old filling, \nespecially if it is dirty. The deeper a cavity gets inside the tooth where the \nnerve lives, the more the tooth hurts. \n\nSIGNS: \n\n• Pain when drinking water or eating \nsomething sweet. \n\n• A hole (or black spot) on the tooth, or \nbetween two teeth. \n\n• Pain if food gets caught inside the hole. \n\n• No pain when you tap the tooth. \n\n\n\nTREATMENT (when there is no abscess): \n\nTry to remove any loose piece of filling with a probe. Then, following the \nsteps in Chapter 10, put in a temporary filling. \n\nNow: \n\n1 . Fill the hole with cement. If you have no cement, put some cotton into \nthe hole to keep food out. \n\n2 . Look for cavities or broken fillings in the other teeth. Fill each one with \ncement before it gets worse and starts to hurt. \n\nSoon (within a few months): \n\n3 . Arrange for someone to replace the temporary filling with a permanent \none. You will need a person who has experience using a dental drill \n(see page 151), or doing Atraumatic Restorative Treatment (ART), a \nway to remove cavities without drilling.. \n\nA groove on the neck of a tooth is a more difficult \ncavity to fill. For the temporary cement to hold \nproperly, you need to shape the groove with \na drill. To help temporarily, you can put a little \nfluoride toothpaste on the groove (page 205). Do \nthis once each week until the inside part of the groove is stronger and the \ntooth hurts less. Or, you can paint the inside of the groove with oil of cloves \n(eugenol) to reduce the pain. \n\nTo avoid making the problem worse, ( 1 ) do not use a hard toothbrush; \n\n( 2 ) do not brush back and forth along the gums; and ( 3 ) do not chew tobacco \nor betel nut and do not hold them against the teeth. \n\n\n\n\n\nWhere There Is No Dentist 2010 93 \n\n\n\nTOOTH ABSCESS \n\nA cavity that is not filled grows bigger and deeper until it touches the nerve. \nGerms travel inside the tooth's root and start an infection called an abscess. \n\nPus forms at the end of the root, inside the bone. As the pus increases, it \ncauses great pressure. This is why an abscess causes severe pain. \n\n\n\nSIGNS: \n\n• Pain all the time, even when trying \nto sleep. \n\n• Tooth often feels longer, and even \na bit loose. \n\n• Tooth hurts when it is tapped. \n\n• A sore on the gums near where \nthe root ends (gum bubble). \n\n• Swelling of the gums around the \ntooth, or swelling of the face on \nthe same side as the bad tooth. \n\n\n\n\nTREATMENT: \n\nIf there is no swelling, take out the tooth immediately (unless you are able \nto give root canal treatment). This allows the pus to escape and relieves the \npain. See Chapter 1 1 . \n\nIf there is swelling, treat the swelling first. Take out the tooth only after the \nswelling goes down. This is necessary because an anesthetic (see Chapter \n9) will not work if there is swelling. \n\nTo treat the swelling, give an antibiotic. Penicillin by mouth is best. Use an \ninjection only when the person is in immediate danger. For example, inject \npenicillin when the person has a fever or if the swelling is pressing against \nthe throat. But remember you can treat most serious infections with simple \npenicillin by mouth. For the doses for serious infections, look below the box \non the next page. If you still think an injection is necessary, look at the \nsection on 'aqueous procaine penicillin' on page 204. \n\nAdults and children over 25 kg (60 pounds) of weight should take the same \namount of oral penicillin. Children under 25 kg should take V 2 as much. For \nmost infections, penicillin by mouth is taken 4 times a day for 5 to 7 days. \n\nThe first dose is double and then the regular dose is taken every 6 hours. The \n\nperson should take all of the penicillin, even if the pain or swelling goes \ndown. For the correct doses, see the next page. \n\n\n\n94 Where There Is No Dentist 2010 \n\n\n\nTHE BEST CHOICE \n\n\nSECOND CHOICE \n(for those allergic to penicillin) \n\n\nPenicillin: 1 tablet = 250 mg \n\nGive enough tablets for 5 to 7 days \n\n\nErythromycin: 1 tablet (or capsule) = 250 mg \n\nGive enough tablets for 5 days \n\n\nFirst Dose (take all at once) \n\nAdults 4 tablets \n\nand children over 25 kg (1000 mg) \n\nChildren under 25 kg 2 tablets \n\n(500 mg) \n\nThen every 6 hours for 5 to 7 days \n\nAdults 2 tablets \n\nand children over 25 kg (500 mg) \n\nChildren under 25 kg 1 tablet \n\n(250 mg) \n\n\nFirst Dose (take all at once) \n\nAdults 4 tablets \n\nand children over 25 kg (1000 mg) \n\nChildren under 25 kg 2 tablets \n\n(500 mg) \n\nThen every 6 hours for 5 days \n\nAdults 2 tablets \n\nand children over 25 kg (500 mg) \n\nChildren under 25 kg 1 tablet \n\n(250 mg) \n\n\nIMPORTANT: to allow it to best fight infection, \ntake penicillin before eating. \n\n\nIMPORTANT: to avoid upset stomach, take \nerythromycin with meals. \n\n\n\nNote: If you do not have penicillin, use amoxicillin, 3 times a day for 7 days. \nAdults and children over 25 kg take 500 mg each dose, and children under \n25 kg take 250 mg each dose. To use ampicillin, see Where There Is No \nDoctor. People allergic to penicillin will also be allergic to amoxicillin and \nampicillin. \n\nFor many infections, taking penicillin for 5 days should be enough. For \nserious infections, it may be necessary to take the antibiotics for 7 days. \n\nFor however long you take them, always take the double dose the first time, \nand then the regular dose 4 times a day (every 6 hours). If the infection does \nnot heal, you may need a different medicine. Usually you can take out the \ntooth 1 or 2 days before the end of the antibiotic treatment, but the person \nmust continue to take all of the tablets, even after you have taken out \nthe tooth. If not, the infection might come back even stronger than before. \n\nIf the swelling is 'pointing', open it with a sharp sterile knife to release the \npus. Cover the wound with a sterile dressing to keep it clean. If you are not \nable to do that, explain how to reduce the swelling with heat. As often as \npossible until the swelling goes away: \n\n• soak a cloth in warm water and hold it against the face. \n\n• hold warm water inside the mouth near the swelling. It is not \nnecessary to add salt to the water. \n\nFinally, give the person medicine for pain. A 2-day supply will be enough, \nbecause the penicillin and the heat will reduce the pressure and that will \nreduce the pain. The best medicines for pain are aspirin, which comes in \n300 mg tablets, and acetaminophen (paracetamol), which comes in \n500 mg tablets. Aspirin is usually cheaper, but acetaminophen does not cause \nstomach pain and it is safer than aspirin for children. (To avoid stomach pain, \ntake aspirin with food, milk, or water.) See doses at the top of the next page. \n\n\n\nOi \n\n\n\nWhere There Is No Dentist 2010 95 \n\n\n\nEVERY 6 HOURS (4 times a day): aspirin or acetominophen \n\n\n\nadults \n\n\n\n\n600 mg \n\n\n1000 mg \n\n\nchildren \n\n\n8 to 12 years \n\n\n300 mg \n\n\n500 mg \n\n\n\n\n3 to 7 years \n\n\n150 mg \n\n\n250 mg \n\n\n\n\n1 to 2 years \n\n\ndo not use \n\n\n125 mg \n\n\n\nINFECTED SINUS \n\nA sinus is a hollow place inside the bone. There is a sinus under the eyes, on \neach side of the nose. Because the sinus is very close to the roots of the top \nteeth, these teeth may hurt if the sinus becomes infected. \n\nSIGNS: \n\n• Toothache in several top teeth. The \nteeth look healthy, but hurt when you tap \nthem. \n\n• A head cold, and plugged nose. She can \nonly breathe through her mouth. \n\n• Hurts when you press against the bone \nunder her eyes. \n\n• Tooth feels different when patient bends over forward. \n\nTREATMENT: \n\nDo not take out any teeth. They will feel better after you treat the sinus \ninfection. \n\n\n\n\n1 . Give penicillin for 5 days (page 94). \n\n\n\n2 . Explain to the person that she should: \n\n• drink lots of water. \n\n• breathe steam from boiling water to clear \nher nose. \n\n• hold a warm wet cloth against her face, as \noften as possible. \n\n• not try to blow her nose, or else her ears will \nhurt. Wiping the nose is better. \n\n3 . See the person again after 3 days, and \n\n\n\n\n• examine her teeth closely, tapping them to be sure they are strong \nand healthy. \n\n• if she is not better, get help from a more experienced health worker. \n\n\n\nWWW. nCSpCrifln .org \n\n\n\n96 Where There Is No Dentist 2010 \n\n\n\nTOOTH INJURIES \n\n1. Broken tooth \n\nIt is possible to save a broken tooth. It depends on where the tooth is \nbroken and whether its nerve is still covere \n\nSIGNS: \n\n• Pain when breathing air or drinking \nwater. \n\n• Blood from the gums around the tooth \n\n• Tooth moves when you touch it. \n\nTREATMENT: \n\nTake out the broken tooth if: \n\n• its nerve is not covered. If no one can give special root canal \ntreatment, the tooth must come out. Germs from the saliva have \nalready gone inside the tooth and started a small infection. \n\n• its root is broken. To see if it is broken, push gently against the \ntooth as you feel the bone around its roots. The tooth's root \nprobably is broken if the tooth moves but the bone does not. The \nroot probably is not broken if both the tooth and bone move. \nHowever, the bone around the roots may be broken (page 109). \n\nYou can save a broken tooth if the nerve is still covered and the \nroot is not broken. To do this, use a file on the sharp edges around the \nbreak. This makes them smooth so they do not cut the tongue. Later, an \nexperienced dental worker who has the equipment can cover the broken \npart with a cap or a filling. Until this is possible, tell the person how to \nprotect the tooth: \n\n• Give the tooth a rest. Use other teeth to eat. \n\n• Do not drink things that are very hot or cold, and do not eat spicy \nfood. \n\n• Watch the tooth. See if it changes color (gets darker). Also watch \nthe gums near the root. See if a sore (gum bubble) develops. \n\nA dark tooth and gum bubble are signs that the tooth is dying. Take it out, \nunless you can give special nerve treatment. \n\n\n\nAt) \n\n\n\n\nWhere There Is No Dentist 2010 97 \n\n\n\n2. Tooth knocked out \n\nWhen a tooth is knocked out of the mouth, you should ask two questions: \n\n(1) Was it a baby tooth? (2) How long ago did it happen? \n\nBaby tooth. There is no reason to try to put a baby tooth back into the socket. \nTell the child to bite on some cotton to stop the bleeding. Then wait for the \npermanent tooth to replace it. Warn the mother that the permanent tooth \nmay take more time than usual to grow into the mouth. \n\nSimilarly, there is no need for \ntreatment if the baby tooth is \npushed up under the gum. \n\nThe tooth may grow back into the \nright place later, or it may turn dark \nand die. if you see a darkened tooth \nor a gum bubble (page 74), take out \nthe baby tooth before it hurts the \npermanent tooth that is growing \nunder it. \n\nPermanent tooth. A permanent tooth is worth saving. How long ago was \nit knocked out? If it was less than 12 hours ago, you can put a permanent \ntooth back into the socket. The sooner you do this the better, so do not \nwait. If you replace the tooth in the first hour, it has a much better \nchance of joining with the gum and bone. In order to heal and to join the \nbone, the tooth must be held firmly. \n\na) Wash the tooth \ngently with saline, \nmilk, or clean water. \n\nThere should not be \nany bits of dirt on the \nroot of the tooth. \n\nKeep the tooth \ndamp with wet \ncotton gauze. \n\n\n\n\n\nDo not scrape away any skin from the \nroot or from the inside of the socket. \n\n\n\nWWW. nCSpCriUll .org \n\n\n\n98 Where There Is No Dentist 2010 \n\n\n\nb) If you can not use anesthetic, tell the patient that it will hurt \n\nsomewhat. Gently push the tooth up into the socket. As you push it \nup, use a slight turning movement \nback and forth. \n\n\n\nThe biting edge of the loose \ntooth should be at the same \nlevel as the teeth beside it. \n\nHold it in place with your \nfingers for about 5 minutes. \n\nc) Soften some beeswax and \nform it into 2 thin rolls. Place 1 \nroll near the gums on the front \nside of 5 teeth: the loose tooth \nand the 2 teeth on each side \nof it. Press the wax firmly, but \ncarefully, against these teeth. \n\nDo the same with the second \nroll of wax on the back side of \nthe same teeth, again near the \ngums. \n\nIt is good if the wax on the \nback side is touching the wax \non the front side. This helps \nthe wax hold the teeth more \nfirmly. To do this, you can \npush the wax between the \nteeth with the end of your \ncotton tweezers. \n\n\n\n\nKeep the wax in its position \nfor at least 3 weeks. \n\n\n\nTell the person with the injured tooth to return to see you several \ntimes. The tooth may die several months or even several years later (see \npage 47). If that happens, you must take out the tooth, unless you can do \nroot canal treatment. \n\nIf it is possible, take an X-ray of the tooth 6 months later and then again each \nyear. Look at the X-ray picture of the root to be sure an infection is not eating \nit away. To do this, compare the root with the roots of the teeth beside it. \n\n\n\nWhere There Is No Dentist 2010 99 \n\n\n\nLOOSE TOOTH \n\nA tooth may be loose for one of several reasons. Decide the reason before \ngiving the treatment. \n\n\n\nIF THE TOOTH IS LOOSE \nBECAUSE \n\n\nTHE BEST TREATMENT \n\n\n♦ \n\n\n\n\na new permanent tooth is \ngrowing under it. \n\n\n1 . tell the mother and child what is happening. \n\n2. pull out the loose baby tooth, if it is hurting the \nchild. \n\n\ngum disease or an old abscess has \neaten the bone around its roots. \n\n\n1 . take out the tooth, especially if it also hurts. \n\n2. explain to the person what to do to prevent this \nproblem in other teeth. (See Chapter 5.) \n\n\nits root has been broken. \n\n\ntake out both parts of the tooth. If you have trouble \ntaking out the broken root, leave it and try again a \nweek later. \n\n\nthe bone around its root is cracked. \n(The bone moves when you push \nagainst the tooth.) \n\n\nDo not take out the tooth. If you do, the bone will \ncome out with it. Instead, hold the tooth with wires \n(page 110). \n\n\n\nA tooth may also be loose because another \ntooth is biting too hard against it. \n\nSIGNS: \n\n• You can feel the tooth move when \nthe upper and lower teeth meet. \n\n• That tooth hurts. \n\n\n\nTREATMENT: \n\n\n\n\nYou need to remove a bit of each of the teeth that are biting too hard. Use \neither a dental worker's drill, a small file, or a hard stone. \n\n\n\n1. Smooth the inside edge \nof the upper tooth. \n\n2. Smooth the outside edge \nof the lower tooth. \n\n\n\n\nWWW. \n\n\n\nnesperiun.org \n\n\n\n100 Where There Is No Dentist 2010 \n\n\n\nNEW TOOTH GROWING IN \n\nA new tooth cuts through the gums when it grows into the mouth. Germs \ncan easily go under the gums in that place and cause an infection. When the \nopposite tooth bites against the sore gum it can make an infection worse. \n\n\n\nSIGNS: \n\n• Toothache at the back of the jaw. \n\n• Mouth cannot open properly. \n\n• A bad taste coming from the back \nof the mouth. \n\n• Sore throat. \n\n• Skin over the new tooth is sore \nand hurts when you touch it. \n\n• The age of the person is the right \nage for growing a new molar \ntooth (page 66). \n\n\n\n\nInfection in the gums and pressure from \nthe new tooth are painful. Notice the \n'flap' of skin over the new tooth. \n\n\n\nTREATMENT: \n\nDo not take out a new tooth while there is still infection and pain. Wait \nfor the infection to finish. Then decide if there is room for the tooth to grow \nin. A dental X-ray can help you make that decision. New molar teeth are \noften difficult to take out. Ask an experienced dental worker to take out the \ntooth, if it must be done. \n\nWhat you can do \n\nFirst, treat the infection. Then wait for the new tooth to grow more into the \nmouth. Tell the person what is happening. Tell him what he can do to keep \nthe gums healthy while the tooth grows in: \n\n• Rinse the area with warm salt water (page 7). Make 4 cups each day \nuntil the mouth opens normally again. Then make 1 cup each day to \nprevent the problem from returning. Keep rinsing this way until the \ntooth grows all the way in. \n\n• Field a warm wet cloth against the jaw as often as possible each day. \n\n• Take aspirin for pain (page 94). \n\nGive penicillin (pages 93-94) if there is fever, a swelling, or if he is only able \nto open his mouth a little. \n\n\n\nWhere There Is No Dentist 2010 101 \n\n\n\nTEETHING \n\n\n\nWhen babies and small children first get their teeth, it is called teething. \nThis can make the child unhappy, because his gums are sore. \n\n\n\nTREATMENT: \n\nIf the child has another sickness, do not blame it on teething. Look for \nanother cause and treat it separately. Also, do not cut the gum over the \nnew tooth. Let the tooth grow through the gum by itself. \n\n1 . Give acetaminophen for pain and fever (page 94). \n\n2 . Give the child something hard to bite against. This will help the tooth to \ngrow through the gums faster. For example, let him chew on a dry hard \nbiscuit. \n\n\n\nInfection can start in the gums whenever the teeth near them are not clean. \nFor example, there may be swelling between only 2 teeth or between many \nteeth. In addition, gums that are weak from poor nutrition are not able to \nresist the infection. This is why pregnant women and people living with FIIV \nmust take special care to eat well and clean their teeth carefully. When a \nperson has FIIV, his body cannot fight infections well, so a gum infection can \nquickly get worse (page 183). \n\n\n\n\nTeething does not cause fever, \n\n\n\nBut a child can have any of \nthese problems at the same \ntime as he gets a new tooth. \n\n\n\nhead colds, or cough. \n\n\n\nGUM DISEASE STARTING \n\n\n\nSIGNS: \n\n• Gums are red instead of pink. \n\n\n\n\n• Gums are loose instead of \ntight against the tooth. \n\n\n\n• Between the teeth, gums are \nround instead of pointed. \n\n\n\nJ\\ \n\n\n\n. Gums bleed when the person Feel for tartar under the gum-or \n\nbrushes or flosses. \n\n\n\n• Gums bleed when the person \nbrushes or flosses. \n\n\n\n• Gums bleed when you press \n\n\n\nagainst them, or when you scrape away food from under them. \n• The person has bad breath and a bad taste inside the mouth. \n\n\n\nWWW. ncspcriun.org \n\n\n\n102 Where There Is No Dentist 2010 \n\n\n\nTREATMENT: \n\nExplain to the person the cause of her gum problem and what she can do \nto help herself. The only way to stop gum disease is to remove plaque and \ntartar from the teeth and then to keep them clean. \n\n1 . Show her how to clean her teeth better near the gums (page 69). \n\n2 . Tell her to rinse her mouth with warm salt water (page 7). Make 4 cups \neach day until the bleeding stops. Then make 1 cup each day to keep \nthe gums strong and tough. \n\n3 . Tell her to eat fresh fruits and vegetables. Guavas, oranges, pineapples, \npapayas, tomatoes, peas, and green leaves give strength to gums. \n\n4 . Gently reach under the gums and remove tartar (or loose piece of \nfishbone) that is caught there (see Chapter 8). \n\nSometimes a pregnant woman's gums become swollen, and the swelling \ndoes not go down even after cleaning with a soft brush and rinsing with salt \nwater. These swellings must be cut away. But she should wait to have this \nsmall operation until after the baby is born. \n\nMORE SERIOUS GUM DISEASE \n\nVincent's infection of the gums, also called trench mouth, affects both \nadults and children. In its worst form, it can eat a hole through the cheek of a \nweak child (page 121). \n\nA person with Vincent's Infection may not want to eat because his teeth \nhurt when he chews food. That can make a child's malnutrition worse. \n\nYou must prevent this problem from starting, especially in a child who is \nweak from sickness. Teach mothers to clean their children's teeth and to get \ntheir children to rinse their mouths with warm salt water. \n\nSIGNS: \n\n• Gums between the teeth are dying \nand turning gray. \n\n• Pus and old blood collect around \nthe teeth. \n\n• Burning pain from the gums. \n\n• Bleeding from the gums. \n\n• The mouth smells bad. \n\nTREATMENT: \n\nYou will need to see the person over a 2-week period. Start some \ntreatment now: \n\n1 . If the person is already sick, give penicillin for 7 days (page 94). \n\n\n\n\nWhere There Is No Dentist 2010 103 \n\n\n\n2 . Clean away the pus, old food, and big pieces of tartar. Then: \n\n• Tell the person to rinse his mouth with warm water. \n\n• Wipe his gums with cotton soaked in a 3% solution of hydrogen \nperoxide, iodine, disinfectant mouth wash, or warm salt water. Rinse \nwith warm water. For a child, use a weaker solution, such as 1 part \nhydrogen peroxide mixed with 5 parts water. \n\n• Scrape away the bigger pieces of tartar. Do not try to remove all of it. \nYou can do that later. Put topical anesthetic on the gums if you have \nsome (first dry the area with cotton so the topical anesthetic will stay \nlonger). Rinse away any loose bits of tartar with warm water. \n\n3 . Teach the person how to care for the gums at home: \n\n• Rinse at home for 3 days with a weak solution of hydrogen peroxide, \n(page 8), iodine, disinfectant mouth wash, or warm salt water. Try \n\nto hold the solution in the mouth for several minutes. The longer the \nsolution touches the gums, the better it is for the gums. Rinse once \nevery hour. After 3 days, change to salt water, 4 cups a day. \n\n• Clean the teeth with a soft brush. Parents can clean children's teeth. \nShow them how (page 1 8), and ask them to do it even if the gums \nbleed. \n\n\n\n\nFor a young child who is not able to \nrinse. Mother or Father can wipe his \ngums with the weak solution 4 times \na day. \n\nShow parents how to do this. Give \nthem some cotton gauze and hydrogen \nperoxide, iodine, or disinfectant mouth \nwash to take home. \n\n\n\n4 . Cook food that is soft (like pounded yam) and not spicy (no pepper). Eat \nfresh fruits and vegetables that give strength to the gums (page 102). \n\nIf you cannot eat well because of pain, take a multi-vitamin, or at least \nVitamin C and Zinc. \n\n• Stop smoking and stop chewing betel nut. \n\nOne week later, scrape away the rest of the tartar from the teeth. Then \nuse the person's own brush and show him how to do a better job of \ncleaning his teeth. \n\n\n\nWWW. \n\n\n\nnespen^n.org \n\n\n\n104 Where There Is No Dentist 2010 \n\n\n\nFEVER BLISTERS \n\nHerpes virus is a kind of germ that causes fever blisters. Fever blisters are \nsores that can form inside the mouth on the gums or outside on the lips. Blisters \non the inside cheeks only are not from herpes (see canker sores, page 106). \n\n\n\nSores inside the mouth are a serious problem that usually affect children \nbetween 1 and 5 years old. A child with fever blisters in his mouth can become \nvery sick. Fie will not be able to eat properly. If he does not drink enough fluids, \nhe can become dehydrated (lose his body water). This is dangerousi Fever \nblisters are also a problem for people living with FI IV. See pages 186 to 187. \n\n\n\nInside the mouth \n\n\n\nSIGNS: \n\nSore throat. \n\nFever. \n\nCrying, stops sucking 2-3 days before sores appear. \nSpit spills from the mouth because it hurts to swallow. \nPainful swelling under the jaw. \n\n\n\n\nBright red blisters on the gums, but not between the teeth. Blisters also \nmay be on the roof of the mouth. \n\n\n\nTREATMENT: \n\nMedicine cannot kill the herpes virus. The sores will go away by themselves in \nabout 10 days. The treatment is to help the person feel more comfortable and \nto be sure he gets enough to eat and drink. \n\n1. Give aspirin or acetaminophen for fever (page 94). \n\n2. Wipe milk or yogurt over the sores to protect them before eating. Wash \nyour hands before touching the inside of someone's mouth! (See \npage 86.) Then give food that is soft and not spicy. If the person cannot \neat, prepare a special milk-oil drink, as on page 1 \n\n3. Give lots of fluids to drink. \n\nSores on the lips usually occur after the age of 5. \n\nThey often appear when the person is weak and \nsick (for example, with diarrhea or pneumonia.) \n\nUsually there is no fever. The blisters soon break \nopen and release water. When they dry, a crust \nforms. The blisters often return. When sores leak \nwater they can pass infection. If you or anyone else \ntouches them, wash your hands immediately. \n\nTo prevent the blisters from becoming infected, put an antibacterial cream \nor petroleum jelly (Vaseline) on them. If you hold ice against the sores for \nseveral minutes each day, it may help them heal faster. See page 187 for more \noptions. \n\n\n\n\nWhere There Is No Dentist 2010 105 \n\n\n\nTHRUSH \n\nThrush is an infection caused by a yeast fungus called Candida. It often \nappears when a person is weak and poorly nourished, or sick and taking \nmedicine like tetracycline or ampicillin. In a baby, thrush usually appears \non the tongue or top of the mouth. It can stop the baby from sucking. In \nan adult, thrush often occurs under a denture. Thrush is a very common \nproblem for people living with HIV (see pages 180 to 181). \n\nSIGNS: \n\n• White patches on the tongue, cheek, or \ntop of the mouth. Wipe the white area: If \nthere is no bleeding it is old milk. If there \nis bleeding, it is thrush. \n\n• The child may not want to suck or eat. \n\n\n\nTREATMENT: \n\nThere is usually something else present which is helping thrush to grow. \n\nTry to find what it is and deal with it. For example, treat the malnutrition, \ndiabetes, or anemia, change or stop the antibiotic medicine, or clean the \ndenture and leave it out of the mouth for a while. Then: \n\n1 . Cover the white patches with nystatin drops. Use a full dropper 4 or 5 \ntimes a day until the patches are gone. If you do not have nystatin you \ncan soak a piece of cotton in gentian violet and use it to paint the white \npatches 2 times a day. \n\nIf the baby's mother has sore, painful nipples, she may also have thrush \nin her breasts. She should treat her nipples the same way she treats \nthe baby's mouth. \n\nDo not use penicillin or any other antibiotic unless you need to \ntreat something different. Thrush can get worse when a person uses \nan antibiotic for a long time. \n\n2 . Continue breastfeeding. For older persons, make their food soft and \neasy to chew. \n\nIMPORTANT: Sometimes white lines appear on the inside of an adult's \ncheek or on the roof of the mouth. If these lines become sore and do not \nget better with treatment, they can change into a cancer (page 1 25). To \nprevent this cancer, ask the person to stop smoking (especially pipes), stop \nchewing betel nut, and get dentures adjusted if they do not fit properly. \n\n\n\n\n\nWWW. ncspcriun.org \n\n\n\n106 Where There Is No Dentist 2010 \n\n\n\nCANKER SORES \n\nThe exact cause of canker sores is not known. Canker sores affect both \nadults and children, and are very common among youth. \n\nOne or more sores can appear at any time. These sores hurt, especially \nwhen pieces of food touch them. \n\n\n\nSIGNS: \n\n• A sore can appear on the cheeks, \ninside the lips, on the tongue, or below \nthe gums on the smooth skin. \n\n• The sore is white or yellow with the \nskin around it bright red. \n\n• The person may have had a similar kind \nof sore before. It tends to come back. \n\n\n\n\nNote: a sharp edge of a denture rubbing against the gums can \nmake a similar kind of sore. \n\nTREATMENT: \n\nA canker sore goes away by itself in about 10 days. Medicine does not make \nthat happen any faster. (However, smoothing a denture or fixing a broken \ntooth does help.) The treatment is simple. Tell the person how to feel more \ncomfortable while waiting for the 1 0 days to pass: \n\n• Eat foods that are soft and not likely to hurt the sore. \n\n• Do not eat spicy food. \n\n• Drink lots of water. \n\n• Chew food on the other side of the mouth, away from the sore. \n\nA denture which does not fit \nshould be remade. \n\nIn the meantime, leave the \ndenture out of the mouth for \n2 or 3 days. \n\nAsk the person to rinse with \nwarm sait water, 4 cups each \nday until the sore is better. \n\nIf the sore continues after 1 0 days, it may be infected. Give penicillin (page 93). \n\nA sore that does not heal after antibiotic treatment may be cancer (see \npage 125). See a doctor immediately. \n\n\n\n\nWhere There Is No Dentist 2010 107 \n\n\n\nSORES AT THE CORNERS OF THE MOUTH \n\nTeeth support the lips. When they come together for chewing, the teeth \nstop the person's chin from moving any closer to the nose. \n\nA person without many teeth looks old. A person with a poor fitting denture \nalso looks old. \n\nThe distance from his chin to his \nnose is shorter than normal. \n\nHe must close his jaw further to \neat. That causes lines to form at \nthe corners of his mouth. \n\nPoor health can make lines at \nthe corners of the mouth crack \nand become sore. These cracks are \noften infected with thrush and can be treated with nystatin (see page 105). \nIf sores are not at the corners but around the mouth, they could be due to a \nbacterial infection (see page 94). \n\n\n\n\nA person with missing teeth needs dentures. Dentures will help him \nchew more food and make him look younger. They support his lips and \nopen his mouth more. (See page 164). \n\n\n\nA child who has had a fever or measles often \nmouth can crack and become sore. \n\n\n\nCracks and sores appearing at the \ncorners of a child's mouth are signs of \ndehydration and malnutrition. \n\n\n\nhas dry lips. The corners of her \n\n\n\n\nThe child needs to eat the kind of foods that give strength, energy, and \nprotection. Feed her beans, milk, eggs, fish, oils, fruits, and green leafy \nvegetables (see page 67). \n\n\n\nTREATMENT (when sores occur): \n\n1 . Wash the sores with soap and hot water. \n\n2 . Mix 1 part sulfur with 10 parts of petroleum jelly (Vaseline). \n\n3 . Smear some on the sores 3-4 times a day. \n\n\n\nWWW. ncspcrisn .org \n\n\n\n\n108 Where There Is No Dentist 2010 \n\n\n\nPART 2 \n\nSOME SPECIAL PROBLEMS \n\n\n\nYou will find some problems that are too serious for you to treat. If you can, \nsend the sick person to a more experienced dental worker as soon as possible. \n\nSometimes, however, it is better to start some of the treatment yourself. \nEarly treatment can prevent some problems from becoming more serious. \nAlso, if you know what to do when someone returns from the hospital, you \ncan help that person to get well faster. \n\nSometimes, you will find it impossible to get help. Therefore, we will discuss \neach of these more serious problems in detail, so you can give as much help \nas necessary. \n\nBROKEN BONE \n\nThree main bones form the face and lower jaw. \n\n\n\n\n\nA bone can break completely, or part of it can crack. In either case, the teeth \nare usually pushed out of position. Look for this as a sign of a broken bone. \n\nSIGNS of a broken bone: \n\n• The person has had an injury. \n\n• When teeth are closed, some upper \nteeth do not meet lower teeth. \n\n• The person cannot open or \nclose the mouth properly. \n\n• There is bleeding from between 2 teeth. \n\n• There is swelling or a bruise on the face or jaw. \n\n• There is bleeding into the eye. \n\n\n\n\nWhere There Is No Dentist 2010 109 \n\n\n\nSIGNS of a cracked bone \n\n\n\naround the tooth's roots: \n\n• When you move one tooth, \nthe tooth beside it also moves. \n\n• When you move the loose \ntooth, the bone moves with it. \n\n• Blood is coming from \n\nunder the gums. ® \n\nTREATMENT: \n\n\n\n\nPUSH GENTLY \nAGA1N5T ONE \nTOOTH \n\n\n\n@ AND THE OTHER \ny' TOOTH ALSO MOVES \n\n\n\nBECAUSE THE \n0ONE AROUND \nTHEIR ROOTS \n\nts cracked. \n\n\n\nWhen a bone is broken or cracked, the treatment is to hold the broken \nparts together so that the parts can rejoin. The usual way to do this is to put \nwires around the teeth. An experienced dental worker should do this. There \nare two things you can do. First, provide emergency care. Later, show the \nperson how to eat and how to keep his mouth clean. \n\nEmergency care (pages 109-110): \n\n1. Be sure the person can breathe. \n\n2 . Stop the bleeding. \n\n3. Put a bandage on the person's head. \n\n4. Give penicillin to stop infection. \n\n5. Give aspirin or acetominophen for pain. \n\n\n\n1. Be sure the person can breathe. \n\n\n\n\nLater, carry him to the hospital in that position. If he goes in a car, be sure \nhe sits with his head forward. Flis jaw and tongue will be forward and he \nwill breathe more easily. \n\nLook inside the mouth to see if any tooth is broken and very loose. A \nbroken piece of tooth can fall out and block the person's airway, so take \nout the broken part now. You can leave in the root, but if you do, tell the \ndental workers at the hospital (p. 213). They will remove the root when \nthey put on the final wires. \n\n2. Stop the bleeding. \n\nWipe away the dried blood from his face and from inside his mouth. Look \nfor the place that is bleeding. Sew any deep cuts on his face (see Where \nThere Is No Doctor, p. 86). If you gently press cotton gauze against the \nbleeding gums, it will usually control the bleeding. \n\n\n\n110 Where There Is No Dentist 2010 \n\n\n\nBleeding inside the mouth, from between the broken parts of the \nbone, is more difficult to stop. You must pull the two sides together \nand hold them in that position. To do this, you need wire that is thin, \nstrong, and bends easily. 'Ligature wire' (0.20 gauge) is best. \n\n\n\nPlace a piece of wire around 2 teeth, \none on each side of the break. Choose \nthe strongest tooth on each side — the \nones with the longest or the most roots. \nTighten the wire around the two strong \nteeth with pliers or a hemostat. \n\n\n\n\nAsk the person to close his teeth. Lift up the broken part of the jaw and \nhold it so the lower teeth meet the upper teeth properly. This is the \nnormal way the jawbone holds the teeth. \n\n\n\nNow join the wires. Twist and tighten \nthem together. This may be painful. \n\nYou can inject local anesthetic — see \nChapter 8. You must twist the wire tight \nenough to hold the broken parts together. \n\n\n\n\nBend the end of the twisted wire toward the teeth. Now it cannot poke \nthe person's lips or cheek. \n\n3. Put on a head bandage. \n\nGently close the person's jaw so that his teeth come together. Support it \nin this position with a head-and-chin bandage. \n\n\n\n\nTie the bandage to support the jaw, not to pull it. \nDo not make it too tight. It is all right if his mouth \nstays partly open with the teeth slightly apart. \n\nBe sure not to let the bandage choke the person. \n\n\n\n4. Give penicillin by injection (page 204) for 5 days to stop infection inside \nthe bone. \n\n5. Give something for pain. Aspirin (page 94) may be enough. Give \n\n600 mg by mouth, 4 to 6 times a day, as needed. For children, see doses \non page 1 65. If there is a lot of pain and the person cannot sleep, give \ncodeine. The dose for an adult is 30 mg, 4 to 6 times a day as needed. \n\n\n\nWhere There Is No Dentist 2010 111 \n\n\n\nSend the person to the hospital as soon as possible. The person must have \nwires placed on his teeth within a week of the accident. The wires must \nremain there for 4 to 6 weeks. Every week, the person must return to the \nhospital to have the wires tightened. During this time he cannot open his \nmouth to chew food or brush his teeth. \n\n\n\nCARING FOR A PERSON WHO CANNOT EAT PROPERLY \n1. Give liquid foods for strength and energy. \n\nPrepare food in two ways: (a) First, a milk-oil drink to build strength and \nthen (b) a special soup to keep him strong and give him energy. \n\nTo build strength: Milk-oil drink \n\nMix for him each day at your clinic: \n\n• 9 cups of water • 1 50 ml of peanut oil or coconut milk \n\n• 3 cups of milk powder • cup of honey or 1 cup of sugar \n\n\n\nLeave some near his bed, and keep the rest in a cool place. \n\n\n\nTo keep strength and give energy: Special vegetable soup \n\nCut into small pieces and cook together in a pot of water: \n\n\n\n\nVi tin of fish or a handful of dried fish \n4 small spoonfuls of peanut oil or palm oil \n6 sweet potatoes or small yams \n1 large handful of green leaves \n1 small spoonful of salt \n\n\n\n\n\nPour the soup into an empty tin with small holes made in the bottom. \n\nUse the back of a spoon to press as much of the cooked food as you can \nthrough the holes. The person can suck the soup between the teeth to \nthe throat and then swallow it. Clean the tin and set it in boiling water, so \nyou can use it again the next day. \n\n2. Keep the teeth clean and the gums tough. \n\nThe person must learn to clean teeth and gums or the gums can quickly \nbecome infected and the mouth will feel sore. So: \n\n• Scrub both the wires and the teeth with a soft brush after drinking \nsoup. \n\n• Rinse with warm salt water (page 7), 2 cups every day. \n\n\n\nWWW. nCSpCriUll .org \n\n\n\n112 Where There Is No Dentist 2010 \n\n\n\nLOOSE TEETH \n\n\n\n\nB€ND TMC NCKDI.E \nAROUNP TUE TOOTH \nSO YT DOES NOT \n-STICK OUT-. \n\n\n\n\nIf the bone around the roots of the teeth is cracked, those teeth will be \nloose. Do not take the teeth out until the bone is healed. Otherwise, \nbone will come out with the teeth and there will be a big hole in the jaw. \nInstead, support the teeth, in order to hold both sides of the bone steady. \n\n1 . With your thumb and finger, gently \nmove the loose teeth and bone back \ninto normal position. \n\n2 . Cut a hypodermic needle and use it \nas a splint. Make it long enough to fit \naround two strong teeth on each side of \nthe loose teeth. Curve the needle so it \nfits the curve of the teeth. To make the \nsharp ends smooth, use a file or rub the \nends against a stone. \n\n3 . Tie each tooth to the needle. Use short \npieces of 0.20 gauge ligature wire (page 1 10). \n\nPut one end of the wire under the needle. \n\nBring it around the back of one tooth and \nout to the front again over the needle. \n\nUse the end of a small instrument to \nhold down the wire at the back of the \nteeth. Then twist the ends together. \n\nTighten the wire around each one of \nthe 6 teeth. \n\n4 . Cut the ends of the ligature wire. Turn \nthem toward the teeth, so they will not \ncut the lip. \n\n5 . Tighten the wires the next day, and then once each week. But be \ncareful. Only Vi a turn usually is needed. More, and the wire will break. \nAlways twist in the direction a clock moves. With this habit, you will \nremember which way tightens the wire and which way loosens it. \n\n6 . Explain to the person that it takes 4 weeks for the bone to heal. The \nwires must remain on the teeth for this time. To help the teeth to heal, \nask the person to: \n\n• give these teeth a rest. Use other teeth for chewing. \n\n• clean both the teeth and the wires with a soft brush. \n\n• rinse with warm salt water, 2 cups every day (page 8). \n\n• return to have the wires tightened every week. \n\n7 . After 4 weeks, cut and remove the wires. Ask the person to watch \nthose teeth. A dark tooth and gum bubble are signs that the tooth is \ndying. Take it out, unless you can give special nerve treatment. \n\n\n\nUSE A 5TRON&' \nHCMOSTAT OR \nNEEDLE HOLDER \n\n\n\n\nk \n\nnespenan.org \n\n\nNOTICE \n\nThis book is to help people meet most of their common health \nneeds for and by themselves. But it does not have all the answers. \nIn case of serious illness or if you are uncertain about how to \nhandle a health problem, get advice from a health worker or \ndoctor whenever possible. \n\n\n\n\nWhere There Is No Doctor 2010 1 \n\n\nHome Cures \nand Popular Beliefs \n\n\nCHAPTER \n\n1 \n\n\nEverywhere on earth people use home remedies. In some places, the \nolder or traditional ways of healing have been passed down from parents to \nchildren for hundreds of years. \n\nMany home remedies have great value. Others have less. And some may \nbe risky or harmful. Home remedies, like modern medicines, must be used \nwith caution. \n\nTry to do no harm. \n\nOnly use remedies if you are sure they are \nsafe and know exactly how to use them. \n\n\nHOME CURES THAT HELP \n\nFor many sicknesses, time-tested home \nremedies work as well as modern medicines — \nor even better. They are often cheaper. And \nin some cases they are safer. \n\nFor example, many of the herbal teas \npeople use for home treatment of coughs \nand colds do more good and cause fewer \nproblems than cough syrups and strong \nmedicines some doctors prescribe. \n\nAlso, the ‘rice water’, teas, or sweetened \ndrinks that many mothers give to babies with \ndiarrhea are often safer and do more good \nthan any modern medicine. What matters \nmost is that a baby with diarrhea get plenty of \nliquids (see p. 151). \n\nThe Limitations \nof Home Remedies \n\n\n\nFOR COUGHS, COLDS, AND \nCOMMON DIARRHEA, HERBAL TEAS \nARE OFTEN BETTER, CHEAPER, AND \nSAFER THAN MODERN MEDICINES. \n\n\nSome diseases are helped by home remedies. Others can be treated better \nwith modern medicine. This is true for most serious infections. Sicknesses like \npneumonia, tetanus, typhoid, tuberculosis, appendicitis, diseases caused by sexual \ncontact, and fever after childbirth should be treated with modern medicines as soon \nas possible. For these diseases, do not lose time trying to treat them first with home \nremedies only. \n\nIt is sometimes hard to be sure which home remedies work well and which do \nnot. More careful studies are needed. For this reason: \n\n\nIt is often safer to treat very serious illnesses with modern \nmedicine — following the advice of a health worker if possible. \n\n\nwww. nespenan.org \n\n\n2 Where There Is No Doctor 2010 \n\n\nOld Ways and New \n\nSome modern ways of meeting health needs work better than old ones. But at times \nthe older, traditional ways are best. For example, traditional ways of caring for children \nor old people are often kinder and work better than some newer, less personal ways. \n\nNot many years ago everyone thought that mother’s milk was the best food for a \nyoung baby. They were right! Then the big companies that make canned and artificial \nmilk began to tell mothers that bottle feeding was better. This is not true, but many \nmothers believed them and started to bottle feed their babies. As a result, thousands \nof babies have suffered and died needlessly from infection or hunger. For the reasons \nbreast is best, see p. 271 . \n\n\nRespect your people’s traditions and build on them. \n\n\nFor more ideas for building on local traditions, see Helping Health Workers \nLearn, Chapter 7. \n\nBELIEFS THAT CAN MAKE PEOPLE WELL \n\nSome home remedies have a direct effect on the body. Others seem to work only \nbecause people believe in them. The healing power of belief can be very strong. \n\nFor example, I once saw a man who \nsuffered from a very bad headache. To \ncure him, a woman gave him a small \npiece of yam, or sweet potato. She \ntold him it was a strong painkiller. Fie \nbelieved her — and the pain went away \nquickly. \n\nIt was his faith in her treatment, and \nnot the yam itself, that made him feel \nbetter. \n\nMany home remedies work in this \nway. They help largely because people \nhave faith in them. For this reason, they \n\nare especially useful to cure illnesses that are partly in people’s minds, or \nthose caused in part by a person’s beliefs, worry, or fears. \n\nIncluded in this group of sicknesses are: bewitchment or hexing, unreasonable \nor hysterical fear, uncertain ‘aches and pains’ (especially in persons going through \nstressful times, such as teenage girls or older women), and anxiety or nervous worry. \nAlso included are some cases of asthma, hiccups, indigestion, stomach ulcers, \nmigraine headaches, and even warts. \n\nFor all of these problems, the manner or ‘touch’ of the healer can be very \nimportant. What it often comes down to is showing you care, helping the sick person \nbelieve he will get well, or simply helping him relax. \n\n\n\nwww. Jl6Sp6ri3n.org \n\n\nWhere There Is No Doctor 2010 3 \n\n\nSometimes a person's belief in a remedy can help with problems that have \ncompletely physical causes. \n\nFor example, Mexican villagers have the following home cures for poisonous \nsnakebite: \n\n\n\nIn other lands people have their own snakebite remedies — often many different \nones. As far as we know, none of these home remedies has any direct effect \nagainst snake poison. The person who says that a home remedy kept a snake’s \npoison from harming him at all was probably bitten by a non-poisonous snake! \n\nYet any of these home remedies may do some good if a person believes in it. \n\nIf it makes him less afraid, his pulse will slow down, he will move and tremble less, \nand as a result, the poison will spread through his body more slowly. So there is \nless danger! \n\nBut the benefit of these home remedies for snakebite is limited. In spite of their \ncommon use, many people still become very ill or die. As far as we know: \n\n\nNo home cure for poisonous bites (whether from snakes, \nscorpions, spiders, or other poisonous animals) has much \neffect beyond that of the healing power of belief. \n\n\nFor snakebite it is usually better to use modern treatment. Be prepared: obtain \n‘antivenoms' or ‘serums’ for poisonous bites before you need them (see p. 105). \nDo not wait until it is too late. \n\n\nwww. nespenan.org \n\n\n4 Where There Is No Doctor 2010 \n\n\nBELIEFS THAT CAN MAKE PEOPLE SICK \n\nThe power of belief can help heal people. But it can also harm them. If a person \nbelieves strongly enough that something will hurt him, his own fear can make him sick. \nFor example: \n\n\n\nOnce I was called to see a woman \nwho had just had a miscarriage and \nwas still bleeding a little. There was \nan orange tree near her house. So I \nsuggested she drink a glass of orange \njuice. (Oranges have vitamin C which \nhelps strengthen blood vessels.) She \ndrank it — even though she was afraid \nit would harm her. \n\n\nHer fear was so great that soon she \nbecame very ill. I examined her, but \ncould find nothing physically wrong. \n\nI tried to comfort her, telling her she \nwas not in danger. But she said she \nwas going to die. At last I gave her an \ninjection of distilled (completely pure) \nwater. Distilled water has no medical \neffect. But since she had great faith in \ninjections, she quickly got better. \n\n\nActually, the juice did not harm her. What harmed her was her belief that it would \nmake her sick. And what made her well was her faith in injections! \n\n\nIn this same way, many persons go on believing false ideas about witchcraft, \ninjections, diet, and many other things. Much needless suffering is the result. \n\n\nPerhaps, in a way, I had helped this woman. But the more I thought about it, the more \nI realized I had also wronged her; I had led her to believe things that were not true. \n\n\nI wanted to set this right. So a few days later, when she was completely well, I went \nto her home and apologized for what I had done. I tried to help her understand that not \nthe orange juice, but her fear had made her so sick. And that not the injection of water, \nbut her freedom from fear had helped her get well. \n\n\nBy understanding the truth about the orange, the injection, and the tricks of her own \nmind, perhaps this woman and her family will become freer from fear and better able \nto care for their health in the future. For health is closely related to understanding and \nfreedom from fear. \n\n\nwww. nespenan.org \n\n\nWhere There Is No Doctor 2010 5 \n\n\nMany things do harm only because \npeople believe they are harmful. \n\n\nWITCHCRAFT— BLACK MAGIC— AND THE EVIL EYE \n\nIf a person believes strongly enough that someone has the power to harm him, \nhe may actually become ill. Anyone who believes he is bewitched or has been given \nthe evil eye is really the victim of his own fears (see Susto, p. 24). \n\n\nA ‘witch’ has no power over \nother people, except for her ability \nto make them believe that she has. \nFor this reason: \n\n\nIt is impossible to bewitch \na person who does not believe \nin witchcraft. \n\n\nSome people think that they \nare ‘bewitched’ when they have \nstrange or frightening illnesses \n(such as tumors of the genitals or \ncirrhosis of the liver, see p. 328). \nSuch sicknesses have nothing to do \nwith witchcraft or black magic. Their \ncauses are natural. \n\n\n\nDo not waste your money at ‘magic centers’ that claim to cure witchcraft. \nAnd do not seek revenge against a witch, because it will not solve anything. If \nyou are seriously ill, go for medical help. \n\n\n\nwww. nespenan.org \n\n\n6 Where There Is No Doctor 2010 \n\n\nQUESTIONS AND ANSWERS ON SOME FOLK BELIEFS \nAND HOME REMEDIES \n\nThese examples are from the mountains of Mexico, the area that I know best. \nPerhaps some of the beliefs of your people are similar. Think about ways to learn which \nbeliefs in your area lead to better health and which do not. \n\n\nWhen people think \nsomeone is bewitched, is \nit true that he will get well \nif his relatives harm or kill \nthe witch? \n\n\n\nFALSE! No one is ever \nhelped by harming \nsomeone else. \n\n\nIs it true that when the ‘soft \nspot’ on top of a baby’s \nhead sinks inward this \nmeans the baby will die \nof diarrhea unless he gets \nspecial treatment? \n\n\n\nThis is often true. The ‘soft \nspot’ sinks because the \nbaby has lost too much \nliquid (see p. 151). Unless \nhe gets more liquid soon, he \nmay die (see p. 152). \n\n\nIs it true that if the light of \nthe eclipsing moon falls \non a pregnant mother, \nher child will be born \ndeformed or retarded? \n\n\n\nThis is not true! But children \nmay be born retarded, deaf, \nor deformed if the mother \ndoes not use iodized salt, if \nshe takes certain medicines, \nor for other reasons (see \np. 318). \n\n\nIs it true that mothers \nshould give birth in a \ndarkened room? \n\n\n\nIt is true that soft light \nis easier on the eyes of \nboth the mother and the \nnewborn child. But there \nshould be enough light for \nthe midwife to see what \nshe is doing. \n\n\nwww. hespenan.org \n\n\nWhere There Is No Doctor 2010 7 \n\n\nIs it true that a newborn \nbaby should not be \nbathed until the cord \nfalls off? \n\n\n\nTrue! The stump of the \ncord should be kept \ndry until it falls off. But \nthe baby can be gently \ncleaned with a clean, soft, \ndamp cloth. \n\n\n\nA mother should wash with \nwarm water the day after \ngiving birth. The custom \nof not bathing for weeks \nfollowing childbirth can lead \nto infections. \n\n\nIs it true that traditional \nbreast feeding is better \nthan ‘modern’ bottle \nfeeding? \n\n\n\n\nTRUE! Breast milk is \nbetter food and also \nhelps protect the baby \nagainst infection. \n\n\n\nIn the weeks following \nchildbirth, women should \nnot avoid any nutritious \nfoods. Instead, they \nshould eat plenty of fruit, \nvegetables, meat, milk, \neggs, whole grains, and \nbeans (see p. 276). \n\n\nwww. nespenan.org \n\n\n8 Where There Is No Doctor 2010 \n\n\nIs it a good idea to \nbathe a sick person, \nor will it do him harm? \n\n\n\nIt is a good idea. Sick \npeople should be bathed \nin warm water every day. \n\n\nIs it true that \noranges, guavas, \nand other fruits are \nharmful when one \nhas a cold or a \nfever? \n\n\n\nNO! All fruits and juices \nare helpful when one \nhas a cold or fever. They \ndo not cause congestion \nor harm of any kind. \n\n\nIs it true that when \na person has a high \nfever, he should be \nwrapped up so that \nthe air will not harm \nhim? \n\n\n\n\n\nNO! When a person has \na high fever, take off all \ncovers and clothing. Let \nthe air reach his body. \nThis will help the fever go \ndown (see p. 76). \n\n\nIs it true that tea made \nfrom willow bark will \nhelp bring fever down \nand stop pain? \n\n\n\nTrue. It helps. Willow \nbark has a natural \nmedicine in it very \nmuch like aspirin. \n\n\nwww. n6Sp6ri311.org \n\n\nWhere There Is No Doctor 2010 9 \n\n\nSUNKEN FONTANEL OR SOFT SPOT \n\nThe fontanel is the soft spot on the top of a newborn \nbaby’s head. It is where the bones of his skull have not \nformed completely. Normally it takes a year to a year \nand a half for the soft spot to close completely. \n\nMothers in different lands realize that when the soft \nspot sinks inward their babies are in danger. They have \nmany beliefs to explain this. In Latin America mothers \nthink the baby's brains have slipped downward. They \ntry to correct this by sucking on the soft spot, by \npushing up on the roof of the mouth, or by holding the \nbaby upside down and slapping his feet. This does not \nhelp because. . . A sunken soft spot is really caused \nby dehydration (see p. 151). \n\nThis means the child is losing more liquid than \nhe is drinking. He is too dry — usually because he has \ndiarrhea, or diarrhea with vomiting. \n\nTreatment: \n\n1 . Give the child plenty of liquid: Rehydration Drink (see p. 152), breast milk, or \nboiled water. \n\n2. If necessary, treat the causes of the diarrhea and vomiting (see p. 152 to \n161). For most diarrheas, medicine is not needed, and may do more harm \nthan good. \n\nTO CURE A SUNKEN SOFT SPOT. \n\n\n\n\n\nNote: If the soft spot is swollen or bulges upward, this may be a sign of meningitis. \nBegin treatment at once (see p. 185), and get medical help. \n\n\nWWW. \n\n\nnespenan.org \n\n\n\n10 Where There Is No Doctor 2010 \n\n\nWAYS TO TELL WHETHER A HOME REMEDY \nWORKS OR NOT \n\nBecause a lot of people use a home cure does not necessarily mean it works well or \nis safe. It is often hard to know which remedies are helpful and which may be harmful. \nCareful study is needed to be sure. Here are four rules to help tell which remedies are \nleast likely to work, or are dangerous. (Examples are from Mexican villages.) \n\n\n1 . THE MORE REMEDIES THERE ARE FOR ANY ONE ILLNESS, THE LESS LIKELY \nIT IS THAT ANY OF THEM WORKS. \n\n\nFor example: In rural Mexico there are many home remedies for goiter, none of \nwhich does any real good. Here are some of them: \n\n\n1 . to tie a crab \non the goiter \n\n\nDON’T \n\n\n\n\n3. to smear the brains of a 4. to smear human \n\n\n\nNot one of these many remedies works. If it did, the others would not be needed. \n\nWhen a sickness has just one popular cure, it is more likely to be a good one. For \n\nprevention and treatment of goiter use iodized salt (p. 130). \n\n\n2. FOUL OR DISGUSTING REMEDIES ARE NOT LIKELY TO HELP— AND ARE \nOFTEN HARMFUL. \n\n\nFor example: \n\n1 . the idea that leprosy can be cured \nby a drink made of rotting snakes \n\n\n\n2. the idea that syphilis can \nbe cured by eating a vulture \n\n\n\nThese two remedies do not help at all. The first one can cause dangerous infections. \nBelief in remedies like these sometimes causes delay in getting proper medical care. \n\n\nwww. nespenan.org \n\n\nWhere There Is No Doctor 2010 11 \n\n\n3. REMEDIES THAT USE ANIMAL OR HUMAN WASTE DO NO GOOD AND CAN \nCAUSE DANGEROUS INFECTIONS. NEVER USE THEM. \n\n\nExamples: \n\n1 . Putting human feces around the \neye does not cure blurred vision \nand can cause infections. \n\n\n\n2. Smearing cow dung on the head \nto fight ringworm can cause tetanus \nand other dangerous infections. \n\n\n\n\nAlso, the droppings of rabbits or other animals do not help heal burns. To use \nthem is very dangerous. Cow dung, held in the hand, cannot help control fits. Teas \nmade from human, pig, or any other animal feces do not cure anything. They can \nmake people sicker. Never put feces on the navel of a newborn baby. This can \ncause tetanus. \n\n\n4. THE MORE A REMEDY RESEMBLES THE SICKNESS IT IS SAID TO CURE, THE \nMORE LIKELY ITS BENEFITS COME ONLY FROM THE POWER OF BELIEF \n\n\nThe association between each of the following illnesses and its remedy is clear in \nthese examples from Mexico: \n\n\n1 . for a nosebleed, using yesca 2. for deafness, putting \n\n(a bright red mushroom) powdered rattlesnake ’s \n\nrattle in the ear \n\n\n3. for dog bite, drink tea made \nfrom the dog’s tail \n\n\n\n4. for scorpion sting, tying \na scorpion against the stung \nfinger \n\n\n\n5. to prevent diarrhea when a child \nis teething, putting a necklace of \nsnake’s fangs around the baby’s \nneck \n\n\n\n6. to ‘bring out’ the rash of \nmeasles, making tea from \nkapok bark \n\n\n\nThese remedies, and many other similar ones, have no curative value in \nthemselves. They may be of some benefit if people believe in them. But for serious \nproblems, be sure their use does not delay more effective treatment. \n\n\nwww. nespenan.org \n\n\n\n12 Where There Is No Doctor 2010 \n\n\nMEDICINAL PLANTS \n\nMany plants have curative powers. Some of the best modern medicines are made \nfrom wild herbs. \n\nNevertheless, not all ‘curative herbs’ people use have medical value... and those \nthat have are sometimes used the wrong way. Try to learn about the herbs in your area \nand find out which ones are worthwhile. \n\nCAUTION! Some medicinal herbs are very poisonous if taken in more \nthan the recommended dose. For this reason it is often safer to use \nmodern medicine, since the dosage is easier to control. \n\n\n\nHere are a few examples of plants that can be useful if used correctly: \n\n\nANGELS TRUMPET (Datura arborea) \n\nThe leaves of this and certain other members of the \nnightshade family contain a drug that helps to calm \nintestinal cramps, stomach-aches, and even gallbladder \npain. \n\nGrind up 1 or 2 leaves of Angel’s Trumpet and soak \nthem for a day in 7 tablespoons (100 ml.) of water. \n\n\n\nDosage: Between 10 and 15 drops every 4 hours (adults only). \n\n\n\nWARNING: Angel’s Trumpet is very poisonous if you take more \nthan the recommended dose. \n\n\nCORN SILK (the tassels or ‘silk’ from an ear of maize) \n\nA tea made from corn silk makes a person pass \nmore urine. This can help reduce swelling of the \nfeet — especially in pregnant women (see p. 176 \nand 248). \n\nBoil a large handful of corn silk in water and \ndrink 1 or 2 glasses. It is not dangerous. \n\nGARLIC \n\n\n\nA drink made from garlic may help get rid of pinworms. \n\nChop finely, or crush, 4 cloves of garlic and mix with 1 glass \nof liquid (water, juice, or milk). \n\nDosage: Drink 1 glass daily for 3 weeks. \n\nTo treat vaginal infections with garlic, see p. 241 and 242. \n\n\n\nwww. nespenan.org \n\n\nWhere There Is No Doctor 2010 13 \n\n\nCARDON CACTUS (Pachycerius pectin-aboriginum) \n\nCactus juice can be used to clean wounds when there is no \nboiled water and no way to get any. Cardon cactus also helps stop \na wound from bleeding, because the juice makes the cut blood \nvessels squeeze shut. \n\nCut a piece of the cactus \nwith a clean knife and press it \nfirmly against the wound. \n\nWhen the bleeding is under \ncontrol, tie a piece of the \ncactus to the wound with a \nstrip of cloth. \n\nAfter 2 or 3 hours, take \noff the cactus and clean the wound with boiled water and soap. There \ninstructions on how to care for wounds and control bleeding on pages \n\n\n\n\nare more \n82 to 87. \n\n\nALOE VERA (Sabila) \n\nAloe vera can be used to treat minor burns and wounds. The thick, slimy juice \ninside the plant calms pain and itching, aids healing, and \nhelps prevent infection. Cut off a piece of the plant, peel \nback the outer layer, and apply the fleshy leaf or juice directly \nto the burn or wound. \n\nAloe can also help treat stomach ulcers and gastritis. \n\nChop the spongy leaves into small pieces, soak them in \nwater overnight, and then drink one glass of the slimy, bitter \nliquid every 2 hours. \n\n\n\nPAPAYA \n\nRipe papayas are rich in vitamins and also aid digestion. \n\nEating them is especially helpful for weak or old people \nwho complain of upset stomach when they eat meat, \nchicken, or eggs. Papaya makes these foods easier to \ndigest. \n\nPapaya can also help get rid of intestinal worms, \nalthough modern medicines work better. Collect 3 or 4 \nteaspoons (15-20 ml.) of the ‘milk’ that comes out when \nthe green fruit or trunk of the tree is cut. Mix this with an \nequal amount of sugar or honey and stir it into a cup of \nhot water. If possible, drink along with a laxative. \n\nEven better, dry and crush to a powder the papaya seeds. Take 3 teaspoons \nmixed with 1 glass water or some honey 3 times a day for 7 days. \n\nPapayas can also be used for treating pressure sores. The fruit contains \nchemicals that help soften and make dead flesh easier to remove. First clean and \nwash out a pressure sore that has dead flesh in it. Then soak a sterile cloth or gauze \nwith ‘milk’ from the trunk or green fruit of a papaya plant and pack this into the sore, \nRepeat cleaning and repacking 3 times a day. \n\n\n\nwww. nespenan.org \n\n\n14 Where There Is No Doctor 2010 \n\n\nHOMEMADE CASTS— \n\nFOR KEEPING BROKEN BONES IN PLACE \n\n\nIn Mexico several different plants such as tepeguaje (a tree of the bean family) and \nsolda con solda (a huge, tree-climbing arum lily) are used to make casts. However, any \nplant will do if a syrup can be made from it that will dry hard and firm and will not irritate \nthe skin. In India, traditional bone-setters make casts using a mixture of egg whites \nand herbs instead of a syrup made from plant juices. But the method is similar. Try out \ndifferent plants in your area. \n\n\nFor a cast using tepeguaje: Put 1 kilogram of the bark \ninto 5 liters of water and boil until only 2 liters are left. Strain \nand boil until a thick syrup is formed. Dip strips of flannel or \nclean sheet in the syrup and carefully use as follows. \n\nMake sure the bones are in a good position (p. 98). \n\nDo not put the cast directly against the skin. \n\n\n\nWrap the arm or leg in a soft cloth. \n\nThen follow with a layer of cotton or wild kapok. \n\nFinally, put on the wet cloth strips so that they form a \ncast that is firm but not too tight. \n\n\n\nMost doctors recommend that the cast cover \nthe joint above and the joint below the break, to \nkeep the broken bones from moving. \n\nThis would mean that, for a broken wrist, the \ncast should cover almost the whole arm, like this: \n\nLeave the finger tips uncovered so that you \ncan see if they keep a good color. \n\nHowever, traditional bone-setters in China \nand Latin America use a short cast on a simple \nbreak of the arm saying that a little movement of \nthe bone-ends speeds healing. Recent scientific \nstudies have proven this to be true. \n\nA temporary leg or arm splint can be made of \ncardboard, folded paper, or the thick curved stem \nof dried banana leaf, or palm leaf. \n\n\n\n\nCAUTION: Even if the cast is not very tight when you put it on, the broken limb may \nswell up later. If the person complains that the cast is too tight, or if his fingers or toes \nbecome cold, white, or blue, take the cast off and put on a new, looser one. \n\nNever put on a cast over a cut or a wound. \n\n\n1 ill AjlirT ~ \nwww. nespenan.org \n\n\nWhere There Is No Doctor 2010 15 \n\n\nENEMAS, LAXATIVES, AND PURGES: \nWHEN TO USE THEM AND WHEN NOT TO \n\n\nMany people give enemas and take laxatives far \ntoo often. The ‘urge to purge' is world wide. \n\nEnemas and purges are very popular home \ncures. And they are often very harmful. Many \npeople believe fever and diarrhea can be ‘washed \nout' by giving an enema (running water into the gut \nthrough the anus) or by using a purge, or strong \nlaxative. Unfortunately, such efforts to clean or \npurge the sick body often cause more injury to the \nalready damaged gut. \n\n\n\nRarely do enemas or laxatives do any good at all. \nOften they are dangerous — especially strong laxatives. \n\n\nCASES IN WHICH IT IS DANGEROUS TO USE ENEMAS OR LAXATIVES \n\nNever use an enema or laxative if a person has a severe stomach-ache or any \nother sign of appendicitis or ‘acute abdomen’ (see p. 93), even if he passes \ndays without a bowel movement. \n\nNever give an enema or laxative to a person with a bullet wound or other injury to \nthe gut. \n\nNever give a strong laxative to a weak or sick person. It will weaken him more. \n\nNever give an enema or purge to a baby less than 2 years old. \n\nNever give a laxative or purge to a child with high fever, vomiting, diarrhea or \nsigns of dehydration (see p. 151). It can increase dehydration and kill the \nchild. \n\nDo not make a habit of using laxatives often (see Constipation, p. 126). \n\n\nTHE CORRECT USES OF ENEMAS \n\n\n1. Simple enemas can help relieve constipation (dry, hard, difficult stools). \n\nUse warm water only, or water with a little soap in it. \n\n2. When a person with severe vomiting is dehydrated, you can try replacing water \nby giving an enema of Rehydration Drink very slowly (see p. 152). \n\n\nwww. nespenan.org \n\n\n16 Where There Is No Doctor 2010 \n\n\nPURGES AND LAXATIVES THAT ARE OFTEN USED \n\n\nCASTOR OIL \nSENNA LEAF \n\nCASCARA (cascara sagrada) \n\n\nThese are irritating purges that often do \nmore harm than good. It is better not to \nuse them. \n\n\nMAGNESIUM HYDROXIDE \nMILK OF MAGNESIA \n\n\nThese are salt purges. Use them only in \nlow doses, as laxative for constipation. \n\n\nEPSOM SALTS (magnesium sulfate) Do not use them often and never when \n\n\n(see p. 382) \n\n\nthere is pain in the belly. \n\n\nMINERAL OIL \n(see p. 382) \n\n\nThis is sometimes used for constipation in \npersons with piles. ..but it is like passing \ngreased rocks. Not recommended. \n\n\nCORRECT USES OF LAXATIVES AND PURGES \n\n\nLaxatives are like purges but weaker. All the products listed above are laxatives \nwhen taken in small doses and purges when taken in large doses. Laxatives soften and \nhurry the bowel movement; purges cause diarrhea. \n\nPurges: The only time a person should use a strong dose of a purge is when he has \ntaken a poison and must clean it out quickly (see p. 103). At any other time a purge is \nharmful. \n\nLaxatives: One can use milk of magnesia or other magnesium salts in small doses, \nas laxatives, in some cases of constipation. People with hemorrhoids (piles, p. 175) \nwho have constipation can take mineral oil but this only makes their stools slippery, not \nsoft. The dose for mineral oil is 3 to 6 teaspoons at bedtime (never with a meal because \nthe oil will rob the body of important vitamins in the food). This is not the best way. \n\nSuppositories , or bullet-shaped pills that can be pushed up the rectum, can also be \nused to relieve constipation or piles (see pages 175, 382, and 392). \n\n\nFoods with fiber. The healthiest and most gentle way to have softer, more frequent \nstools is to drink a lot of water and to eat more foods with lots of natural fiber, or \n‘roughage’ like cassava, yam, or bran (wheat husks) and other whole grain cereals \n(see p. 126). Eating plenty of fruits and vegetables also helps. \n\nPeople who traditionally eat lots of food with natural fiber suffer much less from piles, \nconstipation, and cancer of the gut than do people who eat a lot of refined ‘modern’ \nfoods. For better bowel habits, avoid refined foods and eat foods prepared from \nunpolished or unrefined grains. \n\n\nA BETTER WAY \n\n\nWWW. \n\n\n\nl.org \n\n\n17 \n\n\nSicknesses That \nAre Often Confused \n\n\nCHAPTER \n\n2 \n\n\nWHAT CAUSES SICKNESS? \n\nPersons from different countries or backgrounds have different ways to explain \nwhat causes sickness. \n\nA baby gets diarrhea. But why? \n\nPeople in small villages may \n\nsay it is because the parents \ndid something wrong, or \nperhaps because they made \na god or spirit angry. \n\nA doctor may say it is because \nthe child has an infection. \n\nA public health officer may say \n\nit is because the villagers do \nnot have a good water system \nor use latrines. \n\nA social reformer may say the unhealthy conditions that lead to frequent \nchildhood diarrhea are caused by an unfair distribution of land and wealth. \n\nA teacher may place the blame on lack of education. \n\nPeople see the cause of sickness in terms of their own experience and point \nof view. Who then is right about the cause? Possibly everyone is right, or partly \nright. This is because. . . \n\n\n\nSickness usually results from a combination of causes. \n\n\n\n“Why my child?” \n\n\nEach of the causes suggested above may be a part \nof the reason why a baby gets diarrhea. \n\nTo prevent and treat sickness successfully, it helps \nto have as full an understanding as possible about the \ncommon sicknesses in your area and the combination \nof things that causes them. \n\nIn this book, different sicknesses are discussed \nmostly according to the systems and terms of modern \nor scientific medicine. \n\nTo make good use of this book, and safe use of \nthe medicines it recommends, you will need some \nunderstanding of sicknesses and their causes \naccording to medical science. Reading this chapter \nmay help. \n\n\nwww. hespenan.org \n\n\n18 Where There Is No Doctor 2010 \n\n\nDIFFERENT KINDS OF SICKNESSES AND THEIR CAUSES \n\nWhen considering how to prevent or treat different sicknesses, it helps to think of \nthem in two groups: infectious and non-infectious. \n\nInfectious diseases are those that spread from one person to another. Healthy \npersons must be protected from people with these sicknesses. \n\nNon-infectious diseases do not spread from person to person. They have other \ncauses. Therefore, it is important to know which sicknesses are infectious and which \nare not. \n\n\nNon-infectious Diseases \n\nNon-infectious diseases have many different causes. But they are never caused by \ngerms, bacteria, or other living organisms that attack the body. They never spread from \none person to another. It is important to realize that antibiotics, or medicines that fight \ngerms (see p. 55), do not help cure non-infectious diseases. \n\n\nRemember: Antibiotics are of no use for non-infectious diseases. \n\n\nEXAMPLES OF NON-INFECTIOUS DISEASES \n\n\nProblems caused by something \nthat wears out or goes wrong \nwithin the body: \n\nrheumatism \nheart attack \nepileptic seizures \nstroke \n\nmigraine headaches \n\ncataract \n\ncancer \n\n\nProblems caused by something \nfrom outside that harms or \ntroubles the body: \n\nallergies \n\nasthma \n\npoisons \n\nsnakebite \n\ncough from smoking \nstomach ulcer \nalcoholism \n\n\nProblems caused by a lack of \nsomething the body needs: \n\nmalnutrition \n\nanemia \n\npellagra \n\nnight blindness and \nxerophthalmia \ngoiter and cretinism \ncirrhosis of the liver \n(part of the cause) \n\n\nProblems people are born with: \n\n\nProblems that begin in the mind \n(mental ‘illnesses’): \n\n\nharelip \n\ncrossed or wall-eyes \n(squint) \n\nother deformities \n\n\nepilepsy (some kinds) \nretarded (slow) \nchildren \nbirthmarks \n\n\nfear that something is harmful when it is not \n(paranoia) \n\nnervous worry (anxiety) \nbelief in hexes (witchcraft) \nuncontrolled fear (hysteria) \n\n\nInfectious Diseases \n\nInfectious diseases are caused by bacteria and other organisms (living things) that \nharm the body. They are spread in many ways. Here are some of the most important \nkinds of organisms that cause infections and examples of sicknesses they cause: \n\n\nwww. nespenan.org \n\n\nWhere There Is No Doctor 2010 19 \n\n\nEXAMPLES OF INFECTIOUS DISEASES \n\n\nOrganism that causes \nthe sickness \n\nName of the sickness \n\nHow it is spread or \nenters the body \n\nPrincipal medicine \n\n\ntuberculosis \n\nthrough the air \n(coughing) \n\n\n\n\ntetanus \n\ndirty wounds \n\n\n\n\nsome diarrhea \n\ndirty fingers, water, flies \n\n\ndifferent \nantibiotics \n► for different \n\nbacteria \n\n(microbes or germs) \n\npneumonia \n(some kinds) \n\nthrough the air \n(coughing) \n\n\n\ngonorrhea, \nchlamydia, and \nsyphillis \n\nsexual contact \n\n\nbacterial \n\ninfections \n\n\nearache \n\nwith a cold \n\n\n\n\ninfected wounds \n\ncontact with dirty things \n\n\n\n\nsores with pus \n\ndirect contact (by touch) \n\nj \n\n\nvirus \n\n(germs smaller \n\ncolds, flu, measles, \nmumps, chickenpox, \ninfantile paralysis, \nvirus diarrhea \n\nfrom someone who is \nsick, through the \nair, by coughing, \nflies, etc. \n\naspirin and other \npainkillers \n(Medicines like \nantibiotics do not \nfight viruses effectively) \n\nrabies \n\nanimal bites \n\nVaccinations prevent \nsome virus infections. \n\nthan bacteria) \n\nwarts \n\ntouch \n\n\nHIV \n\nbody fluids of someone \ninfected get inside \nanother person's \nbody \n\nAntiretroviral \nmedicines fight HIV. \n\nfungus \n\nringworm \nathlete’s foot \njock itch \n\nby touch or from \nclothing \n\nsulfur and vinegar \nointments: undecylenic, \nbenzoic, salicylic acid \ngriseofulvin \n\ninternal parasites \n(harmful animals \nliving in the body) \n\nIn the gut: \nworms \n\namebas (dysentery) \n\nfeces-to-mouth \nlack of cleanliness \n\ndifferent specific \nmedicines \n\nIn the blood: \nmalaria \n\nmosquito bite \n\nchloroquine (or other \nmalaria medicine) \n\nexternal parasites \n(harmful animals \nliving on the body) \n\nlice \n\nfleas \n\nbedbugs \n\nscabies \n\nby contact with \ninfected persons \nor their clothes \n\npermethrin, \nkeeping very clean \n\n\nBacteria, like many of the organisms that cause infections, are \nso small you cannot see them without a microscope — an instrument \nthat makes tiny things look bigger. Viruses are even smaller than \nbacteria. \n\nAntibiotics (penicillin, tetracycline, etc.) are medicines that \nhelp cure certain illnesses caused by bacteria. Antibiotics have \nno effect on illnesses caused by most viruses, such as colds, flu, mumps, \nchickenpox, etc. Do not treat virus infections with antibiotics. They will not help \nand may be harmful (see Antibiotics, p. 55). \n\n\n\nwww. nCSpCri3Il.org \n\n\n20 Where There Is No Doctor 2010 \n\n\nSICKNESSES THAT ARE HARD TO TELL APART \n\n\nSometimes diseases that have different causes and require different treatment result \nin problems that look very much alike. For example: \n\n1 . A child who slowly becomes thin and \nwasted, while his belly gets more and more \nswollen, could have any (or several) of the \nfollowing problems: \n\n• malnutrition (see p. 112) \n\n• a lot of roundworms, p. 140, (usually together \nwith malnutrition) \n\n• advanced tuberculosis (p. 179) \n\n• a long-term severe urinary infection (p. 234) \n\n• any of several problems of the liver or spleen \n\n• leukemia (cancer of the blood) \n\n\n\n2. An older person with a big, open, slowly \ngrowing sore on the ankle could have: \n\n• bad circulation that results from varicose \nveins or other causes (p. 213) \n\n• diabetes (p. 127) \n\n• infection of the bone (osteomyelitis) \n\n• leprosy (p. 191) \n\n• tuberculosis of the skin (p. 212) \n\n• advanced syphilis (p. 237) \n\n\n\nThe medical treatment for each of these diseases is different, so to treat them \ncorrectly it is important to tell them apart. \n\nMany illnesses at first seem very similar. But if you ask the right questions and know \nwhat to look for, you can often learn information and see certain signs that will help tell \nyou what illness a person has. \n\nThis book describes the typical history and signs for many illnesses. But be careful! \nDiseases do not always show the signs described for them — or the signs may be \nconfusing. For difficult cases, the help of a skilled health worker or doctor is often \nneeded. Sometimes special tests or analyses are necessary. \n\n\nWork within your limits! \n\nIn using this book, remember it is easy to make mistakes. \nNever pretend you know something you do not. \n\nIf you are not fairly sure what an illness is and how to \ntreat it, or if the illness is very serious — get medical help. \n\n\nwww. hesperian. or \n\n\nWhere There Is No Doctor 2010 21 \n\n\nSICKNESSES THAT ARE OFTEN CONFUSED \nOR GIVEN THE SAME NAME \n\nMany of the common names people use for their sicknesses were first used \nlong before anyone knew about germs or bacteria or the medicines that fight them. \nDifferent diseases that caused more or less similar problems-such as ‘high fever’ or \n'pain in the side’ — were often given a single name. In many parts of the world, these \ncommon names are still used. City-trained doctors often neither know nor use these \nnames. For this reason, people sometimes think they apply to ‘sicknesses doctors \ndo not treat’. So they treat these home sicknesses with herbs or home remedies. \n\nActually, most of these home sicknesses or ‘folk diseases’ are the same ones \nknown to medical science. Only the names are different. \n\nFor many sicknesses, home remedies work well. But for some sicknesses, \ntreatment with modern medicine works much better and may be life-saving. This \nis especially true for dangerous infections like pneumonia, typhoid, tuberculosis, or \ninfections after giving birth. \n\nTo know which sicknesses definitely require modern medicines and to decide \nwhat medicine to use, it is important that you try to find out what the disease is in \nthe terms used by trained health workers and in this book. \n\n\nIf you cannot find the sickness you are looking for in \nthis book, look for it under a different name or in the \nchapter that covers the same sort of problem. \n\nUse the list of CONTENTS and the INDEX. \n\n\nIf you are unsure what the sickness is — especially if it seems serious — try to get \nmedical help. \n\nThe rest of this chapter gives examples of common or traditional names people \nuse for various sicknesses. Often a single name is given to diseases that are \ndifferent according to medical science. \n\nExamples cannot be given for each country or area where this book may be \nused. Therefore, I have kept those from the Spanish edition, with names used by \nvillagers in western Mexico. They will not be the same names you use. However, \npeople in many parts of the world see and speak of their illnesses in a similar way. \nSo the examples may help you think about how people name diseases in your area. \n\nCan you think of a name your people use for the following ‘folk diseases’? If you \ncan, write it in after the Spanish name, where it says, \n\n\nName in Your Area: \n\n\nwww.nespenan.org \n\n\n22 Where There Is No Doctor 2010 \n\n\nEXAMPLES OF LOCAL NAMES FOR SICKNESSES \n\nSpanish Name: EMPACHO (STOPPED-UP GUT) Name in Your Area: \n\nIn medical terms empacho \n(impaction) means that the gut is \nstopped up or obstructed (see \np. 94). But in Mexican \nvillages any illness causing \nstomach-ache or diarrhea may \nbe called empacho. It is said \nthat a ball of hair or something \nelse blocks a part of the gut. \nPeople put the blame on witches \nor evil spirits, and treat with \nmagic cures and cupping (see \npicture). Sometimes folk healers pretend to take a ball of hair and thorns out of the gut \nby sucking on the belly. \n\nDifferent illnesses that cause stomach pain or discomfort and are sometimes called \nempacho are: \n\n• diarrhea or dysentery with cramps (p. 153) \n\n• worms (p. 140) \n\n• swollen stomach due to malnutrition (p. 112) \n\n• indigestion or stomach ulcer (p. 128) \n\n• and rarely, true gut obstruction or appendicitis (p. 94) \n\nMost of these problems are not helped much by magic cures or cupping. To treat \nempacho, try to identify and treat the sickness that causes it. \n\n\n\n\n\n\n\nSpanish Name: DOLOR DE IJAR (SIDE PAINS) Name in Your Area: \n\n\nThis name is used for any pain women get in \none side of their belly. Often the pain goes around \nto the mid or lower back. Possible causes of this \nkind of pain include: \n\n• an infection of the urinary system (the \nkidneys, the bladder, or the tubes that join \nthem, see p. 234) \n\n• cramps or gas pains (see diarrhea, p. 153) \n\n• menstrual pains (see p. 245) \n\n• appendicitis (see p. 94) \n\n• an infection, cyst, or tumor in the womb \nor ovaries (p. 243) or an out-of-place \npregnancy (see p. 280) \n\n\n\nwww. nesperian.org \n\n\nWhere There Is No Doctor 2010 23 \n\n\nSpanish Name: LA CONGESTION (CONGESTION) Name in Your Area: \n\nAny sudden upset or illness that causes great distress is called la congestion by \nMexican villagers. People speak of congestion of: \n\n\nIt is said that la congestion strikes persons who break ‘the diet’ (see p. 123), \nby eating foods that are forbidden or taboo after childbirth, while taking a medicine, \nor when they have a cold or cough. Although these foods usually cause no harm \nand are sometimes just what their bodies need, many people will not touch them \nbecause they are so afraid of getting la congestion. \n\nDifferent illnesses that are sometimes called la congestion are: \n\n• Food poisoning, from eating spoiled food: causes sudden vomiting followed \nby diarrhea, cramps, and weakness (see p. 135). \n\n• A severe allergic reaction, in allergic persons after they eat certain foods \n(shellfish, chocolate, etc,), take certain medicines, or are injected with \npenicillin. May cause vomiting, diarrhea, cold sweat, breathing trouble, itchy \nrash, and severe distress (see p. 166). \n\n• Any sudden upset of the stomach or gut: see diarrhea (p. 153), vomiting \n(p. 161), and acute abdomen (p. 93). \n\n• Sudden or severe difficulty breathing: caused by asthma (p. 167), pneumonia \n(p. 171), or something stuck in the throat (p. 79). \n\n• Illnesses that cause seizures (fits) or paralysis: see seizures (p. 178), tetanus \n(p. 182), meningitis (p. 185), polio (p. 314), and stroke (p. 327). \n\n• Heart attacks: mostly in older persons (p. 325). \n\n\nSpanish Name: LATIDO (PULSING) Name in Your Area: \n\nLatido is a name used in Latin America for a pulsing or ‘jumping’ in the pit of the \nstomach. It is really the pulse of the aorta or big blood vessel coming from the heart. \nThis pulse can be seen and felt on a person who is very thin and hungry. Latido is \noften a sign of malnutrition (p. 112) — or hunger! Eating enough good food is the only \nreal treatment (see p. 110 and 111). \n\n\nthe head, \n\n\nthe chest, \n\n\nthe stomach, \n\n\nor the whole body. \n\n\n\nwww. nespenan.org \n\n\n24 Where There Is No Doctor 2010 \n\n\nSpanish Name: SUSTO (HYSTERIA, FRIGHT) Name in Your Area: \n\nAccording to Mexican villagers, susto is caused by a sudden fright a person has \nhad, or by witchcraft, black magic, or evil spirits. A person with susto is very nervous \nand afraid. He may shake, behave strangely, not be able to sleep, lose weight, or \neven die. \n\nPossible medical explanations for susto: \n\n1 . In many people, susto is a state of fear or hysteria, perhaps caused by the \n‘power of belief (see p. 4). For example, a woman who is afraid someone will hex \nher becomes nervous and does not eat or sleep well. She begins to grow weak and \nlose weight. She takes this as a sign she has been hexed, so she becomes still more \nnervous and frightened. Her susto gets worse and worse. \n\n2. In babies or small children, susto is usually very different. Bad dreams may \ncause a child to cry out in his sleep or wake up frightened. High fevers from any \nillness can cause very strange speech and behavior (delirium). A child that often looks \nand acts worried may be malnourished (p. 112). Sometimes early signs of tetanus \n\n(p. 182) or meningitis (p. 185) are also called susto. \n\nTreatment: \n\nWhen the susto is caused by a specific illness, treat the illness. Help the person \nunderstand its cause. Ask for medical advice, if needed. \n\nWhen the susto is caused by fright, try to comfort the person and help him \nunderstand that his fear itself is the cause of his problem. Magic cures and home \nremedies sometimes help. \n\nIf the frightened person is breathing very hard and fast, his body may be getting \ntoo much air — which may be part of the problem: \n\nEXTREME FRIGHT OR HYSTERIA WITH FAST HEAVY BREATHING \n(HYPERVENTILATION) \n\nSigns: \n\n• person very frightened \n\n• breathing fast and deep \n\n• fast, pounding heartbeat \n\n• numbness or tingling of face, \nhands, or feet \n\n• muscle cramps \n\nTreatment: \n\n• Keep the person as quiet as possible. \n\n• Have her put her face in a paper bag \nand breathe slowly. She should continue \nbreathing the same air for 2 or 3 minutes. \n\nThis will usually calm her down. \n\n• Explain to her that the problem is not dangerous and \nshe will soon be all right. \n\n\n\nwww. hesperian. ore \n\n\nWhere There Is No Doctor 2010 25 \n\n\nMISUNDERSTANDINGS DUE TO CONFUSION OF NAMES \n\nThis page shows 2 examples of misunderstandings that can result when certain \nnames like ‘cancer’ and ‘leprosy’ mean one thing to medical workers and something \nelse to villagers. In talking with health workers-and in using this book: \n\n\nAvoid misunderstanding — go by the signs and history \nof a person’s sickness, not the name people give it! \n\n\nSpanish Name: CANCER (CANCER) Name in Your Area: \n\nMexican villagers use the word cancer for any severe infection of the skin, \nespecially badly infected wounds (p. 88) or gangrene (p. 213). \n\n\nIn modern medical language, cancer is not an infection, but an abnormal growth \nor lump in any part of the body. Common types of cancer that you should watch out \nfor are: \n\n\ncancer of the skin \n(P- 211) \n\n\n\nbreast cancer \n(p. 279) \n\n\n\\ \n\n\n\ncancer of the womb or ovaries \n\n\n(p. 280) \n\n\n\nAny hard, painless, slowly growing lump in any part of your body may be cancer. \nCancer is often dangerous and may need surgery. \n\nAt the first suspicion of cancer seek medical help. \n\n\nSpanish Name: LEPRA (LEPROSY) Name in Your Area: \n\n\nMexican villagers call any open spreading sore lepra. \nThis leads to confusion, because medical workers use this \nterm only for true leprosy (Hansen’s disease, p. 191). Sores \ncommonly called lepra are: \n\n• impetigo and other skin infections (p. 202) \n\n• sores that come from insect bites or scabies (p. 199) \n\n• chronic sores or skin ulcers such as those caused by \npoor circulation (p. 213) \n\n• skin cancer (p. 21 1) \n\n• less commonly, leprosy (p. 191) or tuberculosis of \nthe skin (p. 212) \n\n\n\nThis child has impetigo, not \nleprosy. \n\n\nWWW. \n\n\nnespenan.org \n\n\n26 Where There Is No Doctor 2010 \n\n\nCONFUSION BETWEEN DIFFERENT ILLNESSES \nTHAT CAUSE FEVER \n\nSpanish Name: LA FIEBRE (THE FEVER) Name in Your Area: \n\nCorrectly speaking, a fever is a body \ntemperature higher than normal. But in Latin \nAmerica, a number of serious illnesses that cause \nhigh temperatures are all called la fiebre — or ‘the \nfever’. \n\nTo prevent or treat these diseases successfully, it \nis important to know how to tell one from another. \n\nHere are some of the important acute illnesses in which fever is an outstanding sign. \nThe drawings show the fever pattern (rise and fall of temperature) that is typical for \neach disease. \n\n\n\nMalaria: (see p. 186) \n\nBegins with weakness, chills and \nfever. Fever may come and go for \na few days, with shivering (chills) \nas the temperature rises, and \nsweating as it falls. Then, fever \nmay come for a few hours every \nsecond or third day. On other days, \nthe person may feel more or less \nwell. \n\n\nMALARIA — TYPICAL The solid line shows the rise \n\nFEVER PATTERN and fall of temperature. \n\n\n\nTyphoid: (see p. 188) \n\nBegins like a cold. Temperature \ngoes up a little more each day. \nPulse relatively slow. Sometimes \ndiarrhea and dehydration. \nTrembling or delirium (mind \nwanders). Person very ill. \n\nTyphus: (see p. 190) \n\nSimilar to typhoid. Rash similar to \nthat of measles, with tiny bruises. \n\nHepatitis: (see p. 172) \n\nPerson loses appetite. Does not \nwish to eat or smoke. Wants to \nvomit (nausea). Eyes and skin \nturn yellow; urine orange or \nbrown; stools whitish. Sometimes \nliver becomes large, tender. Mild \nfever. Person very weak. \n\n\nTYPHOID — The fever goes up \n\nTYPICAL FEVER PATTERN a little each day. \n\n\n\nHEPATITIS— Usually the fever \n\nTYPICAL FEVER PATTERN is mild. \n\n\n\nI ! I ! 1 i I I \n\n1 2 3 4 5 6 7 8 9 10 11 12 13 14 \n\n\nDays of Illness \n\n\n\n\nWWW. nespenan.orj \n\n\nWhere There Is No Doctor 2010 27 \n\n\nPneumonia: (see p. 171) \n\nFast, shallow breathing. \nTemperature rises quickly. \nCough with green, yellow, or \nbloody mucus. May be pain in \nchest. Person very ill. \n\n\nPNEUMONIA — TYPICAL FEVER PATTERN \n\n\n\nRheumatic fever: (see p. 310) \n\nMost common in children \nand teenagers. Pain in \njoints. High fever. Often \ncomes after a sore throat. \nMay be pain in the chest \nwith shortness of breath. Or \nuncontrolled movements of \narms and legs. \n\n\nRHEUMATIC FEVER-TYPICAL FEVER PATTERN \n\n\n\nBrucellosis (undulant fever, \nMalta fever): (see p. 188) \n\nBegins slowly with \ntiredness, headache, \nand pains in the bones. \nFever and sweating most \ncommon at night. Fever \ndisappears for a few days \nonly to come back again. \nThis may go on for months \nor years. \n\n\nBRUCELLOSIS — Lever comes in waves. Rises in \n\nTYPICAL LEVER PATTERN the afternoon and falls at night. \n\n\n\nChildbirth fever: (see p. 276) \n\nBegins a day or more after \ngiving birth. Starts with a slight \nfever, which often rises later. \nFoul-smelling vaginal discharge. \nPain and sometimes bleeding. \n\n\nCHILBIRTH FEVER — TYPICAL FEVER PATTERN \n\n\n\nAll of these illnesses can be dangerous. In addition to those shown here, there \nare many other diseases that may cause similar signs and fever. For example, fevers \nthat last for more than 1 month, or night sweats, may be caused by HIV infection \n(see p. 399). When possible, seek medical help. \n\nwww. nespenan.org \n\n\n\nHow To Examine \na Sick Person \n\n\nCHAPTER \n\n\n29 \n\n\n3 \n\nTo find out the needs of a sick person, first you must ask important questions and \nthen examine him carefully. You should look for signs and symptoms that help you tell \nhow ill the person is and what kind of sickness he may have. \n\nAlways examine the person where there is good light, preferably in the sunlight — \nnever in a dark room. \n\nThere are certain basic things to ask and to look for in anyone who is sick. These \ninclude things the sick person feels or reports (symptoms), as well as things you \nnotice on examining him (signs). These signs can be especially important in babies \nand persons unable to talk. In this book the word ‘signs’ is used for both symptoms \nand signs. \n\nWhen you examine a sick person, write down your findings and keep them \nfor the health worker in case he is needed (see p. 44). \n\nQUESTIONS \n\nStart by asking the person about her \nsickness. Be sure to ask the following: \n\nWhat bothers you most right now? \n\nWhat makes you feel better or \nworse? \n\nHow and when did your sickness \nbegin? \n\nHave you had this same trouble \nbefore, or has anyone else in \nyour family or neighborhood \nhad it? \n\nContinue with other questions \nin order to learn the details of the illness. \n\nFor example, if the sick person has a pain, ask her: \n\nWhere does it hurt? (Ask her to point to the exact place with one finger.) \n\nDoes it hurt all the time, or off and on? \n\nWhat is the pain like? (sharp? dull? burning?) \n\nCan you sleep with the pain? \n\nIf the sick person is a baby who still does not talk, look for signs of pain. Notice \nhis movements and how he cries. (For example, a child with an earache sometimes \nrubs the side of his head or pulls at his ear.) \n\n\n\nwww. nesperian.org \n\n\n30 Where There Is No Doctor 2010 \n\n\nGENERAL CONDITION OF HEALTH \n\nBefore touching the sick person, look at him carefully. Observe how ill or weak he \nlooks, the way he moves, how he breathes, and how clear his mind seems. Look for \nsigns of dehydration (see p. 151) and of shock (p. 77). \n\nNotice whether the person looks well nourished or poorly nourished. Has he been \nlosing weight? When a person has lost weight slowly over a long period of time, he may \nhave a chronic illness (one that lasts a long time). \n\nAlso note the color of the skin and eyes. These sometimes change when a person \nis sick. (Dark skin can hide color changes. So look at parts of the body where the skin \nis pale, such as palms of the hands or soles of the feet, the fingernails, or the insides of \nthe lips and eyelids.) \n\n• Paleness, especially of the lips and inside the eyelids, is a sign of anemia (p. 124). \nSkin may also go lighter as a result of tuberculosis (p. 179), or kwashiorkor (p. 1 13). \n\n• Darkening of the skin may be a sign of starvation (see p. 112). \n\n• Bluish skin, especially blueness or darkness of the lips and fingernails, may mean \nserious problems with breathing (p. 79, 167, and 313) or with the heart (p. 325). \nBlue-gray color in an unconscious child may be a sign of cerebral malaria (p. 186). \n\n• A gray-white coloring, with cool moist skin, often means a person is in shock (p. 77). \n\n• Yellow color (jaundice) of the skin and eyes may result from disease in the liver \n(hepatitis, p. 172, cirrhosis, p. 328, or amebic abscess, p. 145) or gallbladder \n(p. 329). It may also occur in newborn babies (p. 274), and in children born with \nsickle cell disease (p. 321). \n\nLook also at the skin when a light is shining across it from one side. This can show \nthe earliest sign of measles rash on the face of a feverish child (p. 311). \n\nTEMPERATURE \n\nIt is often wise to take a sick person’s temperature, even if he \ndoes not seem to have a fever. If the person is very sick, take the \ntemperature at least 4 times each day and write it down. \n\nIt is important to find out when and how the fever comes, how \nlasts, and how it goes away. This may help you identify the disease. Not \n\nIf there is no thermometer, you can get an idea of the \ntemperature by putting the back of one hand on the \nsick person’s forehead and the other on your own or \nthat of another healthy person. If the sick person has \na fever, you should feel the difference. \n\nevery fever is malaria, though in some countries it is often treated as such. Remember \nother possible causes. For example: \n\n• Common cold, and other virus infections (p. 163). The fever is usually mild. \n\n• Typhoid causes a fever that goes on rising for 5 days. Malaria medicine does not help. \n\n• Tuberculosis sometimes causes a mild fever in the afternoon. At night the person \noften sweats, and the fever goes down. \n\n\n\n\nwww. iiesperia.ri.org \n\n\nWhere There Is No Doctor 2010 31 \n\n\nHow to Use a Thermometer \n\nEvery family should have a thermometer. Take the temperature of a sick person \n4 times a day and always write it down. \n\nHow to read the thermometer (using one marked in degrees centigrade — °C): \n\n\nTurn the thermometer until you High Fever \n\n\n\nstops marks the temperature. marks 4Q degrees Q \n\n\nHow to take the temperature: \n\n1. Clean the thermometer well with \nsoap and water or alcohol. Shake \nit hard, with a snap of the wrist, \nuntil it reads less than 36 degrees. \n\n2. Put the thermometer... \n\n\n\nunder the tongue \n(keeping the \nmouth shut) \n\n\nor \n\n\nin the armpit if there carefully, in the anus \n\nis danger of biting or of a small child \n\nthe thermometer (wet or grease it first) \n\n\n\n3. Leave it there for 3 or 4 minutes. \n\n\n\n4. Read it. (An armpit temperature will read a little lower than a mouth reading; \nin the anus it will read a little higher.) \n\n5. Wash the thermometer well with soap and water. \n\n\nNote: in newborn babies a temperature that is unusually high or unsually low \n(below 36) may mean a serious infection (see p. 275). \n\n♦ To learn about other fever patterns, see p. 26 to 27. \n\n♦ To learn what to do for a fever, see p. 75. \n\n\nWWW. \n\n\nnesperian . o r g \n\n\n\n32 Where There Is No Doctor 2010 \n\n\nBREATHING (RESPIRATION) \n\n\nPay special attention to the way the sick person breathes — the depth (deep or \nshallow), rate (how often breaths are taken), and difficulty. Notice if both sides of the \nchest move equally when she breathes. \n\nIf you have a watch or simple timer, count the number of breaths per minute (when \nthe person is quiet). Between 12 and 20 breaths per minute is normal for adults and \nolder children. Up to 30 breaths a minute is normal for children, and 40 for babies. \nPeople with a high fever or serious respiratory illness breathe more quickly than \nnormal. For example, more than 30 shallow breaths a minute in an adult usually means \npneumonia, as does 60 breaths a minute for a newborn baby. \n\nListen carefully to the sound of the breaths. For example: \n\n• A whistle or wheeze and difficulty breathing out can mean asthma (see p. 167). \n\n• A gurgling or snoring noise and difficult breathing in an unconscious person \nmay mean the tongue, mucus (slime or pus), or something else is stuck in the \nthroat and does not let enough air get through. \n\nLook for ‘sucking in’ of the skin between ribs and at the angle of the neck (behind \nthe collar bone) when the person breathes in. This means air has trouble getting \nthrough. Consider the possibility of something stuck in the throat (p. 79), pneumonia \n(p. 171), asthma (p. 167), or bronchitis (mild sucking in, see p. 170). \n\nIf the person has a cough, ask if it keeps her from sleeping. Find out if she coughs \nup mucus, how much, its color, and if there is blood in it. \n\nPay attention to the strength, the rate, and the regularity of the pulse. If you have a \nwatch or timer, count the pulses per minute. \n\n\nPULSE (HEARTBEAT) \n\n\nTo take the person’s pulse, If you cannot find the pulse in \n\nput your fingers on the wrist the wrist, feel for it in the neck \n\nas shown. (Do not use your beside the voicebox. \n\nthumb to feel for the nulse.) \n\n\n\nor put your ear directly or \nthe chest and listen for the \nheartbeat (or use a stethoscope \nif you have one). \n\n\nNORMAL PULSE FOR PEOPLE AT REST \n\n\nadults . , \nchildren \nbabies . \n\n\nfrom 60 to 80 per minute \n\n\n80 to 100 \n100 to 140 \n\n\nwww. nesperian.org \n\n\nWhere There Is No Doctor 2010 33 \n\n\nThe pulse gets much faster with exercise and when a person is nervous, \nfrightened, or has a fever. As a general rule, the pulse increases 20 beats per minute \nfor each degree (°C) rise in fever. \n\nWhen a person is very ill, take the pulse often and write it down along with the \ntemperature and rate of breathing. \n\nIt is important to notice changes in the pulse rate. For example: \n\n• A weak, rapid pulse can mean a state of shock (see p. 77). \n\n• A very rapid, very slow, or irregular pulse could mean heart trouble \n(see p. 325). \n\n• A relatively slow pulse in a person with a high fever may be a sign of typhoid \n(see p. 188). \n\n\nLook at the color of the white part of the eyes. Is it normal, red (p. 219), or yellow? \nAlso note any changes in the sick person’s vision. \n\nHave the person slowly move her eyes up and down and from side to side. \nJerking or uneven movement may be a sign of brain damage. \n\nPay attention to the size and color of the pupils (the black 'window' in the center \nof the eye). If they are very large, it can mean a state of shock (see p. 77). If they are \nvery large, or very small, it can mean poison or the effect of certain drugs. If there is \na white glow, it can mean cataracts (see p. 225) or cancer. \n\nLook at both eyes and note any difference between the two, especially in the size \nof the pupils: \n\nA big difference in the size of the pupils is almost always a medical emergency. \n\n• If the eye with the larger pupil hurts so badly it causes vomiting, the person \n\n\nprobably has GLAUCOMA (see p. 222). \n\n• If the eye with the smaller pupil hurts a great deal, the person may have \nIRITIS, a very serious problem (see p. 221). \n\n• Difference in the size of the pupils of an unconscious person or a person who \nhas had a recent head injury may mean brain damage. It may also mean \nSTROKE (see p. 327). \n\nAlways compare the pupils of a person who is unconscious or has had a \nhead injury. \n\n\nEYES \n\n\n\nf \n\n\n\nnesperian.org \n\n\n\n\nWWW. \n\n\n34 Where There Is No Doctor 2010 \n\nEARS, THROAT, AND NOSE \n\nEars: Always check for signs of pain and \ninfection in the ears-especially in a child with fever \nor a cold. A baby who cries a lot or pulls at his ear \noften has an ear infection (p. 309). \n\nPull the ear gently. If this increases pain, the \ninfection is probably in the tube of the ear (ear \ncanal). Also look for redness or pus inside the ear. \n\nA small flashlight or penlight will help. But never \nput a stick, wire, or other hard object inside the ear. \n\nFind out if the person hears well, or if one side is \nmore deaf than the other. Rub your thumb and fingers together near the person’s ear to \nsee if he can hear it. For deafness and ringing of the ears see page 327. \n\nThroat and Mouth: With a torch (flashlight) or sunlight examine the mouth and \nthroat. To do this hold down tongue with a spoon handle or have the person say \n‘ahhhhh...’ Notice if the throat is red and if the tonsils (2 lumps at the back of the throat) \nare swollen or have spots with pus (see p. 309). Also examine the mouth for sores, \ninflamed gums, sore tongue, rotten or abscessed teeth and other problems. (Read \nChapter 17.) \n\nNose: Is the nose runny or plugged? (Notice if and how a baby breathes through \nhis nose.) Shine a light inside and look for mucus, pus, blood; also look for redness, \nswelling, or bad smell. Check for signs of sinus trouble or hayfever (p. 165). \n\n\n\nSKIN \n\n\nIt is important to examine the sick person’s whole body, no matter how mild the \nsickness may seem. Babies and children should be undressed completely. Look \ncarefully for anything that is not normal, including: \n\n\n• sores, wounds, or splinters \n\n• rashes or welts \n\n\n• spots, patches, or any unusual markings • \n\n• inflammation (sign of infection with redness, • \nheat, pain and swelling) \n\n• swelling or puffiness • \n\n• swollen lymph nodes (little lumps in the \nneck, the armpits, or the groin, see p. 88) \n\nAlways examine little children between the \nbuttocks, in the genital area, between the fingers \nand toes, behind the ears, and in the hair (for \nlice, scabies, ringworm, rashes, and sores). \n\nFor identification of different skin \nproblems, see pages 196 -198. \n\n\nabnormal lumps or masses \nunusual thinning or loss of hair, or \nloss of its color or shine (p. 112) \nloss of eyebrows \n\n\n\nwww. liesperia.ri.org \n\n\nWhere There Is No Doctor 2010 35 \n\n\nTHE BELLY (ABDOMEN) \n\nIf a person has pain in the belly, try to find out exactly where it hurts. \n\nLearn whether the pain is steady or whether it suddenly comes and goes, like \ncramps or colic. \n\nWhen you examine the belly, first look at it for any unusual swelling or lumps. \n\nThe location of the pain often gives a clue to the cause (see the following page). \n\n\nFirst, ask the person to Then, beginning on the opposite side from the spot \n\npoint with one finger where he has pointed, press gently on different \n\nwhere it hurts. parts of the belly to see where it hurts most. \n\n\n\nSee if the belly is soft or hard and whether the person can relax his stomach \nmuscles. A very hard belly could mean an acute abdomen — perhaps appendicitis or \nperitonitis (see p. 94). \n\nIf you suspect peritonitis or appendicitis, do the test for rebound pain described \non page 95. \n\nFeel for any abnormal lumps and hardened areas in the belly. \n\nIf the person has a constant pain in the stomach, with nausea, and has not been \nable to move her bowels, put an ear (or stethoscope) on the belly, like this: \n\n\n\nListen for gurgles in the \nintestines. If you hear nothing \nafter about 2 minutes, this is a \ndanger sign. (See Emergency \nProblems of the Gut, p. 93.) \n\n\nA silent belly is like a silent dog. Beware! \n\n\nwww. nesperian.org \n\n\n\n36 Where There Is No Doctor 2010 \n\n\nThese pictures show the areas of the belly that usually hurt when a person has the \nfollowing problems: \n\n\n\n\nGallbladder Liver \n\n\n\n\nUrinary system \n\n\n\nNote: For different causes of back pain see \n\n\nInflammation or \ntumor of the ovaries, \n\n\n\nwww. hesperiaii.org \n\n\nWhere There Is No Doctor 2010 37 \n\n\nMUSCLES AND NERVES \n\n\nIf a person complains of numbness, weakness, or loss of control in part of his \nbody, or you want to test it: notice the way he walks and moves. Have him stand, sit, \nor lie completely straight, and carefully compare both sides of his body. \n\n\nFace: Have him smile, frown, open his eyes wide, and squeeze \nthem shut. Notice any drooping or weakness on one side. \n\nIf the problem began more or less suddenly, think of a head \ninjury (p. 91), stroke (p. 327), or Bell’s palsy (p. 327). \n\nIf it came slowly, it may be a brain tumor. Get medical advice. \n\nAlso check for normal eye movement, size of pupils (p. 217), \nand how well he can see. \n\n\n\nArms and legs: Look for loss of muscle. Notice — or measure — \ndifference in thickness of arms or legs. \n\n\nWatch how he moves and walks. If muscle loss or weakness affects the whole \nbody, suspect malnutrition (p. 1 12) or a chronic (long-term) illness like tuberculosis. \n\n\nHave him squeeze your \nfingers to compare strength \nin his hands \n\n\n\nand push and pull with his \nfeet against your hand. \n\n\n\n\nAlso have him hold his arms straight Have him he down and lift one leg \n\nout and turn his hands up and down. and then the other. \n\n\n\nNote any \nweakness or \ntrembling. \n\n\n\nIf muscle loss and weakness is uneven or worse on one side, in children, think \nfirst of polio (p. 314); in adults, think of a back problem, a back or head injury, or \nstroke. \n\nFor more information on muscle testing and physical examination of disabled \npersons, see Disabled Village Children , Chapter 4. \n\n\nwww. nespenan.org \n\n\n38 Where There Is No Doctor 2010 \n\n\nCheck for stiffness or tightness of different muscles: \n\n\n\n• If the jaw is stiff or will not open, suspect tetanus (p. 182) or a \nsevere infection of the throat (p. 309) or of a tooth (p. 231). If the \n\n\n• If a child always has some stiff muscles and I meningitis \nmakes strange or jerky movements, he may be spastic ( p. 320). \n\n• If strange or jerky movements come suddenly, with loss of consciousness, he may \nhave seizures (p. 178). If seizures happen often, think of epilepsy. If they happen \nwhen he is ill, the cause may be high fever (p. 76) or dehydration (p. 151) or tetanus \n(p. 182) or meningitis (p. 185). \n\nTo test a person’s reflexes when \n\n\nTo check for loss of feeling in the \nhands, feet, or other parts of the \nbody: \n\nHave the person cover his eyes. Lightly touch or prick the skin in different places. \nAsk him to say ‘yes’ when he feels it. \n\n\n• Loss of feeling in or near spots or pal \non the body is probably leprosy (p. 1 \n\n• Loss of feeling in both hands or feet r \nbe due to diabetes (p. 127) \n\nor leprosy. \n\n• Loss of feeling on one side only \ncould come from a back problem (p. \n174) or injury. \n\n\nproblem began after he yawned or was hit in the jaw, he may \nhave a dislocated jaw. \n\n\n• If the neck or back is stiff and bent \nbackwards, in a very sick child, suspect \nmeningitis. If the head will not bend forward \nor cannot be put between the knees, \nmeningitis is likely (p. 185). \n\n\n\nyou suspect tetanus, see p. 183. \n\n\n\n\nWWW. \n\n\n\n39 \n\n\nHow to Take Care \nof a Sick Person \n\n\nCHAPTER \n\n4 \n\n\nSickness weakens the body. To gain strength and get well quickly, special care is \nneeded. \n\nThe care a sick person receives is frequently \nthe most important part of his treatment. \n\n\nMedicines are often not necessary. But good care is always important. The \nfollowing are the basis of good care: \n\n\n1 . The Comfort of the Sick Person \n\n\nA person who is sick should \nrest in a quiet, comfortable place \nwith plenty of fresh air and light. He \nshould keep from getting too hot or \ncold. If the air is cold or the person \nis chilled, cover him with a sheet or \nblanket. But if the weather is hot or \nthe person has a fever, do not cover \nhim at all (see p. 75). \n\n\n\n\n2. Liquids \n\nIn nearly every sickness, especially when there is \nfever or diarrhea, the sick person should drink plenty \nof liquids: water, tea, juices, broths, etc. \n\n\n3. Personal \nCleanliness \n\nIt is important to keep the sick \nperson clean. He should be bathed \nevery day. If he is too sick to get out of \nbed, wash him with a sponge or cloth \nand lukewarm water. His clothes, \nsheets, and covers must also be \nkept clean. Take care to keep \ncrumbs and bits of food out of the \nbed. \n\n\n\n\nLukewarm \nwater \n\n\nP't C— * i \n\n\nA SICK PERSON SHOULD \nBE BATHED EACH DAY \n\n\nwww.nesperian.org \n\n\n40 Where There Is No Doctor 2010 \n\n4. Good Food \n\nIf the sick person feels like eating, let him. Most \nsicknesses do not require special diets. \n\nA sick person should drink plenty of liquids and \neat a lot of nourishing food (see Chapter 11). \n\nIf the person is very weak, give him as much \nnourishing food as he can eat, many times a day. If \nnecessary, mash the foods, or make them into soups \nor juices. \n\nEnergy foods are especially important — for \nexample, porridges of rice, wheat, oatmeal, potato, or \ncassava. Adding a little sugar and vegetable oil will \nincrease the energy. Also encourage the sick person \nto drink plenty of sweetened drinks, especially if he \nwill not eat much. \n\nA few problems do require special diets. These are explained on the following pages \n\n\nanemia p. 124 \n\nstomach ulcers and heartburn p. 128 \n\nappendicitis, gut obstruction, acute abdomen \n\n(in these cases take no food at all) . . . . p. 93 \ndiabetes p. 127 \n\nheart problems p. 325 \n\ngallbladder problems p.329 \n\nhigh blood pressure p. 125 \n\n\n\nSPECIAL CARE FOR A PERSON \nWHO IS VERY ILL \n\n1. Liquids \n\n\n\nIt is extremely important that a very sick person drink enough liquid. If he only can \ndrink a little at a time, give him small amounts often. If he can barely swallow, give him \nsips every 5 or 10 minutes. \n\n\nMeasure the amount of liquids the person drinks each day. An adult needs to drink \n2 liters or more every day and should urinate at least a cup (60 cc.) of urine 3 or \n4 times daily. If the person is not drinking or urinating enough, or if he begins to \nshow signs of dehydration (p. 151), encourage him to drink more. He should drink \nnutritious liquids, usually with a little salt added. If he will not drink these, give him a \nRehydration Drink (see p. 152). If he cannot drink enough of this, and develops signs \nof dehydration, a health worker may be able to give him intravenous solution. But the \nneed for this can usually be avoided if the person is urged to take small sips often. \n\n\nwww. ll6Sp6ndn.org \n\n\nWhere There Is No Doctor 2010 41 \n\n\n2. Food \n\nIf the person is too sick to eat solid foods, give her soups, milk, juices, broths, \nand other nutritious liquids (see Chapter 11). A porridge of cornmeal, oatmeal, or \nrice is also good, but should be given together with body-building foods. Soups can \nbe made with egg, beans, or well-chopped meat, fish, or chicken. If the person can \neat only a little at a time, she should eat several small meals each day. \n\n\n3. Cleanliness \n\nPersonal cleanliness is very important for a seriously ill person. She should be \nbathed every day with warm water. \n\nChange the bed clothes daily and each time they become dirty. Soiled or \nbloodstained clothes, bedding, and towels of a person with an infectious disease \nshould be handled with care. To kill any viruses or germs, wash these in hot soapy \nwater, or add some chlorine bleach. \n\n\n4. Changing Position in Bed \n\nA person who is very weak and cannot turn over alone should be helped to \nchange position in bed many times each day. This helps prevent bed sores (see \np. 214). \n\nA child who is sick for a long time should be held often on her mother’s lap. \n\nFrequent changing of the person's position also helps to prevent pneumonia, a \nconstant danger for anyone who is very weak or ill and must stay in bed for a long \ntime. If the person has a fever, begins to cough, and breathes with fast, shallow \nbreaths, she probably has pneumonia (see p. 171). \n\n\n5. Watching for Changes \n\nYou should watch for any change in the sick person’s condition that may tell you \nwhether he is getting better or worse. Keep a record of his ‘vital signs’. Write down \nthe following facts 4 times a day: \n\n\nAlso write down the amount of liquids the person drinks and \n\ntemperature pulse breathing \n\n(how many degrees) (beats per minute) (breaths per minute) \n\n\n\nhow many times a day he urinates and has a bowel movement. Save this information \nfor the health worker or doctor. \n\nIt is very important to look for signs that warn you that the person's sickness is \nserious or dangerous. A list of Signs of Dangerous Illness is on the next page. If \nthe person shows any of these signs, seek medical help immediately. \n\n\nwww.nespcriaii.org \n\n\n42 Y Where There Is No Doctor 2009 \n\nSIGNS OF DANGEROUS ILLNESS \n\nA person who has one or more of the following signs \nis probably too sick to be treated at home without \nskilled medical help. His life may be in danger. Seek \nmedical help as soon as possible. Until help comes, \nfollow the instructions on the pages indicated. \n\n\npage \n\n1. Loss of large amounts of blood from anywhere in the body 82, 264, 281 \n\n2. Coughing up blood 179 \n\n3. Marked blueness of lips and nails (if it is new) 30 \n\n4. Great difficulty in breathing; does not improve with rest 167, 325 \n\n5. The person cannot be wakened (coma) 78 \n\n6. The person is so weak he faints when he stands up 325 \n\n7. A day or more without being able to urinate 234 \n\n8. A day or more without being able to drink any liquids 151 \n\n9. Heavy vomiting or severe diarrhea that lasts for more than one day \n\nor more than a few hours in babies 151 \n\n10. Black stools like tar, or vomit with blood or feces 128 \n\n1 1 . Strong, continuous stomach pains with vomiting in a person who \n\ndoes not have diarrhea or cannot have a bowel movement 93 \n\n12. Any strong continuous pain that lasts for more than 3 days 29 to 38 \n\n13. Stiff neck with arched back, with or without a stiff jaw 182, 185 \n\n14. More than one fit (convulsions) \n\nin someone with fever or serious illness 76, 185 \n\n15. High fever (above 39° C) that cannot be \n\nbrought down or that lasts more than 4 or 5 days 75 \n\n16. Weight loss over an extended time 20, 400 \n\n17. Blood in the urine 146, 234 \n\n18. Sores that keep growing and do not go away with treatment 191 , 196, \n\n211 , 212 \n\n19. A lump in any part of the body that keeps getting bigger 196, 280 \n\n20. Problems with pregnancy and childbirth: \n\nany bleeding during pregnancy 249, 281 \n\nswollen face and trouble seeing in the last months 249 \n\nlong delay once the waters have broken and labor has begun 267 \n\nsevere bleeding 264 \n\n\n\nwww.hespenan.org \n\n\nWhere There Is No Doctor 2010 43 \n\nWHEN AND HOWTO LOOK FOR MEDICAL HELP \n\nSeek medical help at the first sign of a dangerous illness. Do not wait until the \nperson is so sick that it becomes difficult or impossible to take him to a health center \nor hospital. \n\n\nIf a sick or injured person's condition could be made \nworse by the difficulties in moving him to a health center, \ntry to bring a health worker to the person. But in \nan emergency when very special attention or \nan operation may be needed (for example, \nappendicitis), do not wait for the health \nworker. Take the person to the health \ncenter or the hospital at once. \n\n\nWhen you need to carry a person \non a stretcher, make sure he is as \ncomfortable as possible and cannot \nfall out. If he has any broken bones, \nsplint them before moving him (see \np. 99). If the sun is very strong, rig \na sheet over the stretcher to give \nshade yet allow fresh air to pass \nunderneath \n\n\n\nWHAT TO TELL THE HEALTH WORKER \n\n\nFor a health worker or doctor to recommend treatment or prescribe medicine \nwisely, she should see the sick person. If the sick person cannot be moved, have \nthe health worker come to him. If this is not possible, send a responsible person who \nknows the details of the illness. Never send a small child or a fool. \n\n\nBefore sending for medical help, examine the sick person carefully and \ncompletely. Then write down the details of his disease and general condition (see \nChapter 3). \n\n\nOn the next page is a form on which you can make a PATIENT REPORT. Several \ncopies of this form are at the end of this book. Tear out one of these forms and \ncarefully complete the report, giving all the details you can. \n\n\nWhen you send someone for medical help, \nalways send a completed information form with him. \n\n\nwww. nCSpCri3Il.org \n\n\n44 Where There Is No Doctor 2010 \n\n\nPATIENT REPORT \n\nTO USE WHEN SENDING FOR MEDICAL HELP \n\nName of the sick person: Age: \n\nMale Female Where is he (she)? \n\nWhat is the main sickness or problem right now? \n\n\nWhen did it begin? \n\nHow did it begin? \n\nHas the person had the same problem before? When? \n\nIs there fever? How high? ° \n\nWhen and for how long? \n\nPain? Where? What kind? \n\n\nWhat is wrong or different from normal in any of the following? \nSkin: Ears: \n\n\nEyes: Mouth and throat: \n\nGenitals: \n\n\nUrine: Much or little? Color? Trouble urinating?. \n\nDescribe: Times in 24 hours: Times at night: \n\nStools: Color? Blood or mucus? Diarrhea? \n\nNumber of times a day: Cramps? Dehydration? \n\nMild or severe? Worms? What kind? \n\n\nBreathing: Breaths per minute: Deep, shallow, or normal? \n\nDifficulty breathing (describe): \n\nCough (describe): \n\nWheezing? Mucus? With blood? \n\nDoes the person have any of the SIGNS OF DANGEROUS ILLNESS listed on \npage 42? Which? (give details) \n\n\nOther signs: \n\nIs the person taking medicine? What? \n\nHas the person ever used medicine that has caused a rash, hives (or bumps) \n\nwith itching, or other allergic reactions? What? \n\nThe state of the sick person is: Not very serious: Serious: \n\nVery serious: \n\nWWW. \n\n\nnespenan.org \n\n\n45 \n\n\nHealing Without \nMedicines \n\n\nCHAPTER \n\n5 \n\n\nFor most sicknesses no medicines are needed. Our bodies have their own \ndefenses, or ways to resist and fight disease. In most cases, these natural defenses \nare far more important to our health than are medicines. \n\n\nPeople will get well from most sicknesses \n— including the common cold and ‘flu’ — by \nthemselves, without need for medicines. \n\n\nTo help the body fight off or overcome a sickness, often all that is needed is to: \n\n\nkeep clean \n\n\nget plenty of rest \n\n\neat well and drink \na lot of liquid \n\n\n\nEven in a case of more serious illness, when a medicine may be needed, it is \nthe body that must overcome the disease; the medicine only helps. Cleanliness, \nrest, nutritious food, and lots of water are still very important. \n\n\nMuch of the art of health care does not — and should not — depend on use of \nmedications. Even if you live in an area where there are no modern medicines, there \nis a great deal you can do to prevent and treat most common sicknesses — if you \nlearn how. \n\n\nMany sicknesses can be prevented or treated without medicines. \n\n\nIf people simply learned how to use water correctly, this alone might do more to \nprevent and cure illnesses than all the medicines they now use. . .and misuse. \n\n\ni iff <1 1 ifT \nwww.nespenan.org \n\n\n46 Where There Is No Doctor 2010 \n\n\nHEALING WITH WATER \n\nMost of us could live without medicines. But no one can live without water. In fact, \nover half (57%) of the human body is water. If everyone living in farms and villages \nmade the best use of water, the amount of sickness and death — especially of children — \ncould be reduced. \n\nFor example, correct use of water is basic both in the prevention and treatment of \ndiarrhea. In many areas diarrhea is the most common cause of sickness and death in \nsmall children. Contaminated (unclean) water is often part of the cause. \n\n\nAn important part of the prevention of diarrhea and many other illnesses is to make \nsure that drinking water is safe. Protect wells and springs from dirt and animals by \nputting fences or walls around them. Use cement or rock to provide good drainage \naround the well or spring, so that rain or spilled water runs away from it. \n\n\nWhere water may be contaminated, an \nimportant part of the prevention of diarrhea \nis to boil or filter the water used for drinking \nor for preparing foods. This is especially \nimportant for babies. Babies' bottles and \neating utensils should also be boiled. If \nregular boiling of bottles is not possible, it is \nsafer to use a cup and water spoon. Washing \nhands with soap and water after a bowel \nmovement (shitting) and before eating or \nhandling foods is also important. \n\n\n\nP \n\nR \n\nE \n\nV \n\nE \n\nN \n\nT \n\nI \n\nO \n\nN \n\n\nT \n\nR \n\nE \n\nA \n\nT \n\nM \n\nE \n\nN \n\nT \n\n\n\nA common cause of death in children with \ndiarrhea is severe dehydration, or loss of \ntoo much water from the body (see p. 151). \nBy giving a child with diarrhea plenty of \nwater (best with sugar or cereal and salt), \ndehydration can often be prevented or \ncorrected (see Rehydration Drink, p. 152). \n\n\nGiving lots of liquids to a child with diarrhea is more important than any \nmedicine. In fact, if enough liquid is given, no medicine is usually needed in the \ntreatment of diarrhea. \n\nOn the next 2 pages are a number of other situations in which it is often more \nimportant to use water correctly than to use medicines. \n\n\nWWW. \n\n\nnespenan.org \n\n\nWhere There Is No Doctor 2010 \n\n\n47 \n\n\nTimes When the Right Use of Water \nMay Do More Good than Medicines \n\n\nPREVENTION \n\n\nto help prevent \n\n\n1 . diarrhea, worms, \ngut infections \n\n\n2. skin infections \n\n\nuse water see page \n\nboil or filter drinking 135 \n\nwater, wash hands, \n\netc. \n\n\nbathe often 133 \n\n\n\n3. wounds becoming \ninfected; tetanus \n\n\nwash wounds well \nwith soap and \nclean water \n\n\n84, 89 \n\n\n\nTREATMENT \n\n\nto treat \n\n1 . diarrhea, \ndehydration \n\n2. illnesses with fever \n\n\nuse water \n\ndrink plenty of liquids \ndrink plenty of liquids \n\n\n\n3. high fever remove clothing 76 \n\nand soak body \nwith cool water \n\n\n4. minor urinary drink plenty of water 235 \n\ninfections \n\n(common in women) \n\n\n5. cough, asthma, \nbronchitis, \npneumonia, \nwhooping cough \n\n\ndrink a lot of water 68 \nand breathe \nhot water vapors \n(to loosen mucus) \n\n\n\nWWW. \n\n\nnespenan.org \n\n\n48 Where There Is No Doctor 2010 \n\n\nto treat \n\n6. sores, impetigo, \nringworm of skin \n\nor scalp, cradle cap, \npimples \n\n7. infected wounds, \nabscesses, boils \n\n8. stiff, sore muscles \nand joints \n\n9. strains and sprains \n\n\n10. itching, burning, \nor weeping irritations \nof the skin \n\n\n11. minor burns \n\n\n12. sore throat or tonsillitis \n\n\n13. acid, lye, dirt, or \nirritating substance \nin eye \n\n\n14. stuffed up nose \n\n\n15. constipation, \nhard stools \n\n\n16. cold sores or \nfever blisters \n\n\nuse water \n\nscrub with soap \nand clean water \n\n\nhot soaks \nor compresses \n\n\nhot compresses \n\n\nthe first day: soak \njoint in cold water; \nthen use hot soaks \n\ncold compresses \n\n\nhold in cold water \nat once \n\ngargle with warm \nsalt water \n\nflood eye with \ncool water at once, \nand continue for \n30 minutes \n\n\nsniff salt water \n\n\ndrink lots of water \n(also, enemas are \nsafer than laxatives, \nbut do not overuse) \n\nhold ice on blister \nfor 1 hr. at first sign \n\n\nsee page \n\n201 , 202, 205, \n211, 215 \n\n\n\n88 , 202 \n\n\n\n\n96 \n\n309 \n\n219 \n\n164 \n\n15, 126 \n\n\n\n\n\n232 \n\n\n\nIn each of the above cases (except pneumonia) when water is used correctly, often \nmedicines are not needed. In this book you will find many suggestions for ways of \nhealing without need for medicine. Use medicines only when absolutely necessary. \n\n\nwww. n6Sp6ridn.org \n\n\n49 \n\n\nRight and Wrong Uses \nof Modern Medicines \n\n\nSome medicines sold in pharmacies or village stores can be very useful. But \nmany are of no value. Of the 60,000 medicines sold in most countries, the World \nHealth Organization says that only about 200 are necessary. \n\nAlso, people sometimes use the best medicines in the wrong way, so that they do \nmore harm than good. To be helpful, medicine must be used correctly. \n\nMany people, including most doctors and health workers, prescribe far more \nmedicines than are needed — and by so doing cause much needless sickness and \ndeath. \n\n\n\nThere is some danger in the use of any medicine. \n\n\nSome medicines are much more dangerous than others. Unfortunately, people \nsometimes use very dangerous medicines for mild sicknesses. (I have seen a baby \ndie because his parents gave him a dangerous medicine, chloramphenicol, for a \ncold.) Never use a dangerous medicine for a mild illness. \n\n\n\nREMEMBER: MEDICINES CAN KILL \n\nGuidelines for the use of medicine: \n\n1 . Use medicines only when necessary. \n\n2. Know the correct use and precautions for any medicine you use (see the \nGREEN PAGES). \n\n3. Be sure to use the right dose. \n\n4. If the medicine does not help, or causes problems, stop using it. \n\n5. When in doubt, seek the advice of a health worker. \n\nNote: Some health workers and many doctors give medicines when none is needed, \noften because they think patients expect medicine and will not be satisfied until they \nget some. Tell your doctor or health worker you only want medicine if it is definitely \nneeded. This will save you money and be safer for your health. \n\n\nOnly use a medicine when you are sure it is needed \nand when you are sure how to use it. \n\n\nwww.iicspcrian.org \n\n\n50 Where There Is No Doctor 2010 \n\n\nTHE MOST DANGEROUS MISUSE OF MEDICINE \n\nHere is a list of the most common and dangerous errors people make in using \nmodern medicines. The improper use of the following medicines causes many deaths \neach year. BE CAREFUL! \n\n1. Chloramphenicol (Chloromycetin) (p. 356) \n\nThe popular use of this medicine for simple diarrhea and other \nmild sicknesses is extremely unfortunate, because it is so risky. Use \nchloramphenicol only for very severe illnesses, like typhoid (see \np. 188). Never give it to newborn babies. \n\n\n\n\n2. Oxytocin (Pitocin), Ergonovine (Ergotrate), and Misoprostol \n\n(Cytotec) (p. 390) \n\nUnfortunately, some midwives use these medicines to speed up \nchildbirth or ‘give strength’ to the mother in labor. This practice is very \ndangerous. It can kill the mother or the child. Use these medicines \nonly to control bleeding after the child is born (see p. 266). \n\n\n3. Injections of any medicine \n\nThe common belief that injections are usually better than medicine taken by mouth \nis not true. Many times medicines taken by mouth work as well as or better than \ninjections. Also, most medicine is more dangerous injected than when taken by \n\nmouth. Injections given to a child who has a mild polio \ninfection (with only signs of a cold) can lead to paralysis \n(see p. 74). Use of injections should be very limited (read \nChapter 9 carefully). \n\n4. Penicillin (p. 350) \n\nPenicillin works only against certain types of infections. Use of penicillin for sprains, \nbruises, or any pain or fever is a great mistake. As a general rule, injuries that do not \nbreak the skin, even if they make large bruises, have no danger of infection; they do \nnot need to be treated with penicillin or any other antibiotic. Neither penicillin nor other \nantibiotics helps colds (see p. 163). \n\nPenicillin is dangerous for some people. Before using it, know its risks and the \nprecautions you must take — see pages 70 and 351 . \n\n\n\n5. Kanamycin and Gentamicin (Garamycin) (p. 358) \n\nToo much use of these antibiotics for babies has caused permanent hearing loss \n(deafness) in millions of babies. Give to babies only for life-threatening infections. For \nmany infections of the newborn, ampicillin works as well and is much less dangerous. \n\n\nwww. nesperian.org \n\n\nWhere There Is No Doctor 2010 51 \n\n\n6. Anti-diarrhea medicines with hydroxyquinolines (Clioquinol, \ndi-iodohydroxyquinoline, halquinol, broxyquinoline: Diodoquin, Enteroquinol, \n\nAmicline, Quogyl, and many other brand names) (p. 369) \n\nIn the past clioquinols were widely used to treat diarrhea. These dangerous \nmedicines are now prohibited in many countries — but in others are still sold. They \ncan cause permanent paralysis, blindness, and even death. For treatment of \ndiarrhea, see Chapter 13. \n\n7. Cortisone and cortico-steroids (Prednisolone, dexamethasone, and others) \n\nThese are powerful anti-inflammatory drugs that are occasionally needed \nfor severe attacks of asthma, arthritis, or severe allergic reactions. But in many \ncountries, steroids are prescribed for minor aches and pains because they often \ngive quick results. This is a big mistake. Steroids cause serious or dangerous side \neffects — especially if used in high doses or for more than a few days. They lower \na person’s defenses against infection. They can make tuberculosis much worse, \ncause bleeding of stomach ulcers, and make bones so weak that they break easily. \n\n\n8. Anabolic steroids (Nandrolone decanoate, Durabotin, Deca-Durabolin, Orabolin; \nstanozolol, Cetabon; oxymetholone, Anapolon; ethylestrenol, Organaboral. There \nare many other brand names.) \n\nAnabolic steroids are made from male hormones and are mistakenly used in \ntonics to help children gain weight and grow. At first the child may grow faster, but \nhe will stop growing sooner and end up shorter than he would have if he had not \ntaken the medicine. Anabolic steroids cause very dangerous side effects. Girls grow \nhair on their faces like boys, which does not go away, even when the child stops \ntaking the medicine. Do not give growth tonics to children. Instead, to help your \nchild grow, use the money to buy food. \n\n\n9. Arthritis medicines (Butazones: oxyphenbutazone, Amidozone; and \nphenylbutazone, Butazolidiri) \n\nThese medicines for joint pain (arthritis) can cause a dangerous, sometimes \ndeadly, blood disease (agranulocytosis). They can also damage the stomach, \nliver, and kidneys. Do not use these dangerous medicines. For arthritis, aspirin \n(p. 378) or ibuprofen (p. 379) is much safer and cheaper. For pain and fever only, \nacetaminophen (p. 379) can be used. \n\n\n10. Vitamin B 12 , liver extract, and iron injections (p. 392) \n\n\n\nVitamin B 12 and liver extract do not help anemia or ‘weakness’ except \nin rare cases. Also, they have certain risks when injected. They should \nonly be used when a specialist has prescribed them after testing the \nblood. Also, avoid injectable iron, such as Inferon. To combat anemia, \niron pills are safer and work as well (see p. 124). \n\n\nwww.licspcrian.org \n\n\n52 Where There Is No Doctor 2010 \n\n\n1 1 . Other vitamins (p. 391 ) \n\nAs a general rule, DO NOT INJECT VITAMINS. Injections are more dangerous, more \nexpensive, and usually no more effective than pills. \n\nUnfortunately, many people waste their money on syrups, tonics, and ‘elixirs’ \nthat contain vitamins. Many lack the most important vitamins (see p. 118). But even \nwhen they contain them, it is wiser to buy more and better food. Body-building and \nprotective foods like beans, eggs, meat, fruit, vegetables, and whole grains are rich in \nvitamins and other nutrients (see p. 111). Giving a thin, weak person good food more \noften will usually help him far more than giving him vitamin and mineral supplements. \n\n\nA person who eats well does not need extra vitamins. \n\n\nTHE BEST WAY TO GET VITAMINS: \n\n\n\nFor more information about vitamins, when they are necessary, and the foods that \nhave them, read Chapter 1 1 , especially pages 1 1 1 and 1 1 8. \n\n\n12. Combination medicines \n\nSometimes, 2 or more medicines are combined in the same pill or tonic. Usually they \nare less effective, and more expensive, when prepared this way. Sometimes they do \nmore harm than good. If someone wants to prescribe combination medicines, ask him \nor her to prescribe only the medicine that is really necessary. Do not waste your money \non unnecessary medicines. \n\nSome medicines for HIV come in combination pills (see p. 397). This makes them \neasier to take. \n\nSome common combination medicines that should be avoided are: \n\n• cough medicines which contain medicines both to suppress a cough and also \nto get rid of mucus. (Cough medicines are almost always useless and a waste of \nmoney, whether or not they combine medicines.) \n\n• antibiotics combined with anti-diarrhea medicine \n\n• antacids to treat stomach ulcers together with medicine to prevent stomach \ncramps \n\n• 2 or more pain medicines (aspirin with acetaminophen — sometimes also with \ncaffeine) \n\n\nwww.nesperian.org \n\n\nWhere There Is No Doctor 2010 53 \n\n\n13. Calcium \n\n\n\nInjecting calcium into a vein can be extremely dangerous. It can \nquickly kill someone if not injected very slowly. Injecting calcium \ninto the buttocks sometimes causes very serious abscesses or \ninfections. \n\n\nNever inject calcium without first seeking medical advice! \n\n\nNote: In Mexico and other countries where people eat a lot of corn tortillas or other \nfoods prepared with lime, it is foolish to use calcium injections or tonics (as is often \ndone to ‘give strength’ or ‘help children grow’). The body gets all the calcium it \nneeds from the lime. \n\n14. ‘Feeding’ through the veins (Intravenous or ‘I.V.’ solutions) \n\nIn some areas, persons who are anemic or very weak spend their last penny to \nhave a liter of I.V. solution put into their veins. They believe that this will make them \nstronger or their blood richer. But they are wrong! Intravenous solution is nothing \nmore than pure water with some salt or sugar in it. It gives less energy than a large \ncandy bar and makes the blood thinner, not richer. It does not help anemia or make \nthe weak person stronger. \n\nAlso when a person who is not well trained puts the I.V. solution into a vein, there \nis danger of an infection entering the blood. This can kill the sick person. \n\nIntravenous solution should be used only when a person can take nothing by \nmouth, or when she is badly dehydrated (see p. 151). \n\nIf the sick person can swallow, give her a liter of water with sugar (or cereal) \nand salt (see Rehydration Drink, p. 152). It will do as much for her as injecting \na liter of I.V. solution. For people who are able to eat, nutritious foods do more to \nstrengthen them than any type of I.V. fluid. \n\n\n\nIf a sick person is able to swallow and keep down liquids \n\n\n\n\nIiT 4 k ifT , \n\n\n\n54 Where There Is No Doctor 2010 \n\n\nWHEN SHOULD MEDICINE NOT BE TAKEN? \n\nMany people have beliefs about things they should not do or eat when taking \nmedicines. For this reason they may stop taking a medicine they need. In truth, no \nmedicine causes harm just because it is taken with certain foods — whether pork, chili \npepper, guava, oranges, or any other food. But foods with lots of grease or spices can \nmake problems of the stomach or gut worse — whether or not any medicine is being \ntaken (see p. 128). Certain medicines will cause bad reactions if a person drinks \nalcohol (see metronidazole, p. 368). \n\nThere are situations when, without a doubt, it is best not to use certain medicines: \n\n\n\n\n1 . Pregnant women or women who are breast feeding \nshould avoid all medicines that are not absolutely necessary. \n(However, they can take limited amounts of vitamins or \niron pills without danger.) Also, pregnant or breast feeding \nwomen with HIV should take medicines to prevent spreading \nHIV to the baby, see p. 398. \n\n\n2. With newborn children, be very careful when using \nmedicines. Whenever possible look for medical help before \ngiving them any type of medicine. Be sure not to give too \nmuch. \n\n\n3. A person who has ever had any sort of allergic reaction — \nhives, itching, etc. — after taking penicillin, ampicillin, a \nsulfonamide, or other medicines, should never use that \nmedicine again for the rest of his life because it would \nbe dangerous (see Dangerous reactions from injections of \ncertain medicines, p. 70). \n\n\n\n4. Persons who have stomach ulcers or heartburn should \navoid medicines that contain aspirin. Most painkillers, and \nall steroids (see p. 51) make ulcers and acid indigestion \nworse. One painkiller that does not irritate the stomach is \nacetaminophen (paracetamol, see p. 379). \n\n\n5. There are specific medicines that are harmful or dangerous to take when you \nhave certain illnesses. For example, persons with hepatitis should not be treated \nwith antibiotics or other strong medicines, because their liver is damaged, and the \nmedicines are more likely to poison the body (see p. 172). \n\n\n6. Persons who are dehydrated or have disease of the kidneys should be especially \ncareful with medicines they take. Do not give more than one does of a medicine that \ncould poison the body unless (or until) the person is urinating normally. For example, \nif a child has high fever and is dehydrated (see p. 76), do not give him more than one \ndose of acetaminophen or aspirin until he begins to urinate. Never give sulfa to a \nperson who is dehydrated. \n\n\nWWW. \n\n\nHesperian. \n\n\nrg \n\n\n55 \n\n\nAntibiotics: What They Are \nand How to Use Them \n\nWhen used correctly, antibiotics are extremely useful and important medicines. \nThey fight certain infections and diseases caused by bacteria. Well-known antibiotics \nare penicillin, tetracycline, streptomycin, chloramphenicol, and the sulfa drugs, or \nsulfonamides. \n\nThe different antibiotics work in different ways against specific infections. \n\nAll antibiotics have dangers in their use, but some are far more dangerous than \nothers. Take great care in choosing and using antibiotics. \n\nThere are many kinds of antibiotics, and each kind is sold under several ‘brand \nnames’ This can be confusing. However, the most important antibiotics fall into a few \nmajor groups: \n\n\nantibiotic group \n\nexamples of \n\nbrand names \n\nsee \n\n(generic name) \n\nbrand names \n\nin your area \n\npage \n\n\n\n(write in) \n\n\nPENICILLINS \n\nPen-V-K \n\n\n350 \n\nAMPICILLINS* \n\nPenbritin \n\n\n352 \n\nTETRACYCLINES \n\nTerramycin \n\n\n355 \n\nSULFAS (SULFONAMIDES) \n\nGantrisin \n\n\n357 \n\nCOTRIMOXAZOLE \n\nBactrim \n\n\n357 \n\nSTREPTOMYCIN, etc. \n\nAmbistryn \n\n\n353, 361 \n\nCHLORAMPHENICOL \n\nChloromycetin \n\n\n356 \n\nERYTHROMYCIN \n\nErythrocin \n\n\n354 \n\nCEPHALOSPORINS \n\nKeflex \n\n\n358 \n\n\n*Note: Ampicillin is a type of penicillin that kills more kinds of bacteria than do \nordinary penicillins. \n\n\nCHAPTER \n\n7 \n\n\nIf you have a brand-name antibiotic and do not know to which group it belongs, \nread the fine print on the bottle or box. For example, if you have some Paraxin 'S' but \n\ndo not know what is in it, read the fine print. It says \n‘chloramphenicol’. \n\n\n\n\n\n\nEach capsule contains \nChloramphenicol . . . 250 mg. \n\n\nLook up chloramphenicol in the GREEN PAGES \n(p. 356). You will find it must be used only for a \nfew very serious illnesses, like typhoid, and is \nespecially dangerous when given to the newborn. \n\n\nNever use an antibiotic unless you know to what group it belongs, what \ndiseases it fights, and the precautions you must take to use it safely. \n\nwww.ncspcria.n.org \n\n\n56 Where There Is No Doctor 2010 \n\n\nInformation on the uses, dosage, risks, and precautions for the antibiotics \nrecommended in this book can be found in the GREEN PAGES. Look for the name of \nmedicine in the alphabetical list at the beginning of those pages. \n\nGUIDELINES FOR THE USE OF ALL ANTIBIOTICS \n\n1 . If you do not know exactly how to use the antibiotic and what infections it can be \nused for, do not use it. \n\n2. Use only an antibiotic that is recommended for the infection you wish to treat. \n(Look for the illness in this book.) \n\n3. Know the risks in using the antibiotic and take all the recommended precautions \n(see the GREEN PAGES). \n\n4. Use the antibiotic only in the recommended does — no more, no less. The does \ndepends on the illness and the age or weight of the sick person. \n\n5. Never use injections of antibiotics if taking them by mouth is likely to work as \nwell. Inject only when absolutely necessary. \n\n6. Keep using the antibiotics until the illness is completely cured, or for at least \n2 days after the fever and other signs of infection have gone. (Some illnesses, like \ntuberculosis and leprosy, need to be treated for many months or years after the person \nfeels better. Follow the instructions for each illness.) \n\n7. If the antibiotic causes a skin rash, itching, difficult breathing, or any serious \nreactions, the person must stop using it and never use it again (see p. 70). \n\n8. Only use antibiotics when the need is great. When antibiotics are used too \nmuch they begin not to work as well. \n\nGUIDELINES FOR THE USE OF CERTAIN ANTIBIOTICS \n\n1. Before you inject penicillin or ampicillin, always have ready ampules of Adrenalin \n(epinephrine) to control an allergic reaction if one occurs (p. 70). \n\n2. For persons who are allergic to penicillin, use another antibiotic such as \nerythromycin or a sulfa (see p. 354 and 357). \n\n3. Do not use tetracycline, ampicillin, or another broad-spectrum antibiotic for an \nillness that can probably be controlled with penicillin or another narrow-spectrum \nantibiotic (see p. 58). Broad-spectrum antibiotics attack many more kinds of bacteria \nthan narrow-spectrum antibiotics. \n\n4. As a rule, use chloramphenicol only for certain severe or life-threatening illnesses \nlike typhoid. It is a dangerous drug. Never use it for mild illness. And never give it to \nnewborn children (except perhaps for whooping cough, p. 313). \n\n5. Never inject tetracycline or chloramphenicol. They are safer, less painful, and do \nas much or more good when taken by mouth. \n\n6. Do not give tetracycline to pregnant women or to children under 8 years old. It \ncan damage new teeth and bones (see p. 355). \n\n\nwww.nesperian.org \n\n\nWhere There Is No Doctor 2010 57 \n\n\n7. As a general rule, use streptomycin, and products that contain it, only for \ntuberculosis — and always together with other anti-tuberculosis medicines (see \n\np. 361). Streptomycin in combination with penicillin can be used for deep wounds to \nthe gut, appendicitis, and other specific infections when ampicillin is not available \n(or is too costly), but should never be used for colds, flu, and common respiratory \ninfections. \n\n8. All medicines in the streptomycin group (including kanamycin and gentamicin) \nare quite toxic (poisonous). Too often they are prescribed for mild infections where \nthey may do more harm than good. Use only for certain very serious infections for \nwhich these medicines are recommended. \n\n9. Eating yogurt or curdled milk helps to replace necessary bacteria killed by \nantibiotics like ampicillin and to return the body’s natural balance to normal (see \nnext page). \n\n\nWHAT TO DO IF AN ANTIBIOTIC DOES NOT SEEM TO HELP \n\n\nFor most common infections antibiotics begin to bring improvement in a day or \ntwo. If the antibiotic you are using does not seem to help, it is possible that: \n\n1 . The illness is not what you think. You may be using the wrong medicine. Try to \nfind out more exactly what the illness is — and use the right medicine. \n\n2. The dose of the antibiotic is not correct. Check it. \n\n3. The bacteria have become resistant to this antibiotic (they no longer are \nharmed by it). Try another one of the antibiotics recommended for that illness. \n\n4. You may not know enough to cure the illness. Get medical help, especially if \nthe condition is serious or getting worse. \n\nThese three children had a cold... \n\n\nWhat was \nthe villain? \n\n\nWhat took \nthe toll? \n\n\nWhy did this child \nget well again? \n\n\n\nHe got no \nrisky medicine — \n\n\nPenicillin! \n\n(see Allergic \nShock, p. 70) \n\n\nChloramphenicol ! \n\n(see risks and precautions \nfor this drug, p. 356) \n\n\njust fruit juice, \ngood food, and rest. \n\n\nAntibiotics do no good for the common cold. \n\nUse antibiotics only for infections they are known to help. \n\n\nWWW. \n\n\nliesperian.org \n\n\n58 Where There Is No Doctor 2010 \n\n\nIMPORTANCE OF LIMITED USE OF ANTIBIOTICS \n\nThe use of all medicines should be limited. But this is especially true of antibiotics, \nfor the following reasons: \n\n1. Poisoning and reactions. Antibiotics not only kill bacteria, they can also harm \nthe body, either by poisoning it or by causing allergic reactions. Many people die each \nyear because they take antibiotics they do not need. \n\n2. Upsetting the natural balance. Not all bacteria in the body are harmful. Some \nare necessary for the body to function normally. Antibiotics often kill the good bacteria \nalong with the harmful ones. Babies who are given antibiotics sometimes develop \nfungus or yeast infections of the mouth (thrush, p. 232) or skin (moniliasis, p. 242). This \nis because the antibiotics kill the bacteria that help keep fungus under control. \n\nFor similar reasons, persons who take ampicillin and other broad-spectrum \nantibiotics for several days may develop diarrhea. Antibiotics may kill some kinds of \nbacteria necessary for digestion, upsetting the natural balance of bacteria in the gut. \n\n3. Resistance to treatment. In the long run, the most important reason the use \nof antibiotics should be limited, is that WHEN ANTIBIOTICS ARE USED TOO MUCH, \nTHEY BECOME LESS EFFECTIVE. \n\nWhen attacked many times by the same antibiotic, bacteria become stronger and \nare no longer killed by it. They become resistant to the antibiotic. For this reason, \ncertain dangerous diseases like typhoid are becoming more difficult to treat than they \nwere a few years ago. \n\nIn some places typhoid has become resistant to chloramphenicol, normally the \nbest medicine for treating it. Chloramphenicol has been used far too much for minor \ninfections, infections for which other antibiotics would be safer and work as well, or for \nwhich no antibiotic at all is needed. \n\nThroughout the world important diseases are becoming resistant to antibiotics — \nlargely because antibiotics are used too much for minor infections. If antibiotics \nare to continue to save lives, their use must be much more limited than it is at \npresent. This will depend on their wise use by doctors, health workers, and the people \nthemselves. \n\nFor most minor infections antibiotics are not needed and should not be used. \n\nMinor skin infections can usually be successfully treated with mild soap and water, or \nhot soaks, and perhaps painting them with gentian violet (p. 370). Minor respiratory \ninfections are best treated by drinking lots of liquids, eating good food, and getting \nplenty of rest. For most diarrheas, antibiotics are not necessary and may even be \nharmful. What is most important is to drink lots of liquids (p. 155), and provide enough \nfood as soon as the child will eat. \n\n\nDo not use antibiotics for infections the body can fight successfully \nby itself. Save them for when they are most needed. \n\n\nFor more information on learning to use antibiotics sensibly, see Helping Health \nWorkers Learn, Chapter 19. \n\n\nwww.nesperian.org \n\n\nHow to Measure \nand Give Medicine \n\n\nCHAPTER \n\n\n59 \n\n\n\nSYMBOLS: \n\n= means: is equal to or \n\nis the same as \n\n+ means: and or plus \n\n\n\n1 + 1=2 \n\n\nOne plus one equals two. \n\n\nHOW FRACTIONS ARE SOMETIMES WRITTEN: \n\n\n1 tablet = one whole tablet = \n\n1/2 tablet = half of a tablet = \n\n1 1/2 tablet = one and one-half tablets = \n\n1/4 tablet = one quarter \n\nor of a tablet = \none-fourth \n\n\n\n\n1/8 tablet = one-eighth of a tablet (dividing it \n\ninto 8 equal pieces and taking 1 piece) = \n\n\n\nMEASURING \n\nMedicine is usually weighed in grams (gm.) and milligrams (mg.). \n\n1000 mg. = 1 gm. (one thousand milligrams make one gram) \n\n1 mg. = .001 gm. (one milligram is one one-thousandth part of a gram) \n\n\nExamples: \n\nOne adult aspirin \ntablet contains \n300 milligrams \nof aspirin. \n\n\n.3 gm. \n0.3 gm. \n0.300 gm \n300 mg. \n\n\nAll these are \ndifferent ways \nof saying 300 \nmilligrams. \n\n\n\nOne baby aspirin .075 gm. \n\ncontains 75 milligrams 0.075 gm. \n\nof aspirin. 75.0 mg. \n\n75 mg. \n\n\nAll these are \ndifferent ways \nof saying 75 \nmilligrams. \n\n\nNote: In some countries some medicines are still weighed in grains; gr. = grain and \n1 gr. = 65 mg. This means a 5 gr. aspirin tablet weighs about 300 mg. \n\n\nwww. nespenan.org \n\n\n60 Where There Is No Doctor 2010 \n\n\nMany times it is important to know how many grams or milligrams are in a \nmedicine. \n\n\nFor example, if you want to give a small piece of adult aspirin to a child, instead of \nbaby aspirin, but you do not know how big a piece to give... \n\n| \n\n^Aspirin ? \n\n\nread the small print on the labels of each. \nIt says: aspirin: acetylsalicylic acid .3 gm. \n\n\n(acetylsalicylic acid = aspirin) \n\n\n.3 gm. = 300 mg. and .075 gm. = 75 mg. So, you can see that one adult aspirin \n\n<§> \n\n\nweighs 4 \n\ntimes \n\n75 \n\nmg. \n\n& \n\n75 \n\nmg. \n\n& \n\n75 \n\nmg. \n\n\n75 \n\nmg. \n\nCsi \n\n\n4 baby aspirin \nadd up to \n\n\nIf you cut the adult aspirin \ninto 4 equal pieces, \neach quarter = one baby aspirin \n\n\n300 mg. \n\n\n\n1 regular aspirin \n\n\nQ - © \n\n\nSo if you cut an adult aspirin into 4 pieces, you can give the child 1 piece in place of \na baby aspirin. Both are equal, and the piece of adult aspirin costs less. \n\n\nCAUTION: Many medicines, especially the antibiotics, come in different weights and \nsizes. For example, tetracycline may come in 3 sizes of capsules: \n\n\nCD \n\n\n250 mg. (~J 100 mg. ( IP so \n\n\nmg. \n\n\nBe careful to only give medicine in the recommended amounts. It is very \nimportant to check how many grams or milligrams the medicine contains. \n\n\nFor example: if the prescription says: Take tetracycline, 1 capsule of 250 mg. 4 times a \nday, and you have only 50 mg. capsules, you have to take five 50 mg. capsules 4 times \na day (20 capsules a day). \n\n\n50 mg. + 50 mg. + 50 mg. + 50 mg. + 50 mg. = 250 mg. \n\n\nCD + CD + CD + CD + CD= ( | ) \n\n\nMEASURING PENICILLIN \n\nPenicillin is often measured in units. \n\nU. = unit 1,600,000 U. = 1 gm. or 1,000 mg. \n\n\nMany forms of penicillin (pills and injections) come in doses of 400,000 U. \n\n400,000 U. = 250 mg. \n\nwww. nespenan.org \n\n\nWhere There Is No Doctor 2010 61 \n\n\nMEDICINE IN LIQUID FORM \n\nSyrups, suspensions, tonics, and other liquid medicines are measured in \nmilliliters: \n\nml. = milliliter 1 liter = 1000 ml. \n\n\nOften liquid medicines are prescribed in tablespoons or teaspoons: \n\n1 teaspoon (tsp.) = 5 ml. 1 tablespoon (Tbs.) = 15 ml. \n\n\n\nWhen instructions for a medicine say: Take 1 tsp., this means take 5 ml. \n\nMany of the ‘teaspoons’ people use hold as much as 8 ml. or as little as 3 m. \n\nWhen using a teaspoon to give medicine, it is important that it measure 5 ml. — \nNo more. No less. \n\nHow to Make Sure that the Teaspoon Used \nfor Medicine Measures 5 ml. \n\n\n1. Buy a 5 ml. \nmeasuring spoon. \n\n\nor \n\n\n\n\nWORK AWAY \n\n\n\n\n2. Buy a medicine that comes with a plastic spoon. This \nmeasures 5 ml. when it is full and may also have a line \nthat shows when it is half full (2.5 ml.). Save this spoon \nand use it to measure other medicines. \n\n\n\nwww. nespenan.org \n\n\n62 Where There Is No Doctor 2010 \n\n\nHOW TO GIVE MEDICINES TO SMALL CHILDREN \n\nMany medicines that come as pills or capsules also come in syrups or suspensions \n(special liquid form) for children. If you compare the amount of medicine you get, the \nsyrups are usually more expensive than pills or capsules. You can save money by \nmaking your own syrup in the following way: \n\n\nGrind up the \n\n\n\nor open the capsule \n\n\n\nand mix the \npowder with \nboiled water \n(that has cooled) \nand sugar or \nhoney. \n\n\nsugar \n\nor \n\nhoney \n\n\ncool boiled \nwater \n\n\n\nYou must add lots of sugar or honey \nwhen the medicine is very bitter \n(tetracycline or chloroquine). \n\n\nWhen making syrups for children from pills or capsules, be very careful not to give \ntoo much medicine. Also, do not give honey to babies under 1 year of age. Though \nit is rare, some babies can have a dangerous reaction. \n\nCAUTION: To prevent choking, do not give medicines to a child while she is lying on \nher back, or if her head is pressed back. Always make sure she is sitting up or that her \nhead is lifted forward. Never give medicines by mouth to a child while she is having a \nfit, or while she is asleep or unconscious. \n\n\nHOW MUCH MEDICINE SHOULD YOU GIVE TO CHILDREN \nWHEN YOU ONLY HAVE THE INSTRUCTIONS FOR ADULTS? \n\nGenerally, the smaller the child, the less medicine he needs. Giving more than \nneeded can be dangerous. If you have information about the doses for children, follow \nit carefully. If you do not know the dose, figure it out by using the weight or age of the \nchild. Children should generally be given the following portions of the adult dose: \n\n\nAdults: \n\n\n\n132 lbs. \n\n\nChildren \n8 to 13 years: \n1/2 dose \n\n\n\n66 lbs. \n\n\nChildren \n4 to 7 years: \n1/4 dose \n\n\n\n\n\n33 lbs. \n\n\nChildren \n1 to 3 years: \n1/8 dose \n\n\n\n17.6 lbs. \n\n\nGive a child under \n1 year old the \ndose for a child \nof 1 year, but ask \nmedical advice \nwhen possible. \n\n\n\n11 lbs. \n\n\n1 kilogram (kg.) = 2.2 pounds (lb.) \n\n\nwww. nespenan.org \n\n\nWhere There Is No Doctor 2010 63 \n\n\nHOW TO TAKE MEDICINES \n\n\n\nIt is important to take medicines more or less at the time \nrecommended. Some medicines should be taken only once a \nday, but others must be taken more often. If you do not have a \nclock, it does not matter. If the directions say ‘1 pill every \n8 hours’, take 3 a day: one in the morning, one in the \nafternoon, and one at night. If they say ‘1 pill every 6 hours', \ntake 4 each day: one in the morning, one at midday, one in \nthe afternoon, and one at night. If the directions are ‘1 every \n4 hours', take 6 a day, allowing more or less the same time between pills. \n\n\nWhenever you give a medicine to someone else, it is a good idea to write the \ninstructions and also to have the person repeat to you how and when to take the \nmedicine. Make very sure he understands. \n\n\nTo remind people who cannot read \nwhen to take their medicine, you can \ngive them a note like this \n\nIn the blanks at the bottom draw the \namount of medicine they should take and \ncarefully explain what it means. \n\n\n\nFor example: \n\nThis means 1 tablet 4 times a day, 1 \nat sunrise, 1 at noon, 1 at sunset, and \n1 in the middle of the night. \n\n\no \n\n\ntO- \n\n\no o \n\n\n\nThis means 1/2 tablet 4 times a day. \n\n\nThis means 1 capsule 3 times a day. \n\n\n\n\n\\ / - \n\n~o- \n\ni \\ \n\n\\l 1/ \n\nf> \n\nm \n\nCD \n\n1 \n\n\nLLJ \n\n\nThis means 1/4 tablet twice a day. \n\n\n\n'9- : \n\n\n) \n\n\n\na \n\n\n\nThis means 2 teaspoons twice a day. \n\n\n\nw w w. hespenan.org \n\n\n\n\n\n64 Where There Is No Doctor 2010 \n\n\nWHEN YOU GIVE MEDICINES \nTO ANYONE . . . \n\nAlways write all the following information \non the note with the medicine — even if the \nperson cannot read: \n\n\n• the person’s name ► \n\n• the name of the medicine ► \n\n• what it is for ► \n\n• the dosage ► \n\n\n\n*| \n\nPI \n\nB \n\n°o \n\n\n\n\nName: \n\n7o!r\\r\\r\\y\n…[truncated]", "summary": "Where There Is No Doctor 2010 Wfiere Tfiert Is No Doctor a viCCaqe kecdcfi care danewook -revised edition ~ % VctvicC Werner mtft CaroC Tfmman ancC Jane MameCC witd drawuys dy David Werner rJ ilMi&ifl- www. nesperian.org Where There Is No Doctor 2010 Library of Congress Cataloging-in-Publication Data The Library of Congress has already cataloged the 10-digit ISBN as follows: Werner, David, 1934- Where there is no doctor: a village health care handbook / by…", "source_url": "https://archive.org/details/WhereThereIsNoDoctor-English-DavidWerner", "pdf_url": "https://archive.org/details/WhereThereIsNoDoctor-English-DavidWerner", "case": "hesperian", "sub_case": "DAVID WERNER", "tags": ["hesperian", "RADICAL MEDICINE; PEOPLE'S HEALTH. DAVID WERNER; HERSPERIAN "], "page_count": 0} {"title": "Where There Is No Doctor", "content": "\n*e there Is \"M \n\n\n\nWhere There \nIs No Dentist \n\nby Murray Dickson \n\n\n\nwith an Introduction by David Werner, \nauthor of Where There Is No Doctor \n\n\nCompiled by noonya \n\n\nLibrary of Congress Cataloging in Publication Data \n\nCatalog card No. 82-84067 \n\nDickson, Murray \n\nWhere there is no dentist. \n\nIncludes index. \n\nPalo Alto, CA: Hesperian Foundation \nISBN : 0-942364-05-8 \n\nFirst edition, November 1983 \nSeventh Printing, July 1996 \n\n\nPUBLISHED BY: \n\nThe Hesperian Foundation \nP.O. Box 1692 \nPalo Alto, California 94302 \nU. S. A. \n\n\nCopyright ©1983 by The Hesperian Foundation \n\n\n\nThis book is certainly not intended to be the last word in community \ndental care. It is only a beginning. The author hopes to rewrite and \nimprove the book with suggestions from readers. \n\nNote on the use, adaptation, and translation of this book: \n\nEach country is special, with its own \nparticular customs, health needs, and \nways of caring for people. \n\nThis book, therefore, must be adapted \nby dental workers in each country, using \nthe language that is common to the local \nhealth workers there. \n\nThe author would be pleased to assist \nin any way with those who would translate \nor adapt the book. \n\nThe Hesperian Foundation encourages others to copy, reproduce or adapt \nto meet local needs, any or all parts of this book, including the illustrations, \n\nprovided the parts reproduced are distributed free or at cost \n-not for profit. \n\nAny organization or person who wishes to copy, reproduce or adapt, any or \nall parts of this book for commercial purposes, must first obtain permission \nto do so from the Hesperian Foundation. \n\nPlease contact the Hesperian Foundation before beginning any transla- \ntion or adaptation to avoid duplication of efforts, and for suggestions \nabout adapting the information in this book. The foundation would appreci- \nate receiving a copy of any materials in which text or illustrations from this \nbook have been used. \n\nWe would like to rewrite this book and incorporate many of your ideas. \nIf you have a suggestion, please write to Murray Dickson at The Hesperian \nFoundation. Better yet, if you write your own manual, please set aside \ntwo copies and send one to The Hesperian Foundation, Box 1692, Palo \nAlto, California 94302, USA. Send the other to AHRTAG (Appropriate \nHealth Resources and Technologies Action Group), 29-35 Farringdon \nRoad, London EC1M 3JB, England. Both organizations would like to help \npass along your ideas to others. \n\n\n\nTHANKS \n\nWhere There Is No Dentist is here to fill a need. To many people, it has seemed that \nthe existing books about dental care were either too incomplete or too complicated. \n\nIf this book fills that need, it is only because a number of people worked hard to make \nit happen. To them I owe my sincere thanks. \n\nMuch has happened since that day in Papua New Guinea when David Werner's \nletter arrived. His challenge was simple: \"Since no one else has written a dental manual \nlike this, why don't you?\" With David's encouragement and constant support, I was \nable to take teaching notes and produce a suitable draft that was the basis for this \nbook. To you, David, for your patience in helping me learn, my heartfelt thanks. \nThanks also to'Trude Bock and Bill Bower for the home, food, direction, and support, \nduring a short visit to The Hesperian Foundation in which the book took a definite \nturn for the better. \n\nMichael Blake deserves special mention. As editor of Where There Is No Dentist , it \nwas he who took the manuscript and nursed it along to completion. Michael's \ncommitment to finishing the book was vital, and I sincerely appreciate it. \n\nMy thanks go to Maggie Leung for typing the final draft, and to those dedicated \npersons who helped get the book into final form: Annaloy Nickum (page design); \n\nHal Lockwood (typesetting and paste-up); Paul Chandler, Serena Clayton, and Elaine \nRossi (proofreading); Pat Bernier (typing); and Howard Uno (photostats). \n\nFor their outstanding drawings, I am exceedingly grateful to: June Mehra, Janet \nElliott de Jacques, Michael Marzolla, Joan Thompson, Mindy Mead, Arlene Ustin- \nCartagena, and Lynn Gordon. My own drawings in the manual appear amateurish in \ncomparison. \n\nI want to thank the many persons who reviewed the manuscript and offered \nvaluable suggestions: Ken Cripwell, Bill Bower, Jeff Vore, Aaron Yaschine, Rosalie \nWarpeha, Norma Francisco, Mike Muller, Marcia Anderson, Phil Haskett, Bert Ball, \n\nTom Coles, Sunil Mehra, and John Rogers. In particular, thanks to Chris Lennox who, \nfaced with stressful times in Papua New Guinea, found time to read through two \ndrafts; and to David Morley for his ideas for improving the book and his assistance \nwith its eventual publication. \n\nFor their financial help, I am grateful to the Ella Lyman Cabot Trust, Muttart \nFoundation, the Canadian Organization for Development through Education, and the \nJames C. Penney Foundation. \n\nI thank the C.V. Mosby Company and Dr. Kenneth Snawder for permission to \nadapt several drawings from the Handbook of Clinical Pedodontics, and the \nMedical Missionary Association (6 Canonbury Place, London N1 2NJ, U.K.) \nfor permission to use parts of David Halestrap's book Simple Dental Care. \n\nThis book is based upon several years of practical experience, made possible by \nthe Canadian Organization CUSO. For this opportunity, and for CUSO's active interest \nand involvement in this book, I most gratefully say thanks. \n\nFinally, I want to acknowledge my family's contribution. For weeks on end, my \nwife, Gerri, faithfully read and discussed with me each part of the book as it changed \nand was rewritten. She did this cheerfully, at a time when she was fully occupied in a \ngraduate study program. For much longer than I had anticipated, Gerri and our two \nboys, Michael and Brennan, had to tolerate my preoccupations. \n\nMy parents endured my wanderings and search for answers to human problems \nwith love and a growing sense of understanding. It is my only disappointment that \nthey did not live to see this book in its final form’ \n\n\n\nCONTENTS \n\n\nINTRODUCTION, by David Werner \n\nPart One: Learning and Teaching about Teeth and Gums \n\nChapter 1 : Your Own Teeth and Gums 1 \n\nChapter 2: Teaching Family and Friends In Your Community 9 \n\nChapter 3: Teaching Children At School 17 \n\nChapter 4: School Activities for Learning About Teeth and Gums 33 \n\nChapter 5: Taking Care of Teeth and Gums 59 \n\nPart Two: Treating Dental Problems \n\nChapter 6: Examination and Diagnosis 71 \n\nChapter 7: Treating Some Common Problems 81 \n\nChapter 8: Scaling Teeth 121 \n\nChapter 9: Injecting Inside the Mouth 129 \n\nChapter 10: Cement Fillings 137 \n\nChapter 11: Taking Out a Tooth 147 \n\nREFERENCE PAGES 163 \n\nThe Dental Kit \n\nRecords, Reports, and Surveys \nStory Telling \n\nDental Health Teaching Materials \n\nVOCABULARY 182 \n\n\nINDEX \n\n\n187 \n\n\nINTRODUCTION \n\nby David Werner \n\n\nA healthy tooth is a living part of the body. It is connected by \n'life-lines' of blood and nerve to a person's heart and brain. To separate \nthe tooth from the body, or even to interrupt those 'life-lines', means \ndeath to the tooth. It also means pain and injury to the body, to the \nperson. \n\nLet us look at it another way. The health of the teeth and gums is \nrelated to the health of the whole person, just as the well-being of a \nperson relates to the health of the entire community. \n\nBecause of this, the usual separation between dentistry and general \nhealth care is neither reasonable nor healthy. Basic care of the teeth and \ngums— both preventive and curative— should be part of the 'know-how' of \nall primary health care workers. Ideally, perhaps, Where There is No \nDentist should be a part of Where There Is No Doctor. Think of it as a \ncompanion volume, both to Where There Is No Doctor and Helping Health \nWorkers Learn. \n\nMurray Dickson has taken care to write this book in a way that will \nhelp the readers see dental care as part of community health and \ndevelopment. The approach is what we call 'people centered.' \n\nWhere There Is No Dentist is a book about what people can do for \nthemselves and each other to care for their gums and teeth. It is written \nfor: \n\n• village and neighborhood health workers who want to learn more \nabout dental care as part of a complete community-based approach \nto health; \n\n• school teachers, mothers, fathers, and anyone concerned with \nencouraging dental health in their children and their community; \nand \n\n• those dentists and dental technicians who are looking for ways to \nshare their skills, to help people become more self-reliant at lower \ncost. \n\nJust as with the rest of health care, there is a strong need to \n'deprofessional ize' dentistry— to provide ordinary people and community \nworkers with more skills to prevent and cure problems in the mouth. \n\nAfter all, early care is what makes the dentist's work unnecessary— and \nthis is the care that each person gives to his or her own teeth, or what a \nmother does to protect her children's teeth. \n\n\n\nWhile dental disease is decreasing in richer countries, it is on the increase \nin most poor countries. One reason for this is that people are eating fewer \ntraditional (unrefined) foods and more pre-packaged commercial foods, \noften sweetened with refined sugar. \n\nEven as the need for dental care is growing, there are still far too few \ndentists in poor countries. Most of those few work only in the cities, \nwhere they serve mostly those who can afford their expensive services. \n\nPeople in many countries cannot afford to pay for costly professional \ndental care. Even in rich countries, persons who do not have dental \ninsurance often do not get the attention they need— or go into debt to \nget it. \n\nTwo things can greatly reduce the cost of adequate dental care: popular \neducation about dental health, and the training of primary health workers \nas 'dental health promoters'. In addition, numbers of 'community dental \ntechnicians' can be trained— in 2 to 3 months plus a period of \napprenticeship— to care for up to 90% of the people who have problems \nof pain and infection. \n\nDentists' training usually includes complicated oral surgery, root canal \nwork, orthodontics (straightening teeth), and other complex skills. Yet \nmost dentists rarely do more than pull, drill, and fill teeth— skills that \nrequire a fraction of the training they have received. The simpler, more \ncommon dental problems should be the work of community dental \ntechnicians who are on the 'front lines' (the villages), with secondary \nhelp from dentists for more difficult problems. \n\nWould this reduce quality of service? Not necessarily. Studies have \nshown that dental technicians often can treat problems as well as or better \nthan professional dentists. In Boston (U.S.A.), for example, a study \nshowed many of the basic treatments commonly given by dentists to be \ndone just as well, and often better, by dental technicians with much \nshorter training. \n\nFortunately, in some countries skilled dental technicians have managed \nto become the major providers of the most needed dental services. In \nIndia, there are still 'street-corner' dental technicians with foot-pedal \ndrills, who drill and fill teeth at remarkably low cost. \n\nIn Honduras, dental technicians (who learn largely from each other, \nstarting as helpers) have formed their own union. Their political strength \nrecently was tested when, in the town of T rujillo, a dentist tried to put a \ntechnician out of business. The local technician had removed an infected \nroot left mistakenly by the dentist. The technician had commented on \nthe dentist's carelessness, and the dentist heard about it. The dentist sent \na policeman who shut down the technician's office and took away his \ntools. However, the dental technicians' union took this to court. They \nargued their rights to practice dentistry, because they are the only persons \n\n\n\nworking in marginal communities where dentists' prices are too high for \nthe people. The court decided in favor of the technicians, and ordered the \ndentist to return the technician's tools and pay him for work lost. \n\nIn other countries dentists and community dental workers work in \ncloser harmony. In Guatemala, Ecuador, Papua New Guinea, and \nMozambique, dental technicians are now recognized by the Ministries of \nHealth. In Papua New Guinea and Ecuador, professional dentists train and \nsupervise them to provide dental care to school children. In Ecuador, they \nwork mostly as dentist assistants, bringing high quality services to more \npeople while decreasing costs. The 'dental therapists' in Papua New Guinea \nare trained to extract, drill, and fill teeth, as well as to work on prevention \nof dental problems in school children. \n\nIn Guatemala and Mozambique, dentists from the dental school have \ntrained village health promoters as dental workers who work with people \nof all ages. Their training includes community dental health education, \ncleaning of teeth, extractions, and drilling and filling. These health \nworkers are provided with the few basic instruments needed to provide \nthese services. \n\nIn Project Piaxtla, Mexico (with which I and the Hesperian Foundation \nhave worked for many years), visiting dentists have also helped train \nvillage 'dentics'. They, in turn, now teach basic dental skills to the part- \ntime village health workers. These village dentics, some of whom have had \nonly 3 to 6 years of primary school, now practice— and teach— a wider \nrange of dental skills than the average dentist. Their activities include \ndental health campaigns with school children, community puppet shows \nabout low-cost dental self-care, cleaning of teeth, extractions, drilling and \nfilling, and the making of dentures (false teeth). Several of the dental \nworkers can now do root canal work— a special treatment to remove the \ncentral nerve in order to save an infected tooth. One of the village dentics, \nremembering what he had seen a dentist do, taught himself how to do \nroot canals when his girlfriend had an infected front tooth that he did not \nwant to pull. (He had also learned to check the tooth from time to time \nafterward to .make sure this treatment had been successful.) \n\nWe still have much to learn about dental health. Dentists need to learn \nfrom the knowledge of the local people, as well as the people from the \ndentists. \n\nWe have learned that villagers with little formal education often can \nlearn skills with their hands— such as tooth extractions, puppetry, or \nsurgery— much faster than university students (who have never learned to \nuse their hands for much more than pushing pencils). We also have \nobserved that the best way to learn dentistry is not through school but \nthrough practice, helping someone with more experience who is willing \nto teach. \n\n\n\nWhere There Is No Dentist has 2 parts. The first part (Chapters 1.-5) \ndiscusses teaching and learning about preventive care. It begins by \nencouraging the health worker to examine herself and her family. To be \na good example is the best way to teach. \n\nThe second part (Chapters 6-1 1) talks about diagnosing and treating \ncommon dental problems. It is especially for those who live where they \ncannot reach or afford a dentist. A poor neighborhood in the city can be \nas distant and neglected as a far-off village. This second part is intended \nmainly for health workers who have helped organize people to meet their \nown needs. \n\nI \n\nMurray Dickson— a Canadian with primary care experience in Northern \nCanada, Nigeria, Papua New Guinea, and Mozambique— has written this \nbook in clear, simple language. He takes care to use popular names instead \nof unfamiliar scientific words. For example, instead of speaking of 'dental \nplaque' the author speaks of the 'coating of germs on the teeth,' Such \nsimple language does not weaken the message. The message is stronger \nbecause everyone understands. \n\nThe author has said: \n\nI am sure some dentists will disagree with parts of this book. Some \npoints of disagreement may be small, like the failure to use accepted \ndental terminology. Other ideas, particularly the suggestion that non- \ndental people can be trained to provide many kinds of treatments, may \nmake some dentists angry. \n\nThe book is meant to be a source for argument and discussion. This \nway, it may stimulate others to write the kind of manual that is really \nneeded in their countries. \n\nWe hope that this will be only the first volume of Where There Is No \nDentist It takes the reader as far as simple extraction (pulling) of teeth \nand placement of temporary fillings. As we have seen, village workers can \nalso learn a wide range of more difficult dental skills. We hope that later \nvolumes of Where There Is No Dentist will include permanent fillings, \nhomemade portable drilling equipment (many kinds have been developed), \nthe making of false teeth, and root canal treatment. There is no reason \nwhy village workers cannot learn all of these skills and practice them at \nlow cost to serve the millions who are unserved today. \n\nThe people must answer to the people's needs. The health of teeth and \ngums, along with general health, will improve only when people take the \nlead in caring for themselves. The challenge for dentists and other health \nprofessionals is to allow and encourage this to happen. \n\n\n\n1 \n\nCHAPTER \n\nYour Own Teeth \nand Gums \n\nNext time you look in a mirror, look at your teeth and the skin (gums) \naround them. Look in your children's mouths, too. Look at both gums \nand teeth, because the health of one often depends on the health of the \nother. To be strong, teeth need healthy gums. Healthy gums need clean \nteeth. \n\n\nWhat can good \nteeth give you? \n\n. GOOD HEALTH \n\n• GOOD LOOKS \n\n• GOOD SPEECH \n\n• GOOD EATING \n\n• GOOD BREATH \n\n\nAnd when you think of your teeth, think of your gums. Gums are \nimportant for holding each tooth in place. \n\nYou need strong teeth to eat different kinds of foods. Different foods \nare important for health. Nuts, maize, fruits, and meat are some of the \nbest foods— but they are difficult to bite and chew if your teeth are loose \nand hurting! \n\n\n\n\n\n2 \n\n\nYou can usually tell if your teeth and gums are healthy or not. Look at \nthe pictures on pages 71 and 72 and compare them with your own mouth. \nIf you find a problem in your mouth, look for its name in Chapter 6 and \nlook for its treatment in Chapter 7. \n\n\nMost important: when you are not sure of a \nproblem or how to treat it, talk to an \nexperienced dental worker. \n\n\nIf you notice a problem early, often you can stop it from getting worse. \nIt is even better to prevent the problem from starting. You can do this \nif you know how to keep your teeth and gums healthy. \n\n\n\nBirr Hov/ can \nI KEEP MX \nTEETH AND MY \n\nGums healthy? \n\n\n\nBY EATING ONLY^ \n\ngood healthy \nFood and cleaning \n\nYOUR TEETH \nEVERY DAY/ \n\n\nLearn to take care of your own teeth and gums before you try to teach \nothers. A good example is one of your best teaching tools. People will \nsee that you are healthy, and they will want to know why. When you tell \npeople ways to care for their teeth, they will believe you if they know \nthat you do these things yourself. First take care of your own teeth and \ngums. Then teach your family what you have learned. They, too, will be \ngood examples for others to see. \n\n\n\n3 \n\n\nEAT ONLY GOOD HEALTHY FOODS \n\nThe best food is food that you grow or raise yourself. Mix different \nkinds of food together and eat several times a day. This helps your body \nas well as your teeth and gums to stay strong and healthy. Traditional \nfood is usually good food. \n\nSweet food, especially the kind you buy from the store, can mix with \ngerms and make cavities— holes in the teeth. Soft food sticks to the teeth \neasily and it, too, can make a coating of germs and food on the teeth that \nstarts an infection in the gums— gum disease. \n\nSoft and sweet food and drinks with a \nlot of sugar are bad for both teeth and gums. \n\n\nDo not give a baby anything to drink \nfrom a bottle. Sweet tea, sugar water \nor fruit juice can easily make holes \nin the child’s teeth. \n\n\nREMEMBER: \n\nBREAST \n\nIS \n\nBEST! \n\n\nNO \n\nBAD FOR TEETH \n\n\nEven milk has sugar that can wash over the baby’s teeth and cause cavities when \nit comes from a bottle. \n\n\n\nBreast feed to help a child’s teeth \ngrow and stay strong. An older cl\" \ncan drink from a cup. \n\n\n\nYES \n\nGOOD FOR TEETH \n\n\n\n\n\n\n\n\n\n4 \n\n\nCLEAN YOUR TEETH EVERY DAY \n\n\nIf you do not clean properly, the food that is left on your teeth can \nhurt the teeth as well as the gums near them. \n\nHIDING PLACES \n\n\n\nBits of food stay longer in grooves and \n'hiding places'. This is where both tooth \nand gum problems start. \n\nTo prevent problems you must take special \ncare to keep these protected places clean. \n\nIt is better to clean your teeth carefully \nonce every day than to clean poorly many \ntimes a day. \n\n\nHere are 3 places where problems start. \n\n\nUse a soft brush to clean your teeth. Buy one from the store (be sure it \nsays soft on the package), or make a brush yourself. To make a brush: \n\n\n1 . Use a small branch, \nyoung bamboo, strong \ngrass or the skin from \nsugar cane or betel nut. \n\n\n\n3. Chew one end to make \nit stringy like a \n\n\n\n2. Cut a piece that is still \ngreen and soft. \n\n\n\n4. Sharpen the other end so \nit can clean between the \nteeth (see pages 69-70). \n\n\n\n\\ \n\n\n\n5 \n\n\nYou can twist the fiber from inside a coconut husk into a kind of brush. \nFirst rub it and shake away the loose bits. Then use the end to clean your \nteeth. \n\n\nm \n\nPi \n\n® \\\\ \nil \n\ni \n\n\n\n\nslfi \n\n\nWhatever kind of brush you use, be sure to clean your back teeth as \nwell as your front teeth. Scrub the tops and sides where the grooves are. \nThen push the hairs between the teeth and scrub (page 67). \n\n\nToothpaste is not necessary. \n\nCharcoal or even just water is \nenough. When your teeth are \nclean, rinse away the loose \npieces of food. \n\n\n\n\n\n\n\n\n6 \n\n\nCAVITIES, TOOTHACHES AND ABSCESSES \n\n'Cavities' are holes in teeth. Cavities are made by the infection called \ntooth decay. If you have a black spot on your tooth, it might be a cavity. \nIf that tooth hurts some of the time, such as when- you eat, drink, or \nbreathe cold air, it probably has a cavity in it. \n\nYou will get cavities in your teeth if you eat sweet food and then do \nnot clean your teeth. If you see a cavity starting in your mouth or feel a \ntooth hurting you, get help right away. A dental worker knows how to \nfill the cavity so you can keep that tooth. Do this before the pain gets \nworse. \n\n\nWhen infection \nreaches the inside \nof a tooth, it \nis called a tooth \nabscess. \n\n\n\nIf you do \nnot fill a cavity, \nit grows bigger. \nIt also grows \ndeeper. \n\n\n\nWhen decay touches \nthe nerve inside, \nthe tooth aches, \neven when you try \nto sleep. \n\n\n\nA tooth with an abscess needs treatment at once, before the infection \ncan go into the bone (page 87). In most cases the tooth must be taken out. \nIf it is not possible to do this right away, you can stop the problem from \ngetting any worse if you follow these steps: \n\n\n1. Wash the inside of your mouth with warm \nwater. This removes any bits of food \ncaught inside the cavity. \n\n2. Take aspirin for pain. See page 88 for \namount. \n\n3. Reduce the swelling: \n\n• hold warm water inside your mouth near \nthe bad tooth. \n\n• Wet a cloth with hot water and hold it \nagainst your face. Do not use water hot \nenough to burn yourself! \n\n\n\nA tooth abscess can cause \nswelling like this. \n\n\n\n7 \n\n\nSORE BLEEDING GUMS \n\nHealthy gums fit tightly around the teeth. Gums are infected if they \nare loose, sore, and red, and if they bleed when the teeth are cleaned. \nInfection in the gums is called gum disease. \n\nGum disease, like tooth decay, happens when acid touches the teeth \nand gums. This acid is made when sweet and soft foods mix with germs \n\n\n\nHEALTHY TEETH AND GUMS CAVITIES AND GUM DISEASE \n\nInfection from gum disease can spread into the root fibers and bone (see \npage 40). But you can stop gum disease and prevent it from coming back. \n\nThere are two things to do: clean your teeth better and strengthen your gums. \n\n1 . Even if your gums are sore and they bleed, you must still clean the \nteeth beside them. If more food collects on the teeth, the gum \ninfection will get even worse. Get a soft brush (see p. 4) and use it \ngently. This way you will not hurt the gums when you clean. \n\n2. To make your gums stronger and more able to fight the infection: \n\n* Eat more fresh fruits and green leafy vegetables, and fewer soft \nsticky foods from the store. \n\n• Rinse your mouth with warm salt water. Do this every day, even \nafter your gums feel better. \n\n\n\n(1) Mix some salt with a cup of warm water. (2) Take a \nmouthful and rinse. (3) Spit it out. Repeat until all of the salt \nwater is finished. \n\n\n\n\nMORE SERIOUS GUM DISEASE \n\n\nPainful gums that bleed at the slightest touch need special treatment. \n\nIf you have this problem, ask for help. A dental worker can explain what \nis happening and what needs to be done. A dental worker can also scrape \nthe teeth and remove the tartar that is poking the gums, making them sore \n\n\nAt home, you can do some things to help. \n\n1 . Clean your teeth near the gums with a soft brush. Gently push the \n' brush between the tooth and the gum. It may bleed at first, but \n\nas the gums toughen, the bleeding will stop. \n\n2. Make your food soft, so it is easier to chew. Pounded yam and soup \nare good examples. \n\n3. Eat plenty of fresh fruits and vegetables. If it is difficult for you to \nbite into fruit, squeeze it and drink the juice. \n\n4. Start rinsing your mouth with a mixture of hydrogen peroxide and \nwater. You can get hydrogen peroxide from your clinic or your \npharmacy (chemist). \n\nThe strength of hydrogen peroxide is important. Ask for a 3% \n\nsolution, and mix it evenly with water— that is, 1/2 cup of hydrogen \nperoxide with 1 /2 cup of water. \n\n\nWARNING: Read the label to be sure the solution is 3%. A \n\nmixture with more than 3% hydrogen peroxide can burn \nthe mouth. \n\n\n\nTake some into your mouth and hold it \nthere for about 2 minutes. Then spit it \nout and repeat. Do this every hour you \nare awake. \n\nUse hydrogen peroxide for only 3 days. \nThen change and start rinsing with salt \nwater (page 7). \n\n\nIf you take care, you can keep your teeth for a lifetime. \n\n\n\n\n\n\nCHAPTER \n\n\nTeaching Family and Friends \nIn Your Community \n\n\nOld people can remember when there were fewer problems with teeth \nand gums. Children's teeth were stronger and adults kept their teeth \nlonger. \n\nTimes are changing. Today there are more tooth and gum problems than \never before. In many countries, tooth decay and gum disease are two of \nthe fastest growing health problems. \n\n\nThis unhealthy situation is getting worse, for two reasons: changes in \nthe kind of food people now are eating, and not enough cleaning after \nthey eat. \n\n\nBEFORE, the food people ate was \ntheir own, grown and prepared by \nthemselves. \n\n\n\nEven sugar cane was not as bad as \nthe sticky candy children eat today. \nThe sugar was bad for the teeth, but \nthe fiber in the cane helped rub \nthem clean. \n\n\nNOW, more people are buying \nsofter and sweeter food from the \nstore. This kind of food sticks to \nthe teeth more easily so it has \nmore time to attack the teeth \n\n\n\nEveryone must be more careful \nto clean away soft, sweet food. \nBut many people do not know \nhow. Some, especially children, \ndo not even try. \n\n\n\n10 \n\n\nMany people do not understand that tooth and gum problems are \ncaused by certain kinds of food, and poor cleaning of the teeth. In fact, \nsome have a completely different belief. \n\n\n\nDo not attack a belief because it is traditional. Many traditions are more \nhealthy than 'modern' things. Often, instead of telling people that their \nbelief is wrong, you can remind them of a different tradition that is \nhealthy. \n\n\nHelp your family and friends to recognize their healthy \ntraditions. Then help them find new ways to use these \nsame traditions for better health. \n\n\n( OUR PEOPLE DO NOT \nUSE TOOTHBRUSHES. \nIWE DO NOT HAVE MONEY \n\n\\to buy Such thin&s \nVat the store. \n\n\n\n\n\n11 \n\n\nBE A GOOD EXAMPLE \n\nOther people like to watch what you do before they try something \ndifferent. First show members of your family and then they will be an \nexample to others in your community. For example: \n\n1 . Instead of buying all your foods from the store, buy fresh fruits and \n\nvegetables from the market. It is even \nbetter to grow food in your own \ngarden. \n\nLearn to use several different kinds of \nfoods in each meal. Mixing foods is a \nhealthy idea. Invite friends to share \nyour meals and see the number of \ndifferent foods you have at each meal. \n\n\n2. Do not buy fizzy drinks like Coca-Cola or Fanta. \n\nThey have a lot of added sugar which quickly \nmakes children's teeth rotten. \n\nAlso, do not sweeten your child's milk or tea. \n\nWhen she is young she can learn to enjoy drinks \nthat are not sweet. \n\nClean, cool water, tea with little sugar, milk, or \nwater from a young coconut are best to drink. \n\nFresh fruits are delicious when you are thirsty. \n\nMost important: do not give your child a feeding bottle, especially \none with a sweet drink inside. (See page 3.) \n\n\n3. Keep your children's teeth clean. \nYour friends will notice clean \nteeth or teeth that are dirty or \nhave cavities. Remember, clean \nteeth are healthy teeth. \n\nAn older child can clean his own \nteeth if you show him how. \n\nA younger child cannot. He needs \nhelp. Each day someone older \nshould clean his teeth for him \n(page 16). \n\n\n\n\n\n\n12 \n\n\nWhen you teach, remember that as others learn, \nthey too become teachers. Each person can teach another. \n\n\nEncourage people to pass along what you have taught. Mothers can \nteach family and friends. Students can talk at home with brothers, sisters, \nand older family members. \n\n\nFROM THE HEALTH CLINIC . . . \n\n\n. . .TO THE HOME \n\n\n\nPLEASE HELP \nME CLEAN BABY'S \nTEETH AND THEN \nBROTHER’S TEETH. \n\n, WE WILL DO IT \nEVERY DAY. \n\n\nfirst, I \n\nMUST CLEAN \nMY OWN \nTEETH PROPERLY. \n\n\n\n\n...TOTHESCHOOI \n\n\n. . .TO THE HOME \n\n\nUSE A SOFT TOOTHBRUSH. ^ \nA SOFT BRUSH IS BEST \n\nBECAUSE IT WON’T \nHURT YOUR 6UMS. \nTELL YOUR \n\nFAMILY THAT. , \n\n\n\n\nBROTHER, TRY To BRUSF|\\ \nYOUR BACK TEETH BETTER. \\ \nIF YOU DO, THEN THEY ) \n\nWILL STAY STRONG UNTIL J \nYOU GROW OLD. \n\n1L \"\" \n\n\nIf all learners become teachers, a simple message can begin in the health clinic or school \nand reach many more people at home. \n\n\n\n\n\n13 \n\n\nFINDING THE BEST WAY TO TEACH \n\n\nDeciding what to teach is important, but just as important is how to \n\n\nteach. \n\n\n\nLearning cannot take place when \nyou use words that people do not \nunderstand. They will learn \nsomething only when they see how \nit is related to their lives. \n\n\nRemember this when you teach about eating good food and keeping \nteeth clean. Design your own health messages, but be ready to change \nthem if people are not understanding or accepting what you say. \n\n\nHere are five suggestions for teaching well. \n\n\n1. Learn First From the People \n\n\nGet involved in your community's activities. Learn about people's \nproblems, and then offer to help solve them. People will listen to you \nwhen they know that you care about them and want to help. \n\n\nSit and talk with people. Learn \nabout their customs, traditions \nand beliefs. Respect them. \n\nLearn about their health habits. \nImproving health may require \nchanging some habits and \nstrengthening others. \n\nLearn also about tooth decay \nand gum disease in your community. \n\n\n0 : \n\n\n\n\n\n\n\n\ni m \n\n\n\n\n\n\n\n\nMake people smile— then look into their mouths. \n\n\nFind out how many children and adults are having \nproblems with their teeth and gums. Do a survey such \nas the one on p. 1 76. \n\n\n\n\n14 \n\n\n2. Build New Ideas Onto Old Ones \n\n\nPeople find their own ways to stay healthy. Many traditions are good, \nhelpful, and worth keeping. But some are not. \n\nWhen you teach, start with what people already understand and are \ndoing themselves. Then add new ideas. \n\nThis method of teaching is called 'association of ideas'. It helps people \nto understand new ideas because they can compare them with what they \nalready are doing. \n\nIn this way people can more easily accept, remember, and do what \n\n\n\nA small child cannot find his in the A small child cannot see the \n\nown lice. Mother knows she same way food on his teeth. He needs \n\nmust help him. help with that also. \n\n\n\nDifferent vegetables when in the _ \n\nplanted together— like maize same way \n\nand yams— help each other \nto grow. \n\n\n\nEating different kinds of \nfood helps people to grow. \nEating them several times a \nday makes your teeth and \ngums, as well as your whole \nbody, grow stronger. \n\n\n\n15 \n\n\n3. Keep Your Messages Short and Simple \n\nInstead of partially teaching too many things, it is better to discuss a \nfew things well. After learning what health problems the people feel are \ngreatest, decide what information will help them solve these problems. \nThen think of how to share the information. Try to: \n\n• Use simple words (see page 13). If you must use a big word, take the \ntime to explain it. \n\n• Teach people when they are ready to learn. A sick person, for \nexample, usually wants to know how to prevent his sickness from \nreturning. He will remember what you tell him. \n\n• Repeat the most important message many times. Whenever you teach \nabout staying healthy, remember to emphasize eating good food and \nkeeping teeth clean. Repetition helps people remember. \n\n• Let people see what you mean. See pages 24 to 32 for ways to use \npictures, puppets, and plays. \n\n\n4. Teach Wherever People Get Together \n\nKnowing where to teach is sometimes as important as how you teach. \nInstead of asking people to come to a class you have organized, go to \nthem. Look for ways to fit into their way of living. You both will gain \nfrom the experience. They will ask more questions, and you will learn how \nto work with people to solve problems. \n\nTalk with people where they \ngather near their homes. \n\n\nTalk to men as they \nsit together and \ndiscuss important \nissues. Also go to \ntheir business and \nfarming meetings. \n\n\n\nTeach men and women \nat reading groups. \n\n\n\n16 \n\n\n5. Teach Something People Can Do Right Away \n\n\nIt is good to tell a mother to keep her child's teeth clean, but it is better \nto show her how to do it. She will remember how if she actually watches \nyou clean her child's teeth. \n\nAn even better way for a mother to learn is to let her clean her child's \nteeth while you watch. A person discovers something for herself when she \ndoes it herself. \n\n\n\nPick out a child and clean his teeth yourself. Let \nhis mother watch. \n\nUse a soft brush (or for a baby, a clean cloth). \nGently but quickly brush or wipe his teeth. Do the \nbest you can even if he cries. \n\nIf mothers make this into a habit, the child will \nexpect to have his teeth cleaned and will soon \ncooperate— just the way he does to have lice \nremoved from his hair. \n\n\n\n\nNow let each mother clean her own \nchild's teeth. Teach her to clean on \ntop and on both sides of every \ntooth. \n\n\nAsk her to do the same at home \neach day. At the next clinic, look at \nthe children's teeth and see how \nwell the mothers are doing. Give \nfurther help when needed. Always \npraise and encourage those who are \ndoing well. \n\n\n\nTeaching Children \nAt School \n\n\n17 \n\n\nCHAPTER \n\n\nChildren want to learn. They want to know more about things that are \nreal to them. Family, friends, and teachers are all important sources of \nnew knowledge for the children. \n\nIt is important to keep alive their desire to learn, so \nthat children can continue to ask questions, discover, \nand learn more for themselves. \n\nWhen children are interested in something, they will work \nhard to learn all they can about it. \n\n\n\nIf you relate your teaching to children's interests and needs, they will \nlearn more easily. New information added to what they already know \nhelps children to understand your lesson better. As a result, they will want \nto learn more because the information is both interesting and worthwhile. \n\nTeaching about teeth and gums is important. You must do it well if \nyou want children to pay attention, learn, and finally act to take care of \ntheir own teeth and gums. \n\nAs school children continue to learn, they can share their new ideas and \ninformation at home with brothers, sisters, mothers, fathers, and grand- \nparents. In this way, the circle of teaching and learning described on page \n12 comes back into the family and is complete. \n\nThis chapter has two parts. Part 1 gives seven guidelines for assuring \nthat learning takes place. Part 2 suggests ways to have fun while learning— \nwith stories, games, and pictures. In Chapter 4 there are nine questions on \nteeth and gums with specific activities for learning how to answer them. \n\n\n\n\n18 \n\nPART 1: TEACHING SO THAT \nLEARNING CAN TAKE PLACE \n\nMore children than ever before are \nhaving problems with their teeth and their \ngums. \n\nA tooth that hurts or gums that are sore \ncan affect a student's ability to pay \nattention in school and learn. \n\nTreating the problem makes the child \nfeel better, and that is important. It is \nequally important to prevent the same \nproblem from returning later. \n\nWorking together, teachers and school children \ncan do much to prevent both tooth decay \nand gum disease. \n\nKeeping the mouth healthy involves learning about eating good food \nand keeping teeth clean. Just giving information is not enough, though. To \ntruly learn, children need a chance to find out things for themselves. \n\nForcing a person simply to accept what you say does not work very well. \n\nA student learns not to question. What you \nteach may have no relation to his own \nexperiences and needs. \n\nAs a result, he may end up not doing what \nyou teach— not eating good foods, and \nnot cleaning his teeth. \n\n\nLearning happens when a student with a \nquestion or an idea is able to discover more \nabout it himself. \n\nIt also happens when he has a chance to do \nwhatever is necessary to take better care of \nhimself and his family. \n\nHe can learn by doing. Give him a chance to \neat good food and clean his teeth at school. \n\n\n\n\n\n\n\n\n19 \n\n\nLearninq about teeth and gums can be fun. When the teaching is real \nand practical, students love to learn. Here are some ideas: \n\nTeaching so that learning can take place \n\n1 . Teach and learn together with your school children. \n\n2. Start with what the students already know. \n\n3. Let students see and then do. \n\n4. Let children help each other. \n\n5. Teach about teeth and gums together with other subjects. \n\n6. Be a good example. \n\n7. Make the community part of your classroom. \n\n\n1. Teach and Learn Together with School Children. \n\n\nfK PERMANENT SUCCESSOR u£S\" \nAPICAL TO... PA Y ATTENTION j \nYOU NEED TO KNOW THIS FOR j \n\nYour test'... each pruaarv \n\n\nShare ideas \ninstead of always \ngiving information. \nChildren learn more \nwhen they are \ninvolved. \n\nA lecture transfers \nyour own notes to \nthe children's \nnotebooks without \never passing through \ntheir minds. \n\n\n\nA discussion draws \nout information and \nopinions. \n\nIt helps you to learn \nmore about the \nschool children, \nwhat they already \nknow and believe to \nbe true. \n\nBut it also allows \nyou to introduce \nimportant \ninformation that is \nrelated to the discussion. \n\n\nA Loose tooth! \n\nmay ae r , \n\nRotten.) / 1 KN0W A \n\nI Goot> WAY \n\nTO TAKE OUT> \nA LOOSE \nTOOTH. \n\n\nmS \n\n\n\n\n20 \n\n\n2. Start with What the Students Already Know. \n\nTo have meaning, learning should be a part of daily living. Talk with \nyour students. Find out what they know about teeth and gums, and what \nquestions they might have. \n\n\nAdd information by building upon \nwhat a person already knows. \n\n\nDo not use big words. Scientific names and textbook explanations are \nconfusing, and you usually do not need them. Talk about teeth and gums \nusing words that a school child can understand and use later at home. \n\n\n\n\nThis way lets the students feel good, \nbecause it makes sense and they know \nsomething about it. \n\n\nWhen you can understand new information, you gain confidence and \nyou look forward to learning more. \n\n\n\n\n\n21 \n\n\n3. Let Students See and Do. \n\n\nStudents learn best when they can take part and find out for themselves \nabout something new. \n\n\n\nA lecture about brushing teeth is usually not interesting at all. \n\nLearning is more interesting when students can see how to make a \nbrush and how to clean teeth properly. \n\nIf students can actually make their own brushes and clean their own \nteeth, it is not only interesting but fun. \n\nA student who takes part will not forget. What he learns by doing \nbecomes part of himself. \n\n\n\n\n22 \n\n\n4. Let Children Help Each Other.* \n\n\nIn most families, older children have important work to do— taking care \nof their younger brothers and sisters. These older children can do much to \nteach the younger ones about care of teeth and gums. For example: \n\n\n(1 ) When they feed their younger brothers \nand sisters they can encourage them \nto eat good food, like fruit instead of \ncandy. \n\n(2) They can do a play or puppet show \nabout care of teeth and gums. \n\n(3) They can check the teeth and gums of \nthe younger children and 'score' them \non how healthy they are (see p. 58). \n\n(4) Best of all, they can actually clean the \nteeth of the younger ones, and show \nthem how to clean their own teeth \nwhen they are able. \n\n\n\nHere a group of school children \nin Ajoya, Mexico is putting a \nhigh-fluoride paste (see p. 167) \non the teeth of the younger \nchildren. \n\n\n5. Teach About Teeth and Gums \nTogether with Other Subjects. \n\nTeeth and gums are part of a bigger health picture. Teach about them \nin class at the same time. \n\nEating good food can be part of a discussion on nutrition, teeth, \nfarming methods, and the politics of who owns the lands. \n\nCleaning the teeth can be part of a \ndiscussion on hygiene, clean water, \nand traditions and customs. \n\nA good way for school children to \nlearn about using numbers is to do a \nsurvey in the community. \n\nThe results will tell the children \nsomething about health problems in \ntheir community. For an example of \na survey of health problems, see page \n\n3-14 of Helping Health Workers Learn. \n\n\n\nSTORE FOOD \n\ndumber seHinq . \n\n1 grounJn^hs \n\number sellinq Cota \n4hnk. \n\njmTjwt M I** I b \n\n\n\n\nFor more ideas on how school children can help each other, write to CHI LD-to-child Program, \nInstitute of Child Health, 30 Guilford Street, London WC1 N 1 EH, England. \n\n\n\n23 \n\n\n6. Be a Good Example. \n\nChildren watch people around them. They pay attention to what you \ndo, as well as to what you \n\nBe a good example. \n\nTake care to do \nyourself what you are \nteaching to your \nstudents. \n\nYour family can be \na good example for \nothers. \n\n• Clean your teeth carefully every day. Also/help your children keep \ntheir teeth clean. \n\n• Make a garden near your house and plant a variety of vegetables and \nfruits in it. \n\n• Buy only good, healthy food from the store. Do not buy sweet foods \nand drinks for yourself or your children. \n\n\n\n7. Make the Community Part of Your Classroom. \n\nA child's home and his community are really more important to him \nthan his school. Learning will be more interesting for a student if the \nday-to-day needs of his home and his community are part of school \ndiscussion. \n\nLet students find out more \nabout problems at home and in \ntheir community. \n\nFor example: \n\n• How many small children \nhave cavities or red, bleeding \ngums? \n\n• How many stores have \nmostly sweet snack foods \non their shelves? \n\n• Why do the people not grow \nand eat more local food? \n\nBack in the classroom, students can record what they find. Ask the \nchildren to think of ways to solve the problems they found. If they can \nthink of a program to help solve a health problem, let them go back into \ntheir community and try it. \n\n\n\n\n24 \n\n\nPART 2: MAKING LEARNING EXCITING, \nVISUAL, AND FUN \n\nHere are some ideas to help students see what you are teaching, and to \nhave fun while they learn. Students can also show these things to others. \nTeaching others is an excellent way to learn. \n\nTell a story about food or teeth. For example, tell a story about why a \nwild cat's teeth are different in shape from a goat's teeth (page 38). Stories \nare an excellent way to learn, both for the storyteller and for those \nlistening. Leave time at the end to discuss the story and to introduce new \ninformation. See the example of storytelling on pages 1 77-1 79. \n\nMake up a play or drama about good food or clean teeth. Show it later to \nthe community. \n\nThe play should be about looking for an answer to a real problem. If \nthe children invent the play, they will have to think, plan, and solve \nproblems. A play also helps children learn how to talk with and teach \nothers. \n\n\n\nThese school children in Nicaragua are doing a play about cavities. On the left, germs \nand sweet food are combining and trying to make a hole in the ‘tooth’. But a giant \ntoothbrush (right) beats them away! \n\n\nDo a demonstration using local resources. \n\n\n\n\nTry, for example, the 'tooth \nin the Coca-Cola' test on \npage 46. \n\n\nPuzzles can help school children discover answers for themselves. You can \nmake your own. The best puzzles are with words that the students know \nand can use easily. \n\n\n25 \n\n\nEXAMPLE (for younger children just learning to read) \n\n\n\nAn older child can try to find important words that are more difficult. \n\n\n\n\n/ \n\n/ \n\n\nVILLAGE \nCO-OP STORE \n\n\nabscess \n\nsugar \n\ncavity \n\nsore \n\ninfection \n\n\ncola \n\ntoothache \nS maize \ngreen leaf \ngum disease \n\n\nSpell some of the words diagonally (slanted). It will make the puzzle \nharder. \n\n\n\n26 \n\n\nYou can use pictures on posters, flip charts, and on flannel-boards. \n\nPictures that school children draw themselves are best. They learn \nsimply by drawing them. Also, school children will draw local people and \nlocal experiences, and the people will understand their pictures better than \nthe ones sent from a central office far away. \n\nPhotographs of local people and events are also good. If there is a \nphotography club in a local secondary school, have them take some \npictures for you. They may even print the photographs larger so that you \ncan use them as posters. \n\nAsk the children to make pictures big enough so that a person can \nstand far away and see them easily. \n\n\nLet each child carry her poster home \nto show her family and friends. \n\nHang up other posters in the store, \nchurch, or other places where people \nwill see them. \n\n\nPictures can be made to stick to cloth and then used to tell a story. \nCover a board with a piece of flannel cloth or a soft blanket, to make a \n\nMix some flour and water to make \nglue. Then glue a strip of sandpaper to \nthe back of each picture. The sand- \npaper sticks to the cloth and lets you \nplace the picture where you want on \nthe cloth. \n\nLet the child use her pictures and \ncloth outside of the school, to show \nher story to family and friends. \n\n*For more ideas on flannel-boards, see pages 1 1-1 5 to 11-19 of Helping Health Workers Learn. \n\n\n\n\n\n\n\n27 \n\n\nFlip charts are excellent for telling a story with pictures. Often, people \ncan guess what the story is about just from the pictures. When showing \nthe pictures on a flip chart, ask as many questions as you can, to get the \npeople to tell you the story. \n\n\n\nThis is part of a flip chart presentation on \nmothers’ and children’s health. Notice the \nrings at the top that hold the flip chart \ntogether. They are made from old \nelectrical cords. \n\n\nHere a health worker from \nMozambique is holding a flip chart \nwith pictures about care of teeth \nand gums. There are no words with \nthe pictures. \n\n\nBut he can read a short message \nwritten on the back of the page \nbefore. There are also examples of \n\n\nquestions to ask. ^ \nThis way, anyone \nwho can read can \ntell the 'flip chart \nstory' to others. \n\n\n\nThere is also a \nsmall copy of the \nbig picture on the \nback of the page \nbefore. \n\n\n\nFind a way to attach the sheets of heavy paper. Here are two ways: \nwith 2 thin pieces of wood with metal or wire rings \n\n\n\n\n\n28 \n\n\nFLIP CHARTS-AN EXAMPLE \n\nDental workers in Mozambique created this flip \nchart presentation for teaching in schools. \n\n1 ) Here is a healthy, happy schoolboy. In the \ncircle you see the inside of his mouth. His \nteeth are white and clean. Look at his gums. \nWhat color are they? Are they tight or loose? \nBetween the teeth, are the gums pointed or \nflat? \n\n\n2) This is an unhappy, sick boy. What color are \nhis teeth? Not only are they yellow, there are \nblack spots. These are cavities. \n\nWhat color are his gums? Are they pointed? \n\nLoose, red, swollen gums are signs of gum \n\ndisease. \n\nBoth cavities and gum disease can be treated. \n\n3) What happens if tooth and gum \nproblems are not treated? \n\na) The black hole grows bigger on the \ntooth and a sore forms on the gums \nnear the root. The tooth hurts \nwhenever you touch it. \n\nb) The red, loose gums pull away frorp \nthe tooth. Infection gets to the bone \nand eats it. The tooth loses the bone \nand the gum around it. \n\nThe first problem is a tooth abscess. The second is advanced gum disease. \n\nIf either of these things happens, the tooth must be taken out. \n\n\n4) Why does the boy have cavities and gum \ndisease? There are 2 reasons. \n\na) He eats too many sweet foods. \n\nWhat foods do you see here? \n\nWhat other foods hurt the teeth? \n\nb) He does not clean his teeth regularly. \n\nThe germs in his mouth eat sugar from his \nfood and make acid. Acid causes both \ncavities and gum disease. \n\n\n\n\ne — e \n\n\n\ne — e \n\n\n\n\n\n\n\n\n29 \n\n\n5) What foods can the boy eat to keep his teeth \nand gums healthy? What do you see in this \npicture? \n\nNatural foods, with no sugar added, are the \nbest. The foods you grow yourself and local \nfoods from the market are better than sweet \nfoods from the store. \n\n\n6) How can we clean our teeth? Carefully is the \nimportant word to remember. Clean your \nteeth at least once a day, carefully brushing \nevery part of every tooth— outside, inside, \nand top. Be very careful to push your brush \nbetween your teeth. That is where the germs \nand food collect to make acid. \n\nIf you do not have a toothbrush, you can \nmake one from a stick. Toothpaste is not \nnecessary. Clean water is enough. \n\nChapter 12 in Helping Health Workers Learn is full of ideas on how to \nmake and use pictures effectively. Once you have a good original, you do \nnot need to be an artist to make a good copy. Here is an easy method that \ncan involve every student. \n\nPlace thin see-through paper over the original drawing. Carefully trace a \ncopy. \n\nNow place the copy on a new sheet of heavy paper. Pressing firmly with \na pencil, retrace all of the lines on the thin copy paper. \n\nRemove the \ntracing paper. \nPressure from the \npencil has made \nlines on the poster \npaper. Redraw \nthem with a \npencil so they \nstand out clearly. \n\nYour copy is now \nready for coloring. \nAnd you can use \nyour copy paper \nagain to make \nanother copy. \n\n\n\n\n\n\n\n30 \n\n\nUse puppet shows to aet out the messages \nof eating good food and keeping teeth clean. \n\nStudents can make their own £0 \n\npuppets to look like people or J \n\nanimals. \n\nUsing puppets, it is often easier ^ \n\nto say things that people them- \nselves cannot. For example, \nthey can talk openly about the \nbad food sold at the village store. \n\n\nMr. Lyam, you should \n\\ feel shame for selling \nr ^ T +ha+ kind . \n\nlot food/ \n\n\nChildren can make puppets easily from paper bags. They are good for \nshowing teeth because you can make a wide-open mouth. \n\n\n\n\nOpen and close your \nhand to make it \neat or speak. \n\nTo make a \nbigger puppet, \nattach a \n\ncardboard face^ g \nto the bag. G \n\n\n\nA puppet made from a sock looks \n\nalive. \n\n1. Fit the sock over your hand. \n\n2. Make the mouth by pushing in the \ncloth between your thumb and \nfingers. \n\n3. Add eyes, nose and hair to the \nsock or to a box that fits over it. \n\n\nLoosely fill a cloth bag with old cotton or paper. Put the end of a stick \ninside, and tie the bag to it with tape or string. Make a sad or happy face \nto fit the story. Dress the puppet with an old piece of cloth. \n\n\n\n\n\n\n\n32 \n\n\n\n4) One day later. \n\n(Note how the scene behind the \npuppets changes. It is a flipchart with \npictures to show the different places \nthe puppets 'go'.) \n\n\n5) \"I am a poor farmer/' Pedro's father \ntells Maria. \"I only go to the city two \ntimes a year to sell my crops. I cannot \ntake the boy to the city and pay for \nfillings in his teeth.\" \n\nMaria answers, \"But we can save his \nteeth with a temporary cement filling.\"* \n\n6) \"Then, when you have time and \nmoney, you can go to the city. I know \na dental worker who will put in a \npermanent filling. I trust him. I will \nsend a note with you, and it will not \ncost much.\" \n\n\"Good!\" says the father. \n\n\"Come on, Pedro,\" says Maria, \"I'll \nput some cement in those holes!\" \n\n7) Four months later, Pedro visits the \ndental worker in the city. \"Maria's \ngood fillings saved your teeth,\" he \nsays. \"These permanent fillings will \nlast for years.\" \n\n\"Terrific!\" says Pedro. \n\n8) After the show, the puppets played a \ngame. Throwing a ball into the \naudience, they asked questions like \n\"How do you keep cavities from \nhappening?\" Each child who caught \nthe ball answered the question and \nthrew it back. Then the children in \nthe audience began asking questions \nfor the puppets to answer. \"Why did \nyou get rotten teeth?\" one child asked \nPedro. The puppet looked down and \nsaid, \"Too much candy!\" \n\n\nTo learn how to make a temporary filling, see Chapter 10. \n\n\n31 \n\n\nPUPPET SHOWS-AN EXAMPLE* \n\n\n\nAbove, school children in Ajoya, Mexico are holding puppets they made \nthemselves. On the left, you see them in front of the stage and at right, the \nchildren show how they hold the puppets behind the stage. \n\n\n1 ) They called their puppet show \"Rotten \nTeeth— And A Friend's Advice.\" \n\n\n2) Pedro, a schoolboy, is sad. His friends \nlooked into his mouth and saw two \nteeth with big holes in them. He tells \nhis brother he wants to walk home \nalone. \n\n\n3) On the way, Pedro meets Maria, a \nfriend who is a dental worker. \"I'm \nnot sad because the others are \nlaughing,\" says Pedro. \"I know the \nreal problem. The holes in my teeth \nwill get bigger. My teeth will rot and \nfall out, and maybe my permanent \nteeth coming in will rot, too.\" \n\nMaria thinks she knows what to do. \n\"We will talk to your father,\" she says. \n\n\n\n\n\n\nFor another example of a puppet show, and more suggestions for making puppets, see pages 27-35 \nto 27-39 of Helping Health Workers Learn. \n\n\n33 \n\n\nCHAPTER \n\n\n\nSchool Activities for Learning \nAbout Teeth and Gums \n\n\nWe can help school children in two ways. First, they need treatment \nnow for problems they already have. Second, they need to learn how to \nprevent problems from hurting them (and their families) later. \n\nTreatment and prevention go together. It is a mistake to emphasize only \nprevention and to forget about treatment. In fact, early treatment is the \nfirst step to prevention because it usually meets a person's most strongly \nfelt, immediate need. \n\nAs a community dental worker, you can visit a school and find out \nwhat the felt needs are. Begin with the teacher. Examine for cavities, \nbleeding gums, or other problems. Then look at the students. \n\nChapter 6 tells you how to examine a person. It also helps you decide \nwhat treatment to give, and who should give it. \n\nThen teach how to prevent dental problems. Give the teacher ideas to \nhelp students learn why they have problems, and how to keep the \nproblems from returning. The best way to learn is by doing-through \nactivities, not lectures. This chapter has many suggestions for activities. \n\nThe best health practice is to prevent cavities and gum disease from \neven starting. With these activities, children can do something to guard \n\n\n\n\n\nA Note To Teachers: \n\n\nDo not wait for a dental worker. This book, and especially this chapter, \nis written to help you learn and do things yourself. But do ask your dental \nworker to work with you. He probably has suggestions that would fit your \nsituation. After examining the children, he can help you follow their \nprogress. You can then find out how much they are learning and how \nhealthy they are becoming. \n\nTo begin, talk with your students to find out what they think and \nwhat they already know. What are their traditional beliefs? Some may be \nhelpful, and others may need changing. At first it is best simply to discuss. \n\nAsk the kind of questions that get students talking. Later they will take \npart in discussions more easily. \n\nAdd new information as you go along, changing some ideas but usually \nbuilding upon what the students already know. \n\nThis chapter asks nine questions: \n\n1 . Why do we need teeth and gums? \n\n2. Why do some teeth look different? \n\n3. What holds the teeth? \n\n4. How often do teeth grow in? \n\n5. What makes teeth hurt? \n\n6. How do germs make holes in the teeth? \n\n7. What makes the gums feel sore? \n\n8. What does it mean if a tooth is loose? \n\n9. How can we prevent cavities and sore gums? \n\nFor each question, there is an activity to help students discover answers \nfor themselves. The questions are not in any particular order, nor are they \nwritten for any particular grade level. Make your own lesson plan, using \nthe main idea to help you. Shorten the lesson and make it easier for \nyounger children. Add more information for older students and let them \ndo more activities. \n\n\n\n\n35 \n\n\nWhy Do We Need Teeth and Gums? \n\nTHE IDEA: \n\nYour teeth and the gums around them help you in many ways. \n\nTeeth are important for: \n\nGood Health. Infection from a \nbad tooth can spread to other parts \nof your body. \n\nGood Looks. Healthy teeth that \nlook good help you feel good. \n\nGood Speech. Your tongue and \nlips touching the teeth help you \nmake many sounds. \n\nGood Eating. Your teeth break \nfood into small pieces so that you \ncan swallow and digest it better. \n\nGood Breath. If you leave food around your teeth, your breath will \nsmell bad. \n\nYour gums are important too. \n\nThey fit tightly around the teeth, and \nhelp to keep them strong. Without strong \ngums, your teeth are of no use. Most old \npeople lose teeth because of bad gums, \nnot bad teeth. \n\nTHE ACTIVITY: \n\n1 . Draw or cut pictures of people from magazines. Make posters to \nshow that healthy teeth make a person happy, while bad teeth make a \nperson sad. Use the posters for discussion. \n\nHang up a picture of a person the students \nknow and like. Put black on one of her front \nteeth. Talk about it. \n\nOR \n\nLeave the picture for a few days. Then put \nblack on some of her teeth before the \nstudents come to school. See who notices \nfirst. \n\nWhen someone sees the difference, talk about \nhow the person looks, how teeth can be lost, \nhow to prevent that, and what she can do now. \n\n\n\n\n\n36 \n\n\n\nMake a picture of a person who has lost all of his \nteeth. He looks old. \n\nTalk about how hard it is for him to eat properly \nor speak clearly. \n\n\n2. Have the students say words that use teeth to make sounds. \n\n\n\n\"v\" and \"f\" — friend, fever — the lower lip \ntouches the top teeth. \n\n\"th\" — the, teeth — the tongue touches the \ntop teeth. \n\n\"s\" — sun — air goes between the teeth. \n\nNow, try saying the same words again, but \ndo not let the tongue or lips touch the \nteeth. \n\n\n3. Have students draw pictures of good foods we use our teeth to eat. \nThen draw foods that we can eat if we lose our teeth. \n\nNeed Teeth No Teeth Needed \n\n\n\nMany More! \n\n\n\n\nBut NOT \nMuch More! \n\n\nTalk about this together. T ry to eat a mango or some maize without \nusing your teeth, or using only your front teeth. \n\n\n\n37 \n\n\nWhy Do Some Teeth Look Different? \n\nTHE IDEA: \n\n\nWe need two different kinds of teeth to help us eat our food. \n\n\n\nThe outside of a tooth is the hardest and strongest part of your body. \nWhen a tooth is healthy, it can chew hard food, even bone. The shape of \na tooth allows us to swallow food when the small pieces can slide down its \nsmooth sides. \n\nFood that is not \ncleaned away from \nthe grooves can make \na cavity (hole) in \nthem. \n\n_ A tooth with a cavity \n\nback teeth. v is weak and often \n\nhurts. \n\n\nSmall bits of food \noften get caught \ninside deep lines, or \ngrooves, in a tooth. \n\nLook for them on the \ntop and the sides of \n\n\n\n\n\n\n\n38 \n\n\nTHE ACTIVITY: \n\n1 . Ask the students to bring different kinds of food to class. Bring some \nyourself. \n\nWHICH TEETH DIO YOU USE | \n\nTO EAT THE MAN&O? \n\n\nEat the food using first the front and then \nthe back teeth. \n\nBite a guava using only the back teeth. \n\nChew completely a mango or piece of maize, \nusing only the front teeth. \n\n\n2. Collect teeth from different animals. Let the students discover from \nthe shape of an animal's teeth the kind of food it usually eats. For \ninstance, a wild cat needs sharp pointed teeth to tear meat, but a goat \n\n\n\n\nMake a poster to show the animal, its teeth, and the kind of food it \nlikes to eat. \n\n3. Have each student take a partner. Let each look at the shape of the \nfront and back teeth in the other's mouth. \n\nTalk about the many different kinds of food we need to stay healthy. \nDiscuss which teeth we use to chew meat, fish, mango, and other good \nfoods in your area. (For most foods, the answer is both front and back \nteeth I ) \n\n\n\n\nWhat Holds the Teeth? \n\nTHE IDEA: \n\n\n39 \n\n\nWhen you look inside someone's mouth, you see only the top part of \neach tooth. The bottom part, its root, is inside the bone under the gum. \n\n\n\nfibers connect the \n\n\nThe roots of the \ntooth hold it in \nthe bone just \nlike the roots of \na tree hold it \nfirmly in the \nground. \n\nThe roots of the \ntooth do not \nactually touch \nthe bone. Root \nroot and bone, holding the tooth in place. \n\n\n\nbone \n\n\nroot \n\n\nroot \n\nfibers \n\n\nThe gums do not hold the teeth, but healthy gums will keep harmful \ngerms from getting to the bone and root fibers. When the gums are not \nhealthy, they form deep 'pockets' which collect germs. Soon, these germs \nwill reach the root fibers and bone. The bone pulls away from the tooth \nin order to get away from the germs. With no bone to hold it, the tooth is \nlost. This is the most common reason why teeth fall out. \n\n\nTHE ACTIVITY: \n\n1. Have the students look for \nan old jaw bone from a dog or \nother animal. Notice that bone \ngoes around every root of every \ntooth and holds it tightly. \n\nBreak away some of the bone \nand look at the roots of the \nteeth. \n\n\n\n\nFront teeth need only one root \nbecause they are used for biting. \n\nBack teeth have 2, 3, or even 4 \nroots. That makes them strong \nenough to chew tough meat and \neven break hard bone. \n\n\n40 \n\n\n2. Show your students how infected gums can cause teeth to fall out. \n\n\n\n\nA. When gum disease is beginning, a small red ‘pocket’ forms where the tooth meets \nthe gum. Germs and food collect in the gum and make acid. This makes the gums sore. \nB. As a result, the gum pulls away and the pocket becomes deeper. C. The bone moves \naway from the infection and no longer holds the tooth. \n\n\nTry to think of other ways to teach how gum disease pushes the bone \naway from the tooth. In Jamaica, dental workers ask, \"What do you do if \nsomeone attacks you with a machete (long knife)?\" \"I run away!\" most \npeople answer. \"Exactly,\" say the dental workers, \"and when you have a \nlot of germs attacking the root of your tooth, the bone 'runs away' and \nleaves the tooth with nothing to hold it.\" \n\nTell a story to show how, when the gum moves away from the top of \nthe tooth, the root and bone are open to attack. For example: \n\n\n\nEnrique was sleeping on a cold night when suddenly he had diarrhea. \nStill dreaming, he went outside, and afterward, he forgot to close his pants \ntightly. Suddenly, he saw an ugly monster coming after him! He ran away \nwithout thinking of his pants. Finally he could not run because his pants \nwere around his knees, and the monster caught him. \n\nExplain to the children that when the gums are red near a tooth, they \nare like Enrique's pants— not tight enough around the tooth. When germs \ncome near the tooth, they will go inside and the gums will 'fall down' and \nshow part of the root of the tooth. When this happens, the germs attack \nnot only the top of the tooth, but also the bone and root. \n\n\n\n41 \n\n\nHow Often Do Teeth Grow In? \n\nTHE IDEA: \n\nA child gets two sets of teeth. The first set, baby teeth, starts to grow \nwhen the child is a baby. The second and last set grows in at school age. \nThey are the permanent teeth. Permanent teeth should last a lifetime. \n\nA child grows his first baby tooth at about 7 \nmonths of age. It is usually a front one. \n\nA baby who is poorly nourished, however, may \nnot grow his first tooth until later. Do not wait for \nthe first tooth before giving him the extra soft food \nhe needs to grow and stay healthy. \n\nThe remaining baby teeth grow in over the next 24 \nmonths. By the time the child is 30 months old, \nthere will be a total of 20 baby teeth in his mouth, \n\n10 on top and 10 on the bottom. \n\nMost permanent teeth form under the baby teeth. When the child is \nbetween 6 and 12 years old, the permanent teeth push against the roots of \nthe baby teeth, making them fall out. Not all of the baby teeth fall out \nat once. One tooth at a time becomes loose, falls out, and then is replaced \nwith a permanent tooth. The new tooth may not grow in immediately. \nSometimes 2 or 3 months pass before the new tooth grows into the space. \n\nIn the 6 years between ages 6 and 12, the 20 permanent teeth replace \nthe 20 baby teeth. In addition, 8 other teeth grow in behind the baby \n\nAt 6 years the four 1st permanent \nmolars start to grow in at the back \nof the mouth. This means an 8-year- \nold child should have 24 teeth, or \nspaces for them. \n\nAt 12 years, the four 2nd permanent \nmolars grow in behind the 1st \nmolars. This means a 14-year-old \nchild should have 28 teeth, or \nspaces for them. \n\nBetween 16 and 22 years, the four \n3rd permanent molars grow in. This \nmeans that an adult should have a \ntotal of 32 permanent teeth: 16 on \ntop and 16 on the bottom.* \n\n\nteeth. \n\n\n\n\n— 2*4 tAOLAR. \n\n\nKOIAR \n\n\n\n*(Note: the third molars often do not grow in correctly. This is a very common cause of tooth \npain. See page 64. \n\n\n\n\n42 \n\n\nTHE ACTIVITY: \n\nHave the students examine each other.* Help them learn which are \nbaby teeth and which are permanent teeth. Look for the important 1st \npermanent molars at the back. \n\nShow the students \nhow to count the \nteeth and the spaces \nthat are ready for \nnew teeth to grow \nin. \n\nThen have them \ncount their friends' \nteeth, to find out \n\nhow many teeth should be growing in different age groups. Later, they \ncan do this with their brothers and sisters at home. \n\n• Wash your hands. \n\n• Count the teeth. \n\n• Count the spaces where new teeth have not yet grown in. \n\nTOTAL = teeth + spaces \n\n• Find out the person's age. \n\n\n\nHave the students first write their totals on the blackboard. Then make \na chart for the children to remember and discuss the results. \n\n\n\nHere the children are only counting the teeth. They can also learn to check for cavities and gum \ndisease {see p. 47). \n\n\n\n\n43 \n\n\nDiscuss the number of teeth children have at different ages. Young \nchildren 6 to 12 years old, for example, have 24 teeth; older students, 28 \nteeth; and adults, 32 teeth. \n\n\nAt home, students can count brothers' and sisters' teeth to learn how \nmany teeth small children have. Count only the teeth and not the spaces. \n\n\nTccfti in Ol. •Sma.II C. ki/ai \n\n\nDeb o/‘ \n(broiler) \n\nunder 1 y ea> \n\n1-2 years old \n\n2-T years old \n\n/? \n\n\n\n^(Sister) \n\n\ni t i J J 1 / \n\n/ Ik \nnin / lo \n\n\nC kc, A * a. \n\nQ (6 rY\\o*rhs ) \n\ncid )/ \n\nVo \n\n\n\nW.c.ha.d'i \n\nccoulsj rJ \n\n\n\n///// ///// ., \n\n/ t t / \n\n/do \n\n\nAsk the students what other things they saw inside someone else's \nmouth. This is a good time for students to discover important things about \ngood health practices. Encourage them to learn as much as they can from \nwhat they see, and then show them how to use a book like this to answer \ntheir own questions. For example, if students see cavities and red bleeding \ngums, you can start a discussion on tooth decay and gum disease. Use \nsome of the activities on pages 53 to 58. \n\nFor another example, if the students see a baby who has only a few \nteeth, they may have some interesting questions. Show them this book \nand invite them to read pages 61 to 63 to find answers to questions like \nthese: \n\n• Can Chenia, who is six months old and has no teeth, eat soft foods? \nShould she have more than just breast milk? \n\n• When Chenia’s teeth grow in, will they give her diarrhea and fever? \n\n• Will a 2-year-old girl get more baby teeth? \n\n• Why do we care for baby teeth, when we only need them for a few \nyears? \n\n\n\n\n44 \n\n\nWhat Makes Teeth Hurt? \n\nTHE IDEA: \n\n\nA tooth will hurt if it is broken, loose, or if it has a cavity. Cavities are \nthe usual cause of toothaches. \n\n\nHealthy teeth are alive. \n\n\nTwo thin strings enter each tooth. One, the nerve, comes from the brain \nand carries the message of pain. The other is the blood vessel. It comes \nfrom the heart and carries blood to the tooth. \n\n\nIf you could peel away the \ngum and look inside the bone, \nyou would see that a nerve \nand a blood vessel go into \neach one of a tooth's roots. \n\nThey give the tooth life \nand feeling. \n\n\n\nThe hard cover of the tooth protects the nerve and blood vessel inside \nit. But when tooth decay eats through that cover, the nerve and blood \nvessel are unprotected. A cavity lets food, water and air get closer to the \nnerve, and that can make the tooth hurt. \n\n\nThe sugar in food makes tooth decay possible. Sweet food that is also \nsticky is the worst of all because it glues itself to the teeth. Germs inside \nyour mouth use the sugar to grow and to work harder at making cavities. \n\n\n\nSee the next section for more discussion of how germs and sugar \ncombine to cause cavities. \n\n\n\n\n45 \n\n\nA cavity may look small on the outside, but it is much bigger inside. \nDecay spreads more easily in the soft part under the hard cover of the \ntooth. \n\nA tooth with a cavity may hurt, but it usually does not-hurt all the \ntime. This is because the bottom of the cavity is close, but not yet on \n\n\n\nA small cavity that is not treated grows bigger and gets deeper. When \nthe cavity finally touches the nerve, it causes a tooth abscess. Infection \nfrom the tooth decay going inside the tooth causes the tooth to ache all \nthe time, even when you try to sleep. \n\nInfection can pass from the tooth to the bone. As it spreads under the \nskin, there will be swelling of your face. \n\n\n\nA tooth with an abscess must either be taken out \nor have its nerve treated. \n\n\nAn abscessed tooth is dying. When it dies the tooth changes color from \nwhite to dark yellow, grey, or even black. Pus from the end of its root can \npass to the gum, making a sore called a gum bubble. \n\nA tooth is like a light bulb. \n\nWhen the bulb is alive from power inside, it \nis bright and useful. \n\nThe little wires inside the bulb are like the \nnerves inside the tooth. When the bulb burns \nout, it is dark and not useful any more. \n\n\n\n\n\n\n\n\n\n\n\n\n\n47 \n\n\n' 3. Look inside a tooth for the space where the nerve and blood vessel \nused to be. See how close they were to the tooth's hard outer cover. Look \nfor a small hole at the end of the root. That is the place where the nerve \nand blood vessel enter the tooth. \n\nAsk your dental worker to find an old \ntooth with a cavity and grind it for you. \n\nOR \n\n1 . Take a hammer. \n\n2. Gently break open a tooth. \n\n3. Look inside. \n\nSee how much bigger the cavity is on \nthe inside. It spreads under the hard \ncover. \n\nCut through a rotten yam. See how \nthe rotten part spreads under its skin \nin the same way. \n\n4. Do a project in class. \n\n• Count the number of students with cavities. \n\n• Count the number of teeth having cavities. Show the students how \nto look for them on the tops, sides and between the teeth. \n\n• Find out the person's age. \n\n\n\nHave the students write on the blackboard what they counted. Then \nmake a chart or graph. \n\n\n\n• Decide if tooth decay is a serious problem in your school. Ask your \ndental worker to look at your results and to come and treat the \nstudents, and help you prevent the problem from returning. \n\n• Do the same with brothers and sisters at home. Find out if tooth \ndecay is a problem with these young children. Tell your dental \nworker what you find. \n\n\n\n48 \n\n\nHow Do Germs Make Holes in the Teeth? \n\nTHE IDEA: \n\nAcid makes holes in the teeth. The acid is made when sweet foods mix \nwith germs in your mouth. \n\nIt is not possible to prevent cavities or gum problems by trying to kill \nall of the germs in your mouth. There are too many— and some germs are \ngood for you. The important thing is to keep the germs from getting \ntogether and making a film or coating on your teeth. \n\nThis film on the teeth is called plaque, but you do not need to use this \nword. Every morning we can all feel a 'furry film' on our teeth. This film \nmust not be allowed to stay on the teeth! It will mix with sugar and make \nacid. Worse, if it stays in a group (or 'colony') for more than 24 hours, it \nwill mix with saliva, harden, and make tartar (see page 50). \n\nThe main reason for cleaning teeth is to break up these colonies so they \ncannot make acid. Also, if you forget to clean your teeth, tartar will form, \nand you will need a dental worker to scrape it off. This is why it is \nimportant to clean your teeth at least every 24 hours, so the tartar can \nnever form on your teeth. \n\n\nTHE ACTIVITY: \n\n\nHere is a game called \"Scatter!\" that students can play outside. \nYou need: \n\n\n\n\n\n\nFive 'bases' (a tree, rock, or \nthe corner of a house can be \na base) in a half circle, 1 2 \nmeters apart. Each base \nmust have a 'monitor' who \nstays at the base. Note: \nchildren who cannot run \ncan be good monitors. \n\nOne person with a broom. \nThis person is the \n'decolonizer'. \n\nThe Game: \n\n\n\nChildren in Jocuixtita, Mexico, beginning a \ngame of “Scatter!.” The 'decolonizer’ is the \ngirl in the center with the broom. \n\n\n20 students called \n'colonizers' stand facing the \n\ndecolonizer. When the decolonizer says \"go!\" they try to 'form colonies' \naround the bases before the decolonizer can touch them with the broom. \n\n\n49 \n\n\n\nThe ‘decolonizer' (with broom) has lost the \ngame. The children behind him have formed \na ‘colony’. \n\n\n\nHere the decolonizer stops a boy from \ncompleting a chain. \n\n\nAfter The Game: \n\nTalk to the students about \ngerms in their mouths and how \nsmall they are. Can anyone see \ngerms? No, but they can feel \nthem and taste them. Ask the \ngroup what their mouths feel \nlike in the morning when they \nwake up. You may get these \nanswers: \n\n• my teeth feel mossy! \n\n• my breath is bad. \n\n• I feel a coating on my teeth, \nbut it goes away when I \nbrush them. \n\n\nThe colonizers win if they make \na colony. There are two kinds of \ncolony: (1) 1 5 people touching \none monitor at a base, or (2) a \nchain of 12 people holding \nhands, touching two monitors. \n\nPlay two games: one with \nchildren trying to form the first \nkind of colony, one with the \nsecond kind. These photos are \nfrom the second game. \n\nThe decolonizer tries to stop \nthe others by touching them \nwith the broom. When the \ndecolonizer touches a colonizer \nwith the broom, the colonizer \nmust leave the area for one \nminute. (Give that child a task \nto do— run around the school- \nhouse or lie down and sit up \n30 times.) \n\nThe decolonizer wins if no \ncolonies form in 5 minutes. \n\n\n\nTo teach about things too small to see, look at \nthe suggestion on page 11-29 of Helping Health \nWorkers Learn. \n\n\nTell the students that this coating on the teeth is a 'colony' of germs. \nThey are always trying to group together on the teeth or in spaces between \nthe teeth— just as the 'colonizers' did in the game! \n\n\n\n\n50 \n\n\nWhat Makes the Gums Feel Sore? \n\nTHE IDEA: \n\nHealthy gums fit tightly around the teeth and help to hold them \nstrongly. Healthy gums also cover and protect the bone under them. \n\nHealthy gums are pink in color, or \n\neven blue or dark yellow in some \npeople. But healthy gums are never \nred. \n\nHealthy gums are pointed between \nthe teeth. This lets food slide away \nand be swallowed. \n\nHealthy gums fold under, making a \nlittle pocket around the tooth. \n\nAs we saw with the last activity (p. 48), when you have 'colonies' of \ngerms on your teeth, they can make acid that makes holes on your teeth. \nThe same coating of germs can make a different acid that makes the gums \nsore. This also happens when food mixes with the coating on your teeth. \nSoft food is the worst kind, because when it mixes with spit it sticks more \nand stays longer on your teeth. Juice from tea, betel nut, and meat color \nthis food, making the tooth look dark. \n\n\nHealthy gums become sore because of acid. Also, if the coating on the \nteeth (p. 48) becomes hard, it is called tartar. Tartar can be very sharp \nand hurt the gums. Also, the 'colonies' of germs can make a coating on \ntop of tartar more easily than on a clean tooth. When the colonies are \nnew, they make more acid to cause tooth and gum problems. After 24 \nhours, they harden and make a new layer of tartar. The tartar gets bigger \nand bigger. \n\nSore gums are infected. \n\nInfected gums are red \nand bleed easily. \n\nInfected gums are \nround and swollen \nbetween the teeth. \n\nThey are also loose \ninstead of tight against \nthe teeth. \n\n\nHere is a larger picture of the teeth in the box above: \n\n\n\n\n\n\nInfected gums have a deep gum pocket which catches even more food. \n\n\n\n\n51 \n\n\nInfection in the gums is called gum disease. It is important to treat gum \ndisease early, before it can spread to the root fibers and the bone. \n\nIf you have sore, bleeding \ngums, you can do much to \ntreat the infection yourself. \n\n1 . Clean your teeth with a \nsoft brush gently and more \noften, (see page 69) \n\n2. Eat more fresh fruits and \nvegetables. \n\n3. Rinse your mouth with \nwarm salt water. \n\n4. Clean between your teeth \nwith dental floss or string. \nAt first your gums may \nbleed when you do this. \nBut when the gums are \nstronger the bleeding will \nstop. \n\nTHE ACTIVITY: \n\n1 . Have the students look in each other's mouths. \n\nCan they see the coating on the teeth? Usually they \ncannot. They may see food or 'white stuff', but \nthis is not the coating that makes acid. However, if \nsomeone has been chewing betel nut or eating \nberries, you will see stains on her teeth and the \nstains will be darkest where she has these colonies \nof germs on her teeth. \n\nPut something on the teeth to stain the colonies of germs. T ry using \nfood dye, betel nut or berry juices. Remember: first wash your hands! \nOlder students can rub berries on the teeth of the younger ones. Have \nthem rinse with a little water and spit it out. After this, the colored areas \non the teeth will show where the colonies of germs are forming. Where \nare they? Usually you will see the dark colors: \n\n• between the teeth \n\n• in the pits or holes in the teeth \n\n• on the tops (biting surfaces) of the teeth. \n\nThe older students can now show the younger ones the best way to \nclean teeth (see pages 67-70). Let the younger ones see in the mirror if \nthey are getting the colored juice from their teeth. They will learn that it \nis most difficult to get rid of the color between their teeth. Give them \nsome string, dental floss, or even the soft stem from a young palm leaf, \nand show them how to use it between their teeth (p. 70). Remind them to \nbe gentle, or they will hurt their gums. You should clean between your \nteeth every day. \n\n\n\n\n52 \n\n\nWhat Does It Mean if a Tooth is Loose? \n\n\nTHE IDEA: \n\nBaby teeth become loose when children are between 6 and 12 years old. \nThis is normal. If a loose baby tooth does not have a cavity, and if the \ngums around it are healthy, there is probably a permanent tooth growing \nunder it. \n\nBut a tooth might be loose because it is broken or because it is sick \nfrom an abscess or gum disease. Either can destroy the bone around the \ntooth's roots. \n\nWhen bone is lost, the tooth \nbecomes loose. A loose tooth hurts \nand usually must be taken out. \n\nThere is no medicine to make bone \ngrow back around the roots of loose \nteeth. All you can do is stop the \ninfection from getting worse. \n\n\n\nTHE ACTIVITY: \n\n\n1. Let the students look into each other's mouth for loose baby teeth. \n\n\nLook carefully to see why a tooth is loose. \n\nTouch the gum and bone beside the \nloose tooth. You can feel a bump— it is \nthe new permanent tooth growing. \n\nSave the baby tooth after it has fallen \nout. Look to see how the permanent \ntooth has eaten away its root by pushing \nagainst it. \n\n2. Look for teeth that have cavities or \ngum disease around them. The students \n\n\n\ncan do this with each other, and then \nlater at home. (Remember they must \nwash their hands!) \n\nA tooth that has some of its root \nshowing is probably loose. \n\nUsing your fingers or the handles \nof two spoons, rock the tooth back \nand forth gently. See how much it \nmoves, and ask how much it hurts. \n\nTell the person what he can do to \nprevent other teeth from becoming \nloose. (See the next section.) \n\n\n\n53 \n\n\nHow Can We Prevent Cavities and Sore Gums? \n\nEating good food and carefully cleaning the teeth prevents both tooth \ndecay and gum disease. \n\n\nFood from your own garden and local food from the market is best. \n\nThese foods are good for your body, your teeth, and your gums. \n\n\n\nVegetables, especially Peas and beans, like green Oil, from palm nut \n\nthose with dark green beans, soybeans, winged kernels, ground nuts, \n\nleaves. beans, and mung beans. and coconut. \n\n\n\nFruits, like banana, \nguava, oranges, and \npapaya. \n\n\n\nFish, meat and eggs. \n\n\nClean water, coconut \nwater, and milk are \n\nbest to drink. \n\n\n\nSoft foods and sweet foods from \nthe store are not good for you. Soft \nfoods stick to your teeth easily. They \ncan work longer to cause cavities and \ninfected gums. Sweet foods have \nmostly sugar in them, and it is 'factory \nsugar', not the 'natural sugar' that is \nin the foods in the pictures above. \n\nThis kind of sugar is quick to mix with \ngerms and make acid. Remember: \nnatural sugar makes acid slowly; \nfactory sugar makes acid quickly. \n\nChildren who eat a lot of sugar lose \ntheir appetite for other foods— the \nfoods that help them grow strong, \nstay healthy, and learn well in school. \n\nStore foods are also expensive. You \ncan usually get ‘better food, and more \nof it for the same money, from your \ngarden or in the market. \n\n\n\n54 \n\n\nCleaning your teeth carefully every day is another important way to \ntake care of both teeth and gums. However, cleaning teeth is like building \na house. To do a good job, you need to work slowly and carefully. Once a \nday is enough, if you clean your teeth well every day. \n\n\n\nBuy a brush from the store, or make one yourself (see p. 4). But be sure \nthe cleaning end of the brush is soft so that it won't hurt the gums. \n\n\n\nUse your brush to clean all the teeth, especially the back ones with the \ngrooves. Back teeth are harder to reach and so it is easy not to clean them \nwell enough. Cavities start from sweet food and germs left together inside \nthe grooves. \n\n\n1 . Scrub the inside, \noutside, and top \nof each tooth. \n\n2. Push the hairs of \nyour brush between \ntwo teeth. Sweep \nthe food away. \n\n3. Wash your mouth \nwith water, to \nremove any loose \nbits of food. \n\n\nSmall children are not able to clean their teeth carefully enough by \nthemselves. They need help. Look at the pictures on the cover and p. 16 to \n\nsee how you can do this. Older children can care for younger brothers and \nsisters at home. \n\n\n\n\n\n\n\n55 \n\n\nTHE ACTIVITY : \n\nOne of the best ways to teach is by example. \n\n\n/AND SO AT HOME WE' \n\nPUT BOTH DRIED FISH \nAND OREEN LEAVES \nINTO THE SOUP. MY \nI JchilDREN UK.E IT VERY] \n\\MUCH. YOU WILL TOO / , \n\n\n\nStudents will believe what \ntheir teacher says if they \nknow he eats good food and \ncleans his teeth. \n\nThe reverse is also true. \nLearning is harder when \nstudents know that their \nteacher does not do those \nthings himself. \n\n\nStudents can be a good example for their community, too. They can: \n\n* draw pictures of foods that are both good and bad for teeth. Use \nthem to make posters and flannel-board stories. \n\n* make puppets and plays to discuss ways people can become healthier. \n\n\nThere are some other ways to make learning meaningful and fun. \n\n\n1. Make a garden at school. Divide the ground so that each class has its \nown space to plant a garden. \n\nUse some of the garden's food to prepare a meal for the students, \nperhaps once a week. Students can bring food from home if there is not \nenough ready in the garden. \n\n2. Organize a school lunch program. Each day the students can bring \nsome good food from home. Cooked yams, or maize, nuts, fruit and \nfresh vegetables are all good. Often the students will exchange food \nand talk about the many different foods that can be grown locally. \n\n\n56 \n\n\n3. Find the best way to clean teeth. Divide the class into groups. They \nwill learn more easily in a small group of 4 to 8 students. \n\nGive all the students something to eat that is sweet, sticky and dark in \ncolor, such as sweet chocolate biscuits. Ask the students to look in each \nother's mouth, to see how easily the biscuit sticks to the teeth. One or \ntwo of the students in a group can then try to clean away the pieces of \nbiscuit, using a different method. \n\n\n\nWhen they are finished, the students can look at the teeth to decide if \nthey are clean or not. Put your findings on a chart and talk about what \nyou have learned. \n\n\n\n\n\n57 \n\n\n4. Make cleaning part of a daily health activity. \n\nOlder students can look after younger students. They can first check \ntheir hair for lice, then sores for infection, and teeth for old food or \ngerms. (To see the coating of germs on the teeth, try the activity on page \n51 .) One partner can point out to the other where washing and brushing \ncan be done better. \n\n\n\nCLEANLINESS CAN BEGIN AT SCHOOL \n\n\nAt school, students can wash their hands before lunch and brush their \nteeth afterward. Encourage them to keep a piece of soap and a toothbrush \nor brushstick (p. 4). One day a week, the whole class can rinse with \nfluoride water (p. 167) to prevent cavities. \n\n\n\nThe student \ncan keep the \nbrush at her \nown desk . . . \n\n\n. . . or on a \nrack at the \nback of the \nroom. \n\n\n\n58 \n\n\nHave the students score each other's progress. Do not make it hard to \njudge, or they will not do it. In the example below, the tooth is either \nclean or not clean. \n\n\n\nPick 4 teeth, a back tooth \nand a front tooth— two on \ntop and two on the bottom. \n\nUse the same 4 teeth for \neach person. Look for food \non each tooth near the gums. \n\nA clean tooth = 2 points \nA dirty tooth = 0 point \nTotal possible points each \nday is 4 teeth x 2 = 8 points. \n\nIn this example the score is: \nTooth 1 = 2 points \nTooth 2 = 0 point \nTooth 3 = 0 point \nTooth 4 = 2 points \n\nTotal = 4 points \n\n\nHave each student put his daily score on a chart. At the end of the \nmonth he can see how much he has improved. \n\n\n\n\n\nTaking Care of \nTeeth and Gums \n\n\nCHAPTER \n\n\n59 \n\n\nWe can prevent most tooth and gum problems. This chapter gives more \ninformation about how teeth grow in and how to keep teeth and gums \nhealthy. Share this information and you will prevent problems from \nstarting. \n\nBut remember that people are most interested in the problems they \nhave now. Before listening to what you know about prevention, people \nwill want treatment for the problems that are already causing them pain \nand discomfort. \n\n\nEarly treatment is a form of prevention. \nIt can prevent a tooth or gum problem \nfrom becoming more serious. \n\n\nWhen you treat a person's problem, it shows that you care about him. \nIt also shows that you know what treatment he needs. As his confidence \nin you grows, he will want to learn from you about preventing tooth or \ngum problems. \n\n\n\nIn order to help a person \nit is important to know \nwhat the problem is and \nwhat is the best treatment. \nBut just as important is \nknowing what you are \nnot able to do, and when \nto seek help. \n\nIn this chapter, you \nwill learn more about \nteeth, gums, and problems \naffecting them, but \nyou must never be too \nproud to get help from \nmore experienced dental \nworkers. \n\n\nKNOW YOUR LIMITS. \n\n\n\n60 \n\n\nTAKING CARE OF BABY TEETH \n\n\nA child's baby teeth are being made before birth while the baby is still \ninside the mother's womb. During the last months of pregnancy and the \nfirst few months after the child is born, the baby teeth take their final \n\nform. Pregnant mothers and young children need good food and good \nhealth in order to have strong baby teeth. \n\nStrong teeth Weak teeth \n\nare white and their have yellow marks that \n\nfront surface is smooth. are pitted and rough. \n\n\n\nBaby teeth get marks on them when: 1 ) the pregnant mother is sick or \ndoes not eat good food; 2) the young baby is sick or does not eat good \nfood; or, sometimes, 3) the baby's birth was early or the delivery was \ndifficult. \n\nThe marks are rougher than the rest of \nthe tooth. Food sticks easily to them \nand turns the tooth yellow. \n\nThe marks are also soft. They need to be \ncleaned well every day (p. 61) to prevent \nthem from becoming cavities. A tooth with \na cavity hurts. When children’s teeth \nhurt, they do not want to eat as much. \n\n\n\nCavities in baby teeth can make a child's malnutrition worse. Remember \nthis whenever you see a weak, poorly nourished child. When you examine \na child at the health clinic, lift his lip and look at his teeth. Do this as part \nof your routine examination. \n\n\n\nYou can fill cavities with cement (Chapter \n10). Cement prevents food and air from \ngoing inside the cavity and hurting the \nchild. \n\nA sore on the gums may be a gum bubble. \n\nIf so, it means the tooth has an abscess \n(page 78). That cavity should not be \nfilled with cement. Instead, the tooth needs \nto be taken out (Chapter 1 1 ) before the \ninfection can get worse. \n\n\n\n61 \n\n\n\nFor baby teeth to grow strong, mother and baby must stay healthy.* \nHelp her to understand how important this is. A pregnant mother should: \n\n1. Eat enough good kinds of foods, both for herself and her baby \ngrowing inside (page 66; also see Where There Is No Doctor, Chapter \n1 1 , and Helping Health Workers Learn, pages 25-39 to 25-44.) \n\n2. Attend health clinic each month, so the health workers can examine \nher regularly and she can receive important medicines (see Where \nThere Is No Doctor, page 250). \n\n3. Not use the medicine tetracycline, because it can cause the teeth to \nturn dark. You, the health worker, must remember— do not give \ntetracycline to a pregnant woman or to a young child. If she needs \nan antibiotic, use a different one. \n\nFor baby teeth to stay strong, and to prevent marks from turning into \ncavities, mother should: \n\n1 . Continue to breast feed and never feed her child juice or sweet tea \nfrom a bottle. Start adding soft foods, mashed banana or papaya \nwhen the child is 4 months old. \n\n2. Wipe her baby's teeth with a clean cloth after \nthe baby eats. This cleans the baby's teeth, and \nhelps the baby get used to teeth cleaning. Later \nhe will be happy with a brush. \n\nAround 1 year of age, there will be several baby \nteeth. At that time, mother should start using water— \nnot toothpaste— on a soft brush or brushstick. (With \ntoothpaste, you cannot see the child's teeth clearly because of the bubbles \nit makes.) She should scrub the sides and tops of each baby tooth as well \nas she can (page 67). \n\n\n\nThe child can also try to clean his own teeth. That should be \nencouraged. However, since he is too young to clean properly, mother (or \nfather, or older brother, sister) must clean his teeth once a day for him. \nContinue helping in this way until the child is old enough to go to school. \n\n\n\nYou can make a large brush \nsmaller, to fit more easily into \na young child's mouth. \n\nPull out some of the back hairs, \nor cut them with scissors. \n\n\n‘See the story about pregnancy and dental care on pages 177-179. \n\n\n\n62 \n\n\nWhy Baby Teeth Are Important \n\nBaby teeth are just as important to children as permanent teeth are to \nadults. They help a child to eat, talk, and look good. \n\nHowever, many people feel that it is not worth the effort to look after \nbaby teeth. Nor is it worth fixing them. After all, parents think, the \npermanent teeth will take their place. \n\nThis kind of thinking is understandable. The problem is that we are \nforgetting one other useful purpose of baby teeth. Baby teeth keep space \nin the mouth for the permanent teeth to grow in. If there is not enough \nspace, the new teeth will grow in crooked, and cavities grow faster around \n\nUnder each baby tooth a new permanent \ntooth is growing. \n\nAt the same time, extra permanent \nmolars are forming at the back of the \nmouth, inside the bone (page 41). \n\nFront baby teeth become loose and fall \nout (usually 6-7 years, but sometimes as \nyoung as 5 years) ahead of back baby \nteeth (10-12 years). This is because the \nfront permanent teeth are formed and \n\nPermanent molars (PM) come in ready to grow in first. \n\nbehind the baby molars (BM). \n\nThe permanent molar (1 PM) is often the first of the permanent teeth to \ngrow into the mouth. That happens at 6 years of age. \n\n\nThe first permanent molar grows into Slowly but steadily the upper and \nthe mouth by sliding against the lower permanent molars grow until \n\nback of the second baby molar (2BM). they meet and fit tightly together. \n\n\n\n\n\n\n63 \n\n\nBetween the ages of 6 and 1 1 , a child needs healthy baby molars to \nguide the first permanent molars into position and then to hold them \nthere. When the first permanent molars grow into the right place, this is a \ngood sign. It means the other permanent teeth will also grow in properly, \nbecause they will have enough space. \n\nNote: Some people are born without enough space. But most people \nare not born with this problem— they lose the spaces when they \nremove baby teeth instead of fixing them. \n\n\nhelp \n\nHEALTHY BABY TEETH to make — ► STRAIGHT PERMANENT TEETH \n\n\n\n\n\n10 v ears adult \n\nTell mothers why baby teeth are important. Good food and regular \ncleaning keeps them healthy. They should know that new teeth coming \nin do not cause diarrhea and fever, but that a child may have diarrhea or \nfever at the same time. \n\nIf there is a cavity, fix it so the tooth can be kept in the mouth to do \nits important work (see Chapter 10). \n\n\n\n\n64 \n\n\nTAKING CARE OF MOLAR TEETH \n\nWe often notice front teeth growing in, but not the back ones. Back \nteeth— molars— are not so obvious. Swelling on the face can be either a \nnew molar growing in or an abscess. So, to help you to decide, look at \nthe tooth for a cavity and at the gums beside it for a gum bubble. \n\n\n\nBut if the person is young (16-22 years), it often is not an abscess. The \nthird permanent molar tooth may be growing in at the back of her mouth. \nAs the tooth grows, it cuts through the skin. Just as a dirty cut on a \nperson's hand can get infected, the cut gum around her new tooth also \ncan get infected, causing a swollen face. \n\n\nSee the red swollen skin on \n\nLook behind her back teeth. top of the new tooth. \n\n\n\nIf there is enough space for the tooth, it will grow in by itself It only \nneeds time. Before acting, decide how serious the problem is. \n\nIf there is no swelling and she can open her mouth, explain to her \nwhat is happening and what she can do herself to reduce infection and \ntoughen the gums. The best medicine is to rinse warm salt water over the \nsore area. A good home remedy is to rinse until the tooth grows all the \nway into the mouth. \n\nIf it does appear serious (severe pain, swelling, not able to open the \nmouth), see page 88 for further treatment. \n\n\n\n65 \n\n\nTAKING CARE OF ALL YOUR TEETH \n\nThis book often repeats an important message: eat good food and clean \nyour teeth. It is repeated because this is the most important thing you \ncan learn from this book. Later chapters will discuss what to do when \nproblems occur, but if you follow these two suggestions, you will almost \nnever have problems with your teeth and gums. This is true because good \nfood keeps your whole body healthy, including your teeth. Also, with no \n'colonies' of germs (page 48) or harmful factory sugar (p. 53) on your \nteeth, your mouth cannot make the acids that cause both tooth and gum \nproblems. So, remember: \n\n\n1. Eat Good Food \n\n\nAn easy-to-remember rule is the same foods that are good for the body \nare good for the teeth. A healthy body is the best protection against \ninfection. \n\n\n\nThe MAIN FOOD is \nat the center of \nevery meal. \n\n\nGood nutrition (eating well) means two things: \n\nOne, eat a mixture of different kinds of foods \nevery time you eat. Look at the pictures on page \n53. There are several groups of foods. Every time \nyou eat, try to eat one or two foods from each of \nthe groups. This way, you will get three important \nkinds of food: GROW FOOD (body-building food) \nto give you the protein you need; GLOW FOOD \n(protective food) to give you vitamins and \nminerals; and GO FOOD (concentrated energy \nfood) to give you calories to be active all day. \n\n\nTwo, be sure you eat enough food \nto give your body the energy it needs. \n\nThis is even more important than the \nfirst suggestion. We get half or more \nof our energy from our MAIN FOOD. \nIn most parts of the world, people eat \none low-cost energy food with almost \nevery meal. Depending on the area, \nthis MAIN FOOD may be rice, maize, \nmillet, wheat, cassava, potato, bread- \nfruit, or banana. The MAIN FOOD is \nthe central or 'super' food in the local \ndiet. \n\n\n\nA spoonful of cooking oil added to a \nchild’s food means he only has to eat \nabout % as much of the local main food \nin order to meet his energy needs. The \nadded oil helps make sure he gets enough \ncalories by the time his belly is full. \n\n\n\n66 \n\n\nGROW FOODS \n\n\n\n\n•** QjQT#* \n\n\n\n©i \n\n\n-m w~ \n\nS. \n\n*** ' ' '' ^ ^ \n\n\nBe sure \nalways to eat \nGROW FOODS \nand GLOW \nFOODS to get \nthe vitamins \nand protein \nyou need. \n\nYour energy \nfoods give \nyou the most \nimportant \npart of your \ndiet— calories. \nHalf or more \nof our \n\ncalories come \nfrom the MAIN \nFOOD, and \nmost of the \nother calories \ncome from GO \nFOODS. \n\n\n\nTHE MAIN \nFOODS ANt> \n'GO FOODS* I \nGIVE US THE | \nENERGY TO \nRuN,VJOfcK \nAND PLAY. \n\n\nWARNING ABOUT 'GO FOODS': Although GO FOOD gives us the energy \nwe need, some GO FOODS are worse than others. Honey, molasses and \nespecially white sugar can be very bad for the teeth, even though they \nhave the calories we need. Fruits, nuts, and oils all give us energy (calories) \nwithout attacking the teeth. \n\n\n\n\n2. Clean Your Teeth \n\n\nCleaning teeth requires time and care. If you hurry, you will leave food \nand germs behind, and they continue to make cavities and sore gums. \n\nYou may find that different dental workers recommend different ways \nof brushing teeth. Some ways are definitely better, but often they are \nharder to learn. \n\nTeach a method of cleaning that a person can learn and will do at \nhome. Let him start by scrubbing his teeth (and his children's teeth) back \nand forth, or round and round. Encourage him to improve his method \nonly when you think he is ready. \n\nToothpaste is not necessary. Some people use charcoal or salt instead. \nBut it is the brush hairs that do the cleaning, so water on the brush is \nenough. \n\nScrub the outside, inside, and top of each tooth carefully. \n\n\n\nWhen you finish, feel the tooth with your tongue to make sure it is \nsmooth and clean. \n\nFinally, push the hairs of the brush \nbetween the teeth and sweep away any bits \nof food caught there. Do this for both upper \nand lower teeth. \n\nSweep away in the direction the tooth \ngrows: sweep upper teeth down and lower \nteeth up. \n\n\n\n\n68 \n\n\nExplain how important it is to use a brush with soft hairs. A brush that \nis stiff and hard will hurt the gums, not help them. \n\nFft \n\n\nYES \n\nYou can make a hard brush softer by \nputting the hairs into hot water for a \nfew minutes. \n\nDo not put the plastic handle into the \nhot water, or it will melt. \n\n\nIf your store has only hard brushes, tell the storekeeper that hard \ntoothbrushes do not help the people in the community. Ask him to order \nand sell only soft toothbrushes. \n\n\n\n\nzzr \n\n71 \n\nj f ■ \n\nSOF \n\nT \n\nTooth \n\ns \n\n\n) \n\n\n\n\n) \n\n\nNote: Another important way to reduce cavities is by adding \n\nfluoride to teeth. Fluoride is a substance which, like calcium, \nmakes teeth harder and stronger. \n\nFluoride in drinking water, toothpaste, vitamins, and mouth rinses, \nhelps to prevent cavities. These methods are sometimes expensive. \nPerhaps the most effective and inexpensive method is the weekly \nrinse at school, described on page 1 67. \n\nFluoride can also be found naturally in food and water. For \nexample, tea leaves and most foods from the sea contain a large \namount of fluoride. \n\nSo, your source of fluoride can be either: \n\n\n\n\n\n\n69 \n\n\nCLEANING BETWEEN THE TEETH IS VERY IMPORTANT \n\nHere are three ways to clean between the teeth: \n\n1. Push the hairs of a toothbrush between the teeth, and sweep the bits \nof food away. \n\n\n2. Remove the stem from a palm leaf. Use the thinner end and move it \ngently in and out between the teeth. \n\n\n\n3. Use some thin but strong thread or string. String can be the best \nmethod of all— but you must be careful with it. \n\n\n\nBuy and use Dental Floss. \n\nGet some thin cotton rope This is a special kind of \n\nused for fishing nets. Unwind OR string for cleaning \n\nand use one strand of it. between the teeth. \n\nBe careful! The string can hurt your gums if you do not use it correctly. \nThe next page shows how to use the string, but the best way to learn how \nto 'floss' your teeth is to have someone show you. Ask a dental worker \nwho has experience. \n\n\n\n70 \n\n\nWrap the ends of the string around the middle finger of each hand. \n\n\n\nUse the thumb and finger to guide the string. Go back and forth to \nslide the string between two teeth. Be careful not to let it snap down and \n\n\n\nWith your fingers pull the string against the side of one tooth. Now \nmove the string up and down. Do not pull the string back and forth or \n\nit will cut the gum. \n\n\n\n\nLift the string over the pointed gum and clean the other tooth. \n\n\n\nWhen you have cleaned both teeth, release the string from one finger \nand pull it out from between the teeth. Then wrap it around your two \nmiddle fingers once again, and clean between the next two teeth. \n\n\nRemember: clean teeth and good food \nwill prevent almost all dental problems. \n\n\n\n\n\n71 \n\n\nExamination \nand Diagnosis \n\n\nCHAPTER ^ \n\n\n( ARE THE TEETH HEALTHY Q \n\nWhenever you do an examination, \nremember to examine the mouth. ahy sores \n\n\nYou can prevent much suffering and serious \nsickness when you notice and treat problems \nearly. Whenever you hold a health clinic, try \nto find out how healthy each person's mouth \nis. \n\nAsk if she is having a problem now, or has \nhad a problem recently. \n\nAlways write down what you find out, so you \nremember what treatment that person needs. \n\n1. Are the teeth healthy? \n\nLook for: \n\n\n\n\nWhen you look inside \nsomeone’s mouth, ask \nyourself three questions. \n\n\nTell the person what \nis happening and how \nto keep the skin \naround it healthy \n(page 64). \n\nThey may be \ncavities, which \nshould be filled \nwhen they are \nstill small \n(page 45). \n\n\nTell the person what \nis happening and how \nto prevent it from \ngetting worse or \naffecting other \nteeth (page 52). \n\n\n4. A Dark \nTooth \n\n\nA tooth that is dark is dead. \nInfection from its root can \ngo into the bone (p. 45). \nThis can make a sore on the \ngums (p. 72). \n\n\n\n\n\n\n\n72 \n\n\n2. Are the gums healthy? \n\n\nLook at page 50 and compare the pictures of healthy and unhealthy \ngums. Unhealthy gums often are red and they bleed when you touch them. \n\n\nA bubble on the gums below the tooth is a clear sign \nthat the person has an abscess. The abscess may be \nfrom the tooth, or it may be from the gums. To \ndecide, look carefully at both the tooth and the gum \naround it. \n\nA bubble beside a healthy tooth is a sign of infected \ngums. Scale the tooth carefully. See Chapter 8. \n\n\n\nA bubble beside a decayed tooth is a sign of a tooth \nabscess. See page 87. \n\nA sore on the gums from a badly decayed tooth \nappears when a gum bubble breaks open and lets out \nthe pus from inside. \n\n\nN \n\n\ni \n\n\nV \n\ni j \n\n\nGUM BUBBLE \n\n\n3. Are there any sores? \n\nLook for sores under the smooth skin on the inside of the lips and \ncheeks. Look also under the tongue and along its sides. \n\n\nA \n\n\n\n\n\nmBf ^ \n\n> AocA J \n\n\nt i \n\n1 . A sore on the gums \n\n2. Sores on the inside \n\n3. Sores on the lips \n\nmay be from an \n\nof the lip or cheek \n\nor tongue may be \n\ninfected tooth \n\nmay be from a virus \n\ncancer (p. 119). \n\n(p. 87). \n\n(p. 98). \n\n\n\nAfter your examination, tell the person what you have found. If you \nnotice a problem starting, explain what to do to prevent it from getting \nworse. If there are no problems and the mouth is healthy, congratulate \nthe person. \n\n\nShare your knowledge— explain things to people. \n\nHelp them learn how they can prevent and \neven manage their own problems with their teeth. \n\n\n\n\n\n73 \n\n\nWHERE TO EXAMINE \n\nExamine people in a light and bright place. It is dark inside a person's \nmouth, so you need light to see the teeth and gums. \n\nUse the sun. Examine outside, or inside a room facing the window. With \nsunlight alone, you will be able to see most places in the mouth well \nenough. If you cannot, set up a lamp or have someone hold a lamp for \nyou. Reflect the light off a small mouth mirror onto the tooth or gum. \n\nIf you have a low chair, lift up the person's chin so that you do not \nhave to bend over as far when you look into the mouth. An even better \nway is to have the person sit on some books. The person's head can lean \nback on a piece of cloth. \n\nUse an old chair with a strong back. \n\nAttach two flat sticks to the chair. Then tie a \nstrip of clean cloth to the sticks. Tie it strong \nenough to support the head, but loose enough \nto let the head lean back. \n\n\nTHE INSTRUMENTS YOU NEED \n\nThree instruments are really enough: \n\n\n1 . A wooden tongue blade to hold back the \ncheek, lips, and tongue. \n\n2. A small mirror to let you look more \nclosely at a tooth and the gums around it. \n\n3. A sharp probe to feel for cavities and to \ncheck for tartar under the gum. \n\nIf you have many people to examine, it is helpful to have more than one \nof each instrument. But be sure they are clean. \n\nDirty instruments easily can pass infection \nfrom one person to another. After you finish an \nexamination, clean your instruments in soap \nand water and then leave them in a germ-killing \nsolution like the ones described on page 85. \n\n\n\nC \n\n\nD \n\n\n\n\naBBSagjg \n\n\n\n\n74 \n\n\nA GOOD DIAGNOSIS \n\nYou are making a diagnosis when you decide what a person's problem \nis and what is causing it. To do this, you need information. You need to \nmake a careful examination to make a good diagnosis. \n\nLearn all you can about the person's problem: \n\n1 . Ask questions about the problem. \n\n2. Look at the person's face. Think about the \nperson's age. \n\n3. Examine the mouth more carefully than before. \n\n4. Touch the place that is sore. \n\n\n1. Ask the person about the problem. \n\nGive a sick person a chance to \ndescribe how he is feeling. \n\nListen. Think about what possibly is \nhappening in his mouth. \n\nYou may have an idea what the \nperson has. Now try to find out \nmore by asking questions: \n\n• What is the problem? Ask him to \n\ntalk about the pain, swelling, \nbleeding, or whatever he is feeling. \n\n• Where does it feel that way? See if he can put his finger on the tooth \nor place that is bothering him. \n\n• When do you have the most pain? Find out if it happens all the time \nor only some of the time. \n\n• When did it start? Find out if he has already had this problem before. \nAsk how he took care of it. \n\n• Have you had an accident or injury lately? Infection still inside the \nbone from an old injury in the mouth can make a sore on his face, \nor start swelling. \n\n• Are you having other problems? A head cold or fever can make the \nteeth hurt. \n\n• How old are you? Think about a new tooth coming into the mouth. \n\nAfter you hear the answers to your questions; decide if your original \nidea is the correct diagnosis. If not, try to think of another possibility and \nask more questions. This is the scientific method of making a diagnosis. \nFor a good explanation of scientific method, see Chapter 17 of Helping \nHealth Workers Learn. \n\n\n\n\n\n75 \n\n\nWhen you talk to a woman, find out if she is pregnant. A pregnant \nwoman's gums can easily become infected. The gums may bleed and she \nmay have more tooth decay. But this is not necessary. If a pregnant woman \ntakes extra care of her teeth and gums, she can prevent most dental \nproblems. But if she already has a problem, do not wait for the baby's \nbirth before you help her. You can treat a pregnant woman's mouth \nproblems now. In fact, this may be an important way of protecting her \nbaby as well. See pages 1 77-1 79. \n\n2. Look at the person. \n\nPeople have some problems more often at certain ages. When a person \nfirst comes in to see you, notice his age. Then, before you ask him to open \nhis mouth, look at his face for a sore or swollen area. \n\n\n\nCHILD \n\nSwelling can come from \n\n• mumps \n\n• an infection \nin the spit \ngland (p. 1 1 3) \n\n• a tooth abscess \n(p. 87) \n\n\nSWELLING \n\n\n\nYOUNG PERSON \nSwelling can come from \n\n• a new tooth \ngrowing in \n(p. 94) \n\n• a tooth abscess \n(P- 87) \n\n\n\nADULT \n\nSwelling can come from \n\n• a tooth abscess \n(P- 87) \n\n• a broken jaw \n(p. 107) \n\n• a tumor (p. 119) \n\n\n\nA SORE \n\n\n\n\\ \n\n\nini ' \\ \n\nwy ^ V/jKj \n\n% \n\nV (\\\\\\ jjj \n\n\n\npj y \n\nCHILD \n\nYOUNG PERSON \n\nADULT \n\nA sore can come from \n\nA sore can come from \n\nA sore can come from \n\n• impetigo \n\n• fever blisters \n\n• a tooth abscess \n\n• Vincent’s \n\n(P- 98) \n\n(p. 87) \n\nInfection \n\n• a tooth abscess \n\n• a bone infection \n\n(P- 96) \n\n(P- 87) \n\n(osteomyelitis) \n\n\n\n\n\n76 \n\n\n3. Examine inside the mouth. \n\n\nRemember what the person said, the person's age, and what you saw. \nNow look more closely at the problem area. \n\n\n\nLook at the teeth: \n\n• Is a new one growing in? \n\n• Is a tooth loose? \n\n• Is there a dark (dead) tooth? \n\nLook at the gums: \n\n• Are they red? \n\n• Is there any swelling? \n\n• Do they bleed? \n\n• Are the gums eaten away between the teeth? \n\n\nLook also for sores on the inside of the cheek or lips, and on the tongue. \n\n\n4. Touch the sore place. \n\nTouching is a good way to find out how serious the problem is. This \nwill help you decide which treatment to give. \n\nPush gently against each tooth in the area of pain to see if a tooth is \nloose. Rock the loose tooth backward and forward between your fingers, \nto see if it hurts when you move it. \n\n\n\nUsing the end of \nyour mirror, tap \nagainst several \nteeth, including \nthe one you \nsuspect. \n\nThere is probably \nan abscess on a \ntooth that hurts \nwhen you tap it. \n\n\n\nPress against the gums with cotton gauze. Wait a moment, and then \nlook closely to see if they start bleeding. Then use your probe gently to \nfeel under the gum for tartar. Carefully scrape some away. Wait and look \nagain to see if the gums bleed. When gums bleed, it is a sign of gum disease. \n\n\n\n\n77 \n\n\nLEARN TO TELL SIMILAR PROBLEMS APART \n\n\nIf a person comes to you with a toothache or a \nsore or a loose tooth, there are many possible \ncauses for each problem. The first thing you \nnotice— the toothache, sore or loose tooth— is your \nfirst step to a diagnosis. To this you must add more \ninformation before you can point to the most \nprobable cause. \n\nPut together what you have found with what \nyou already know about teeth and gums. You can \nmake a good diagnosis of a problem without \nknowing a special name for it. \n\nUsually it is easy to make a diagnosis. However, \nsometimes you will not be sure, and these are the \ntimes to seek the advice of a more experienced dental worker. Never \npretend to know something you do not. Only treat problems that you \nare sure about and have supplies to treat properly. See Where There Is No \nDoctor, p. w4. \n\nUse the charts beginning here to help you make the diagnosis. For more \npractice using charts to tell problems apart, see Chapter 21 of Helping \nHealth Workers Learn. \n\n\n\nIF THE PERSON AND YOU FIND OUT \n\nHAS THAT \n\nHE/SHE MAY \nHAVE \n\nSEE \n\nPAGE \n\n* It hurts only after eating * . \n\nor drinking. There is a / cT^< \n\ncavity, but the tooth does t /v A \n\nnot hurt when you tap it. ~ \n\n♦ \n\na cavity \n\n— f — \n86 \n\nPart of the filling has fallen \n\nout, or is cracked and ready XtovWr ^ \n\nto fall out. Eating and \n\ndrinking make the tooth hurt. \n\na cavity under \nan old filling \n\n86 \n\nA TOOTHACHE y he t00t j 1 hurts when chewing \n\n^ food, it may hurt when tapped, \\ A_ J \n\nSy i * 3Ut there > s cavity and \n\nft ' , the tooth looks healthy. 1 A ~ \n\ntartar between \nthe teeth \n\n125 \n\n([ ft's* \\1 \n\n\\ It hurts all the time— even \n\n/ when person tries to sleep. \n\nyS j The tooth hurts when you tap \n\n/ 'l Y'^^r anc * ^ ee * s a ^ loose. \n\nan abscess \n\n87 \n\nIt hurts when person breathes f \n\n/ in cold air. The tooth was \\ \n\nhit recently. ^ ^ \n\na cracked or \nbroken tooth \n\n90 \n\nHe cannot open his mouth \" \n\nproperly. Steady pain and \n\na bad taste are coming from \n\nthe back of the mouth. IrTrHl \n\na new tooth \ngrowing in \n\n94 \n\nSeveral top teeth hurt, even \nwhen you tap them. She had £r$,’ \n\na head cold and can only r? \n\nbreathe through her mouth. \n\nan infected \nsinus \n\n89 \n\n\n\n\n78 \n\n\nIF THE PERSON AND YOU FIND OUT \n\nHAS THAT \n\nHE/SHE MAY \nHAVE \n\nSEE \n\nPAGE \n\n* * \n\nHe had a toothache recently. f ZyCn \n\nThe bad tooth hurts when you 1 f \n\ntap it. R\\j|f \n\n♦ \n\na tooth abscess \n\nT\" \n\n87 \n\nA . \nSWOLLEN FACE She is young, about 18 years mSSS \n\nold, and has trouble opening \n\na new tooth \ngrowing in \n\n94 \n\nJ m}} He was hit on the face or \n\n|/\" ^ // jaw. The bone hurts when \n\nZ' you touch it. The teeth VMlXXT? \n\ndo not fit together properly. \n\na broken bone \n\n102 \n\nThe swelling is under or ****\"**% \n\nbehind the jaw. It gets \n\nworse when he is hungry \\ ^ Jr \n\nand smells food. r~i \n\nan infection \ninside the spit \ngland \n\n113 \n\nThe swelling has been there \n\nfor a long time. It does ■ \n\nnot seem to get better. '^ i yJ \n\na tumor \n\n119 \n\n\n\n\n\n\n79 \n\n\nIF THE PERSON AND YOU FIND OUT \n\nHAS THAT \n\nHE/SHE MAY \nHAVE \n\nSEE \n\nPAGE \n\n♦ ♦ \n\nThe gums are red and swollen. (~T IQr' \n\nThey bleed when the teeth are \n\ncleaned. \n\n? \n\ngum disease \nstarting \n\n~r~ \n\n95 \n\nA SORE MOUTH Between two teeth the gums \n\n, are sore and swollen, like ( V \n\nfrom ,, Ai/fll AJ \n\nINFECTED GUMS a small tumor. V t \n\nsomething \ncaught under \nthe gum \n\n127 \n\nThe gums between the teeth \n\n[V Y ? YU have died and are no longer y~\\ \n\npointed. Pus and blood \naround the teeth make the \nmouth smell bad. \n\nVincent's \nInfection \n(a more serious \ngum infection) \n\n96 \n\nThe gums are bright red and 1 A A )C 7 \n\nsore, but between the teeth \n\nthey are still pointed. OQC^^ \n\nfever blisters on \nthe gums— from \nHerpes Virus \n\n98 \n\n\nA sore on the inside of the * v \n\ncheek, lips, or under the \ntongue, is yellow with the \nskin around it bright red. \n\nFood touching it makes the \nsore hurt more. \n\na canker sore \n\n100 \n\nA sore spot around or \n\nQr under a denture hurts ' \n\nASOREMOUTH when you touch it. j\\ \n\nfrom a ' ' y \\ ' \n\nSMALL SORE \n\na sharp place on \na denture, or an \nold denture that \nneeds to be \nrefitted \n\n100 \n\nin another . , . , , . . \n\n■ A kind of white cloth seems \n\nto be stuck to the top of \nthe mouth or tonaue. It \nmay stop a baby from sucking. \n\n^ / / \n\nthrush \n\n99 \n\nThe sore is near the root \nof a bad tooth. \n\ngum bubble \n\n72 \n\nand \n\n87 \n\nThe corners of the mouth v . \n\nare dry. The lips crack \n\nand are sore. T s ' v - — \n\nmalnutrition \n\n101 \n\nSmall painful blisters on ) \n\nthe lips soon break and \n\nform dry scabs. \n\nfever blisters \n—from Herpes \nVirus \n\n98 \n\nA SORE THAT DOES NOT HEAL PROPERLY MAY BE CANCER (See page 119). \n\n\n\n\n\nIF THE PERSON AND YOU FIND OUT \n\nHAS THAT \n\nHE/SHE MAY \nHAVE \n\nSEE \n\nPAGE \n\n* * \n\n* Inside his mouth, he has y/j \n\na tooth abscess or a tyf'i y \n\nbroken tooth near the sore. X. \\ f \n\nA SORF \n\n♦ \n\nabscessed tooth \ndraining pus to \nthe outside of \nthe face \n\n♦ \n\n114 \n\nON THE FACE \n\nA dark sore ’ s eatin 9 through \nthe cheek. 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[८4 द १ो र द्वहन \n\n\n< + ३५४); \n\n\n1 7071९ 01 1९5९ 51015 2190८77 ५111116 30 कोशाद6 शिक पुर द एन १ छर ह्‌ \n११€५।610६ ।0 ¶€ ५५८६} ६& 01 ¶#)४ 0४1106४4 & 85 6१८0 10 (00£ 86 \n\n\n59066 च [दि ध इन 00 दाचन त्म कतनत (ततत छर तेपृ ते रक तिद १ १९४! \nगि 2४ 510४\" {116 51004 क त {प्न \n1५2४8 {८6९9 86767819 168४ ०५४९ तला वणार ठ \n5608111४ {6 ६१. \n\n\n\n\n\nत शण ज भ ०१२० ८०१५. > \n\n\n1 ० 0९75011 6079018105 ©1 11४65 01185) त {९५८ ५०४९ ठ} {^^ प्र ८111 च [८ ठ इ९ 01 ११५ \n\n\n17} ९1100. ८15 0700990} 21161016 16 हह 00016100 06 66 ता फा पोर6 5 ठा6 काहर्कलातए \n20811. \n\n\n50761196, ॥11५65 01 8 105 ४५१1 पौ 70 लठ ता © 10 प 0 १९०८ तत्प द नह \n0९110 20 10166110 \n\n\nद 83 \n\n\n11€ 0110५५10 07005 1 7601011165 50116111165 0100006 8 08706105 16861101 \n©8।1€५ ^\\[_! ६261८ 51101 8 501१ 11116 816 16610)\n…[truncated]", "summary": "<~ ५ , व्ल 70 (58 (प्राऽ 800 ---~-~--- -- ~~ ॥///6// ^0८/ 67 7/1/5 6004८ 68५ 1/6 151 2८076६5 81 {1€ 0९011010 11115 16115 ४1181 &86|) 01180161 15 20001 89५ 01५65 1116 808 पपोएल ऽ {0 ९ तरल ली 90016615 056५5880 70 । 00/< (९ 4/५ (1 (655, 06 07/16 (1८4 (. 7/1 5(4/6./6८7 1 [00६ 11 {€ ६1.10४ 0409 81 1116 70 1 1/€ ००८ 115 ।5 80 1५0 &>( {1181 11515, 10 106 01706 अ 1{1€ 81018061, 8|| 116 50016615 1) {115 0006 [1 ४०५ 68701 {7५ \\//1121 /014 2301, 1001< 07 11 (400 201011&ा 72716…", "source_url": "https://archive.org/details/in.ernet.dli.2015.553281", "pdf_url": "https://archive.org/details/in.ernet.dli.2015.553281", "doc_date": "1977", "case": "hesperian", "sub_case": "Werner David", "tags": ["hesperian", "C-DAK"], "page_count": 0} {"title": "WHERE THERE IS NO DENTIST - MURRAY DICKSON", "content": "Where There Is \nNo Dentist \n\nby Murray Dickson \n\nupdated and expanded \n\nwith information about hiv/aids \nby Richard Bebermeyer, \n\nMartin Hobdell and Gene Stevenson \n\nIntroduction by David Werner, \nauthor of Where There Is No Doctor \n\n\n\n\n\n\nHesperian encourages others to copy, reproduce, or adapt to meet local needs any \nor all parts of this book, including the illustrations, provided that the parts reproduced \nare distributed free or at cost - not for profit. \n\nAny organization or person who wishes to copy, reproduce, or adapt any or all parts \nof this book for commercial purposes must obtain permission from Hesperian. \n\nBefore beginning any translation or adaptation of this book or its contents, please \ncontact Hesperian for suggestions, updated information, and to avoid duplication of \nefforts. Please send us a copy of any materials in which text or illustrations from this \nbook have been used. \n\nCopyright © 1 983, 2006, 2009 by the Hesperian Foundation. All rights reserved. \n\n\nLibrary of Congress \n\nCatalog card No. 82-84067 \nDickson, Murray \n\nWhere there is no dentist. \n\nIncludes index. \n\nBerkeley, CA: Hesperian Foundation \nISBN: 978-0-942364-05-7 \n\nFirst edition, November 1983 \n\n12th printing, April 2009 \n\nPrinted in Canada on acid-free, 100% recycled paper \n\n\nHesperian \n\n191 9 Addison St., #304 \nBerkeley, California 94704 \nUSA \n\ntel: 1-510-845-1447 \nfax: 1-510-845-9141 \nbookorders@hesperian.org \nwww.hesperian.org \n\n\nwww. nespenan.org \n\n\nTHANKS \n\n\nWhere There Is No Dentist, updated edition, 2009 \n\nThanks from Hesperian \n\nWe continue to be inspired by Murray Dickson and his tireless efforts to \nencourage health and dental promoters and community members to respond \nself-reliantly to their health needs. A few years ago, Murray introduced us to \nRichard Bebermeyer, Martin Hobdell, and Gene Stevenson, whom we thank \nfor volunteering their time to write and develop the manuscript for Chapter 1 2 \nin this book, \"HIV/AIDS and Care of the Teeth and Gums.\" That material was \noriginally published in 2002 and distributed as a supplement to the previous \nedition of Where There Is No Dentist. We also thank Jane Maxwell, who \nedited the supplement with assistance from Darlena David, Julie Gerk, and \nTodd Jailer. \n\nHesperian is lucky to be able to draw upon a large pool of people committed \nto grassroots health, and we owe a debt of gratitude for their insightful \ncomments and suggestions to: Jean Arthur, Alma Carolina Blanco Reyes, \n\nClaire Borket, Roman Carlos, Stephen Cox, Belinda Forbes, Jo Frencken, \nMonica Gandhi, Gene Gowdey, Gerardo Gutierrez, Martin Hobdell, Patcharin \nLekswat, Brian Linde, Francina Lozada Nur, Stephen Moses, Foluso Owotade, \nFrancis Serio, Michael Terry, Garth von Hagen, and P. Wanzala. \n\nNew illustrations in this edition of the book are by: Silvia Barandier, Sara Boore, \nHeidi Broner, Jose de Jesus Chan, Gil Corral, Regina Faul-Doyle, Anna Kallis, \nSusan Klein, Gabriela Nunez, Mona Sfeir, Sarah Wallis, Lihua Wang, and Mary \nAnn Zapalac. \n\nEditing and updating of the 2006 edition was coordinated by Kathleen Vickery \nwith assistance from Todd Jailer and Susan McCallister, production by Inaki \nFernandez de Retana and Leana Rosetti, and additional writing by Fiona \nThomson. For the 2009 edition, editorial coordination by Todd Jailer and \nKathleen Vickery, production by Shu Ping Guan. \n\nThanks from Murray Dickson, 1983 \n\nWhere There Is No Dentist is here to fill a need. To many people, it has \nseemed that the existing books about dental care were either too incomplete \nor too complicated. If this book fills that need, it is only because a number of \npeople worked hard to make it happen. To them I owe my sincere thanks. \n\nMuch has happened since that day in Papua New Guinea when David \nWerner's letter arrived. His challenge was simple: \"Since no one else has \nwritten a dental manual like this, why don't you?\" With David's encouragement \nand constant support, I was able to take teaching notes and produce a suitable \ndraft that was the basic for this book. To you, David, for your patience in \nhelping me learn, my heartfelt thanks. Thanks also to Trude Bock and Bill Bower \nfor the home, food, direction, and support, during a short visit to The Hesperian \nFoundation in which the book took a definite turn for the better. \n\nwww. hespenan.org \n\n\nMichael Blake deserves special mention. As editor of Where There Is No \nDentist, it was he who took the manuscript and nursed it along to completion. \nMichael's commitment to finishing the book was vital, and I sincerely \nappreciate it. \n\nMy thanks go to Maggie Leung for typing the final draft, and to those \ndedicated persons who helped get the book into final form: Annaloy Nickum \n(page design); Hal Lockwood (typesetting and paste-up); Paul Chandler, Serena \nClayton, and Elaine Rossi (proofreading); Pat Bernier (typing); and Howard Uno \n(photostats). \n\nFor their outstanding drawings, I am exceedingly grateful to: June Mehra, \nJanet Elliott de Jacques, Michael Marzolla, Joan Thompson, Mindy Mead, \nArlene Ustin-Cartagena, and Lynn Gordon. My own drawings in the manual \nappear amateurish in comparison. \n\nI want to thank the many persons who reviewed the manuscript and offered \nvaluable suggestions: Ken Cripwell, Bill Bower, Jeff Vore, Aaron Yaschine, \nRosalie Warpeha, Norma Francisco, Mike Muller, Marcia Anderson, Phil \nHaskett, Bert Bali, Tom Coles, Sunil Mehra, and John Rogers. In particular, \nthanks to Chris Lennox who, faced with stressful times in Papua New Guinea, \nfound time to read through two drafts; and to David Morley for his ideas for \nimproving the book and his assistance with its eventual publication. \n\nFor their financial help, I am grateful to the Ella Lyman Cabot Trust, Muttart \nFoundation, the Canadian Organization for Development through Education, \nand the James C. Penney Foundation. \n\nI thank the C.V. Mosby Company and Dr. Kenneth Snawder for permission to \nadapt several drawings from the Handbook of Clinical Pedodontics, and the \nMedical Missionary Association (6 Canonbury Place, London N1 2NJ, U.K.) for \npermission to use parts of David Halestrap's book Simple Dental Care. \n\nThis book is based upon several years of practical experience, made possible \nby the Canadian Organization CUSO. For this opportunity, and for CUSO's \nactive interest and involvement in this book, I most gratefully say thanks. \n\nFinally, I want to acknowledge my family's contribution. For weeks on end, \nmy wife, Gerri, faithfully read and discussed with me each part of the book \nas it changed and was rewritten. She did this cheerfully, at a time when she \nwas fully occupied in a graduate study program. For much longer than I had \nanticipated, Gerri and our two boys, Michael and Brennan, had to tolerate my \npreoccupations. \n\nMy parents endured my wanderings and search for answers to human \nproblems with love and a growing sense of understanding. It is my only \ndisappointment that they did not live to see this book in its final form. \n\n\nwww. nespenan.org \n\n\nCONTENTS \n\n\nIntroduction by David Werner \n\nPart One: Learning and Teaching about Teeth and Gums \n\nChapter 1 : Your Own Teeth and Gums 1 \n\nEat only good healthy foods 3 Sore bleeding gums 7 \n\nClean your teeth every day 4 More serious gum disease 8 \n\nCavities, toothaches and abscesses 6 \n\n\nChapter 2: Teaching Family and Friends in Your Community ... \n\nChapter 3: Teaching Children at School \n\nChapter 4: School Activities for Learning about Teeth and Gums \n\n\nWhy do we need teeth and gums?. \nWhy do some teeth look different? \n\nWhat holds the teeth? \n\nHow often do teeth grow in? \n\nWhat makes teeth hurt? \n\n\n37 How do germs make holes in the teeth? \n\n39 What makes the gums feel sore? \n\n41 What does it mean if a tooth is loose? . \n43 How can we prevent cavities and \n4 g sore gums? \n\n\n9 \n\n19 \n\n35 \n\n50 \n\n52 \n\n54 \n\n55 \n\n\nChapter 5: Taking Care of Teeth and Gums \n\n\n61 \n\n\nPart Two: Treating Dental Problems \n\nChapter 6: Examination and Diagnosis \n\nWhereto examine 75 A good diagnosis \n\nThe instruments you need 75 Learn to tell similar problems apart \n\n\nChapter 7: Treating Some Common Problems \n\nThe first rule of treatment: stay clean! 86 Dislocated jaw \n\nProblems you will see most often 92 Pain in the joint \n\nCavities 92 Swollen gums and epilepsy . . \n\nAbscess 93 Blood in the mouth \n\nInfected sinus 95 After you take out a tooth \n\nTooth injuries 96 Swelling of the face \n\nLoose tooth 99 Pain from the socket \n\nNew tooth growing in 100 Bleeding from the socket . .. . \n\nGumdisease 101 Tetanus \n\nFever blisters 104 Infection in the spit (saliva) gland. \n\nThrush 105 Sores on the face \n\nCanker sores 106 Noma \n\nSome special problems 108 Tumor \n\nBroken bone 108 Cancer \n\nwww. hespenan.org \n\n\n73 \n\n76 \n\n80 \n\n85 \n\n113 \n\n114 \n\n115 \n\n116 \n116 \n116 \n\n117 \n\n118 \n118 \n\n119 \n\n120 \n121 \n125 \n125 \n\n\n127 \n\n\nChapter 8: Scaling Teeth \n\nChapter 9: Injecting Inside the Mouth \n\nChapter 1 0: Cement Fillings \n\nChapter 1 1 : Taking Out a Tooth \n\n\nThe instruments you need 154 False teeth \n\nWhere you work is important 1 56 Problems that can occur \n\nHow to take out the tooth 157 Clean your instruments after you finish \n\nHow to place a suture 161 \n\n\nChapter 1 2: HIV and Care of the Teeth and Gums \n\nWhat is HIV? 171 White or yellow patches in the mouth . \n\nHow is HIV spread? 172 Sores of the skin of the mouth \n\nWhogetsHIV? 173 Infection of the gums \n\nHow HIV affects the mouth 173 Cold sores or fever blisters \n\nHow to examine the mouth for Red or purple patches in the mouth . . . \n\nsigns of HIV or AIDS 174 p r y or painful mouth and throat \n\nDental care for a person with HIV 177 He|pjng peop|e wjth H|v jn \n\nCommon problems caused by HIV your community \n\nand how to treat them 178 Working for change in your community \n\n\nAppendices \n\nGet Rid of Wastes Safely 199 \n\nThe Dental Kit 201 \n\nMedicines 202 \n\nSupplies 205 \n\nInstruments 207 \n\nRecords, Reports, and Surveys 212 \n\nResources 215 \n\nVocabulary 217 \n\nIndex 222 \n\nOther Books from Hesperian 230 \n\n\n135 \n\n143 \n\n153 \n\n163 \n\n165 \n\n167 \n\n169 \n\n. 180 \n. 182 \n. 183 \n. 186 \n. 188 \n. 189 \n\n. 190 \n. 191 \n\n\n,-ilhMiUdL \nwww. nespenan.org \n\n\nINTRODUCTION \n\nby David Werner \n\n\nA healthy tooth is a living part of the body. It is connected by 'life-lines' of \nblood and nerve to a person's heart and brain. To separate the tooth from the \nbody, or even to interrupt those 'life-lines', means death to the tooth. It also \nmeans pain and injury to the body, to the person. \n\nLet us look at it another way. The health of the teeth and gums is related to \nthe health of the whole person, just as the well-being of a person relates to \nthe health of the entire community. \n\nBecause of this, the usual separation between dentistry and general health \ncare is neither reasonable nor healthy. Basic care of the teeth and gums — \nboth preventive and curative — should be part of the 'know-how' of all primary \nhealth care workers. Ideally, perhaps, Where There Is No Dentist should be \na part of Where There Is No Doctor. Think of it as a companion volume, both \nto Where There Is No Doctor and Helping Health Workers Learn. \n\nMurray Dickson has taken care to write this book in a way that will help the \nreaders see dental care as part of community health and development. The \napproach is what we call 'people centered.' \n\nWhere There Is No Dentist is a book about what people can do for \nthemselves and each other to care for their gums and teeth. It is written for: \n\n• village and neighborhood health workers who want to learn more \nabout dental care as part of a complete community-based approach to \nhealth; \n\n• school teachers, mothers, fathers, and anyone concerned with \nencouraging dental health in their children and their community; and \n\n• those dentists and dental technicians who are looking for ways to \nshare their skills, to help people become more self-reliant at lower cost. \n\nJust as with the rest of health care, there is a strong need to \n'deprofessionalize' dentistry — to provide ordinary people and community \nworkers with more skills to prevent and cure problems in the mouth. After \nall, early care is what makes the dentist's work unnecessary — and this is the \ncare that each person gives to his or her own teeth, or what a mother does \nto protect her children's teeth. \n\n\nwww. nesperian.org \n\n\nWhile dental disease is decreasing in richer countries, it is on the increase \nin most poor countries. One reason for this is that people are eating fewer \ntraditional (unrefined) foods and more pre-packaged commercial foods, often \nsweetened with refined sugar. \n\nEven as the need for dental care is growing, there are still far too few \ndentists in poor countries. Most of those few work only in the cities, where \nthey serve mostly those who can afford their expensive services. \n\nPeople in many countries cannot afford to pay for costly professional dental \ncare. Even in rich countries, persons who do not have dental insurance often \ndo not get the attention they need — or go into debt to get it. \n\nTwo things can greatly reduce the cost' of adequate dental care: popular \neducation about dental health, and the training of primary health workers \nas dental health promoters. In addition, numbers of community \ndental technicians can be trained — in 2 to 3 months plus a period of \napprenticeship — to care for up to 90% of the people who have problems of \npain and infection. \n\nDentists' training usually includes complicated oral surgery, root canal \nwork, orthodontics (straightening teeth), and other complex skills. Yet most \ndentists rarely do more than pull, drill, and fill teeth — skills that require a \nfraction of the training they have received. The simpler, more common dental \nproblems should be the work of community dental technicians who are on \nthe front lines (the villages), with secondary help from dentists for more \ndifficult problems. \n\nWould this reduce quality of service? Not necessarily. Studies have shown \nthat dental technicians often can treat problems as well as or better than \nprofessional dentists. In Boston (U.S.A.), for example, a study showed many \nof the basic treatments commonly given by dentists to be done just as well, \nand often better, by dental technicians with much shorter training. \n\nFortunately, in some countries skilled dental technicians have managed to \nbecome the major providers of the most needed dental services. In India, \nthere are still 'street-corner' dental technicians with footpedal drills, who drill \nand fill teeth at remarkably low cost. \n\nIn Elonduras, dental technicians (who learn largely from each other, \nstarting as helpers) have formed their own union. Their political strength \nwas tested when, in the town of Trujillo, a dentist tried to put a technician \nout of business. The local technician had removed an infected root left \nmistakenly by the dentist. The technician had commented on the dentist's \ncarelessness, and the dentist heard about it. The dentist sent a policeman \nwho shut down the technician's office and took away his tools. However, \nthe dental technicians' union look this to court. They argued their rights to \npractice dentistry, because they are the only persons working in marginal \n\n\nwww. hesperian .org \n\n\ncommunities where dentists' prices are too high for the people. The court \ndecided in favor of the technicians, and ordered the dentist to return the \ntechnician's tools and pay him for work lost. \n\nIn other countries dentists and community dental workers work in closer \nharmony. In Guatemala, Ecuador, Papua New Guinea, and Mozambique, \ndental technicians are now recognized by the Ministries of Health. In Papua \nNew Guinea and Ecuador, professional dentists train and supervise them \nto provide dental care to school children. In Ecuador, they work mostly \nas dentist assistants, bringing high quality services to more people while \ndecreasing costs. The 'dental therapists' in Papua New Guinea are trained \nto extract, drill, and fill teeth, as well as to work on prevention of dental \nproblems in school children. \n\nIn Guatemala and Mozambique, dentists from the dental school have trained \nvillage health promoters as dental workers who work with people of all ages. \nTheir training includes community dental health education, cleaning of teeth, \nextractions, and drilling and filling. These health workers are provided with \nthe few basic instruments needed to provide these services. \n\nIn Project Piaxtla Mexico (with which I and the Hesperian Foundation have \nworked for many years), visiting dentists have also helped train village \n'dentics'. They, in turn, now teach basic dental skills to the part-time village \nhealth workers. These village dentics, some of whom have had only 3 to \n6 years of primary school, now practice — and teach — a wider range of \ndental skills than the average dentist. Their activities include dental health \ncampaigns with school children, community puppet shows about low-cost \ndental self-care, cleaning of teeth, extractions, drilling and filling, and the \nmaking of dentures (false teeth). Several of the dental workers can now do \nroot canal work — a special treatment to remove the central nerve in order to \nsave an infected tooth. One of the village dentics, remembering what he had \nseen a dentist do, taught himself how to do root canals when his girlfriend \nhad an infected front tooth that he did not want to pull. (He had also learned \nto check the tooth from time to time afterward to make sure this treatment \nhad been successful.) \n\nWe still have much to learn about dental health. Dentists need to learn from \nthe knowledge of the local people, as well as the people from the dentists. \n\nWe have learned that villagers with little formal education often can learn \nskills with their hands — such as tooth extractions, puppetry, or surgery — \nmuch faster than university students (who have never learned to use their \nhands for much more than pushing pencils). We also have observed that \nthe best way to learn dentistry is not through school but through practice, \nhelping someone with more experience who is willing to teach. \n\n\nwww. hesperian.org \n\n\nWhere There is No Dentist has 2 parts. The first part (Chapters 1-5) \ndiscusses teaching and learning about preventive care. It begins by \nencouraging the health worker to examine herself and her family. To be a \ngood example is the best way to teach. \n\nThe second part (Chapters 6-1 1) talks about diagnosing and treating \ncommon dental problems. It is especially for those who live where they \ncannot reach or afford a dentist. A poor neighborhood in the city can be \nas distant and neglected as a far-off village. This second part is intended \nmainly for health workers who have helped organize people to meet their \nown needs. \n\nMurray Dickson — a Canadian with primary care experience in Northern \nCanada, Nigeria, Papua New Guinea, and Mozambique — has written this \nbook in clear, simple language. He takes care to use popular names instead \nof unfamiliar scientific words. For example, instead of speaking of 'dental \nplaque' the author speaks of the 'coating of germs on the teeth.' Such \nsimple language does not weaken the message. The message is stronger \nbecause everyone understands. \n\nThe author has said: \n\nI am sure some dentists will disagree with parts of this book. \n\nSome points of disagreement may be small, like the failure to \nuse accepted dental terminology. Other ideas, particularly the \nsuggestion that non-dental people can be trained to provide \nmany kinds of treatments, may make some dentists angry. \n\nThe book is meant to be a source for argument and \ndiscussion. This way, it may stimulate others to write the kind \nof manual that is really needed in their countries. \n\nThe people must answer to the people's needs. The health of teeth and \ngums, along with general health, will improve only when people take the \nlead in caring for themselves. The challenge for dentists and other health \nprofessionals is to allow and encourage this to happen. \n\n\nwww. hesperian .org \n\n\nCHAPTER \n\n\n1 \n\n\nYour Own Teeth \nand Gums \n\n\nNext time you look in a mirror, look at your teeth and the skin (gums) around \nthem. Look in your children's mouths, too. Look at both gums and teeth, \nbecause the health of one often depends on the health of the other. To be \n\nstrong, teeth need healthy gums. Healthy gums need clean teeth. \n\n\nWhat can good \nteeth give you? \n\n• GOOD HEALTH \n\n• GOOD LOOKS \n\n• GOOD SPEECH \n\n• GOOD EATING \n\n• GOOD BREATH \n\n\n\nAnd when you think of your teeth, think of your gums. Gums are \nimportant for holding each tooth in place. \n\nYou need strong teeth to eat different kinds of foods. Different foods are \nimportant for health. Nuts, maize, fruits, and meat are some of the best \nfoods — but they are difficult to bite and chew if your teeth are loose and \nhurting! \n\n\n1 \n\n\nI A/. \n\n\n2 Where There Is No Dentist 2009 \n\n\nYou can usually tell if your teeth and gums are healthy or not. Look at the \npictures on pages 73 and 74 and compare them with your own mouth. If you \nfind a problem in your mouth, look for its name in Chapter 6 and look for its \ntreatment in Chapter 7. \n\n\nMost important: when you are not sure of a problem or \nhow to treat it, talk to an experienced dental worker. \n\n\nIf you notice a problem early, often you can stop it from getting worse. It is \neven better to prevent the problem from starting. You can do this if you know \nhow to keep your teeth and gums healthy. \n\n\nLearn to take care of your own teeth and gums before you try to teach \nothers. A good example is one of your best teaching tools. People will see \nthat you are healthy, and they will want to know why. When you tell people \nways to care for their teeth, they will believe you if they know that you do \nthese things yourself. First take care of your own teeth and gums. Then \nteach your family what you have learned. They, too, will be good examples \nfor others to see. \n\n\n\nWWW. \n\n\nhespenan.org \n\n\nWhere There Is No Dentist 2009 3 \n\n\nEAT ONLY GOOD HEALTHY FOODS \n\nThe best food is food that you grow or raise yourself. Mix different kinds of \nfood together and eat several times a day. This helps your body as well as \nyour teeth and gums to stay strong and healthy. Traditional food is usually \ngood food. \n\nSweet food, especially the kind you buy from the store, can mix with germs \nand make cavities — holes in the teeth. Soft food sticks to the teeth easily \nand it, too, can make a coating of germs and food on the teeth that starts an \ninfection in the gums — gum disease. \n\n\nSoft and sweet food \nand drinks with a lot \nof sugar are bad for \nboth teeth and gums. \n\n\n\n\nBreast feed to help a child's teeth \ngrow and stay strong. An older child \ncan drink from a cup. \n\n\n\nYES \n\nGOOD FOR TEETH \n\n\nDo not give a baby anything to drink \nfrom a bottle. Sweet tea, sugar water \nor fruit juice can easily make holes in \nthe child's teeth. \n\n\nREMEMBER: \n\nBREAST \n\nIS \n\nBEST! \n\n\n\nNO \n\nBAD FOR TEETH \n\n\nEven milk has sugar that can wash over the baby's teeth and cause cavities \nwhen it comes from a bottle. \n\n\nw. \n\n\n4 Where There Is No Dentist 2009 \n\n\nCLEAN YOUR TEETH EVERY DAY \n\nIf you do not clean properly, the food that is left on your teeth can hurt the \nteeth as well as the gums near them. \n\n\nHIDING PLACES \n\n\n\nHere are 3 places where problems start. \n\n\nBits of food stay longer in \ngrooves and 'hiding places'. \nThis is where both tooth and \ngum problems start. \n\nTo prevent problems you \nmust take special care to \nkeep these protected places \nclean. \n\nIt is better to clean your \nteeth carefully once every \nday than to clean poorly \nmany times a day. \n\n\nUse a soft brush to clean your teeth. Buy one from the store (be sure it says \nsoft on the package), or make a brush yourself. To make a brush: \n\n1. Use a small branch young 2. Cut a piece that is \n\nbamboo, strong grass or the skin still green and soft, \n\nform sugar cane or betel nut. \n\n\n\n\n3. Chew one end to make it \nstringy like a brush. \n\n\n\n4. Sharpen the other end so \nit can clean between the \nteeth (see pages 71-72). \n\n\n\nwww. nesperian.org \n\n\nWhere There Is No Dentist 2009 5 \n\n\nYou can twist the fiber from inside a coconut husk into a kind of brush. First \nrub it and shake away the loose bits. Then use the end to clean your teeth. \n\n\n\nWhatever kind of brush you use, be sure to clean your back teeth as well as \nyour front teeth. Scrub the tops and sides where the grooves are. Then push \nthe hairs between the teeth and scrub (page 69). \n\n\nToothpaste is not necessary. \n\nCharcoal or even just water is \nenough. When your teeth are \nclean, rinse away the loose \npieces of food. \n\n\n\nw. \n\n\n6 Where There Is No Dentist 2009 \n\nCAVITIES, TOOTHACHES AND ABSCESSES \n\n'Cavities' are holes in teeth. Cavities are made by the infection called tooth \ndecay. If you have a black spot on your tooth, it might be a cavity. If that \ntooth hurts some of the lime, such as when you eat, drink, or breathe cold \nair, it probably has a cavity in it. \n\nYou will get cavities in your teeth if you eat sweet food and then do not \nclean your teeth. If you see a cavity starting in your mouth or feel a \ntooth hurting you, get help right away. If you do not fill a cavity, it grows \nbigger and deeper. A dental worker knows how to fill the cavity so you can \nkeep that tooth. Do this before the pain gets worse. \n\n\n\nEach tooth has roots \nthat hold it in the \njaw bone. Inside \neach root is a nerve, \n(p. 39 to 40 and 45) \n\n\n\nWhen decay \ntouches the nerve \ninside the tooth \naches, even when \nyou try to sleep. \n\n\n\nWhen infection \nreaches the \ninside of a root, \nit is called a \n\ntooth abscess. \n\n\nA tooth with an abscess needs treatment at once, before the infection \ncan go into the bone (page 93). In most cases the tooth must be taken \nout. If it is not possible to do this right away, you can stop the problem from \ngetting any worse if you follow these steps: \n\n\n1. Wash the inside of your mouth with warm \nwater. This removes any bits of food \ncaught inside the cavity. \n\n2 . Take aspirin or acetominophen for pain. \nSee page 95 for amount. \n\n3 . Reduce the swelling: \n\n• hold warm water inside your mouth \nnear the bad tooth. \n\n• Wet a cloth with hot water and \nhold it against your face. Do not \n\nuse water hot enough to burn \nyourself! \n\n\n\nA tooth abscess can cause \nswelling like this. \n\n\nw. \n\n\nWhere There Is No Dentist 2009 7 \n\n\nSORE BLEEDING GUMS \n\nHealthy gums fit tightly around the teeth. Gums are infected if they are \nloose, sore, and red, and if they bleed when the teeth are cleaned. Infection \nin the gums is called gum disease. \n\nGum disease, like tooth decay, happens when acid touches the teeth and \ngums. This acid is made when sweet and soft foods mix with germs (see \npage 50). \n\n\nHEALTHY TEETH AND GUMS CAVITIES AND GUM DISEASE \n\nInfection from gum disease can spread into the root fibers and bone (see \npage 42). But you can stop gum disease and prevent it from coming \nback. There are two things to do: clean your teeth better and strengthen \nyour gums. \n\n1. Even if your gums are sore and they bleed, you must still clean the \nteeth beside them. If more food collects on the teeth, the gum \ninfection will get even worse. Get a soft brush (see p. 4) and use it \ngently. This way you will not hurt the gums when you clean. \n\n2 . To make your gums stronger and more able to fight the infection: \n\n• Eat more fresh fruits and green leafy vegetables, and fewer soft \nsticky foods from the store. \n\n• Rinse your mouth with warm salt water. Do this every day, even \nafter your gums feel better. \n\n\n\n(1 ) Mix some salt with a cup of warm water. (2) Take a mouthful \nand rinse. (3) Spit it out. Repeat until all of the salt water is finished. \n\n\n\n\nw. \n\n\n8 Where There Is No Dentist 2009 \n\nMORE SERIOUS GUM DISEASE \n\nPainful gums that bleed at the slightest touch need special treatment. If \nyou have this problem, ask for help. A dental worker can explain what is \nhappening and what needs to be done. A dental worker can also scrape the \nteeth and remove the tartar that is poking the gums, making them sore. \n\nAt home, you can do some things to help. \n\n• Clean your teeth near the gums with a soft brush. Gently push the \nbrush between the tooth and the gum. It may bleed at first, but as the \ngums toughen, the bleeding will stop. \n\n• Make your food soft, so it is easier to chew. Pounded yam and soup are \ngood examples. \n\n• Eat plenty of fresh fruits and vegetables. If it is difficult for you to bite \ninto fruit, squeeze it and drink the juice. \n\n• Start rinsing your mouth with a mixture of hydrogen peroxide and \nwater. You can get hydrogen peroxide from your clinic or your pharmacy \n(chemist). \n\nThe strength of hydrogen peroxide is important. Ask for a 3% \n\nsolution, and mix it evenly with water — that is, V 2 cup of hydrogen \nperoxide with V 2 cup of water. \n\n\nWARNING: Read the label to be sure the solution \nis 3%. A mixture with more than 3% \nhydrogen peroxide can burn the mouth. \n\n\n\nTake some into your mouth and hold it there for \nabout 2 minutes. Then spit it out and repeat. Do \nthis every hour you are awake. \n\nUse hydrogen peroxide for only 3 days. Then \nchange and start rinsing with salt water (page 7). \n\n\nIf you take care, you can keep your teeth for a lifetime. \n\n\nw \n\n\n\nCHAPTER \n\n\nTeaching Family and \nFriends in Your Community \n\n\nOld people can remember when there were fewer problems with teeth and \ngums. Children's teeth were stronger and adults kept their teeth longer. \n\nTimes are changing. Today there are more tooth and gum problems than \never before. In many countries, tooth decay and gum disease are two of the \nfastest growing health problems. \n\nThis unhealthy situation is getting worse, for two reasons: changes in the \nkind of food people now are eating, and not enough cleaning after they eat. \n\n\nBEFORE, the food people ate \nwas their own, grown and \nprepared by themselves. \n\n\n\nEven sugar cane was not as bad \nas the sticky candy children eat \ntoday. The sugar was bad for the \nteeth, but the fiber in the cane \nhelped rub them clean. \n\n\nNOW, more people are buying \nsofter and sweeter food from \nthe store. This kind of food \nsticks to the teeth more easily \nso it has more time to attack \nthe teeth and gums. \n\n\n\nEveryone must be more careful \nto clean away soft, sweet food. \nBut many people do not know \nhow. Some, especially children, \ndo not even try. \n\n\n9 \n\n\n10 Where There Is No Dentist 2009 \n\n\nMany people do not understand that tooth and gum problems are caused \nby certain kinds of food, and poor cleaning of the teeth. In fact, some have a \ncompletely different belief. \n\n\n\nDo not attack a belief because it is traditional. Many traditions are more \nhealthy than 'modern' things. Often, instead of telling people that their belief \nis wrong, you can remind them of a different tradition that is healthy. \n\n\nHelp your family and friends to recognize their \nhealthy traditions. Then help them find new ways \nto use these same traditions for better health. \n\n\n/OUR PEOPLE DO NOT \nI USE TOOTHBRUSHES. \n[WE DO NOT HAVE MONEY \nl TO BUY SUCH THINGS \nV AT THE STORE. \n\n\nBUT WE CAW MARE \n1 FOR OURSELVES MANY \n^OF THE THINGS THE \nSTORE SELLS. \n\n\n\n\nYes, and we can 1 \n\nMAKE OUR OWN \n\ntoothbrushes from\\ \njhe twig of a tree ; ) \n\n\nWhere There Is No Dentist 2009 11 \n\n\nBE A GOOD EXAMPLE \n\nOther people like to watch what you do before they try something different. \nFirst show members of your family and then they will be an example to \nothers in your community. For example: \n\n\n1. Instead of buying all your foods from the store, buy fresh fruits and \n\nvegetables from the market. It is even \nbetter to grow food in your own garden. \n\nLearn to use several different kinds of \nfoods in each meal. Mixing foods is a \nhealthy idea. Invite friends to share your \nmeals and see the number of different \nfoods you have at each meal. \n\n\n\n2. Do not buy fizzy drinks like Coca-Cola or Fanta. \nThey have a lot of added sugar which quickly \nmakes children's teeth rotten. \n\nAlso, do not sweeten your child's milk or tea. \n\nWhen she is young she can learn to enjoy \ndrinks that are not sweet. \n\nClean, cool water, tea with little sugar, milk, or \nwater from a young coconut are best to drink. \nFresh fruits are delicious when you are thirsty. \n\n\n\nMost important: do not give your child feeding bottle, \nespecially one with a sweet drink inside. (See page 3.) \n\n\n\n3 . Keep your children's teeth clean. \nYour friends will notice clean teeth \nor teeth that are dirty or have \ncavities. Remember, clean teeth \nare healthy teeth. \n\nAn older child can clean his own \nteeth if you show him how. \n\nA younger child cannot. Fie needs \nhelp. Each day someone older \nshould clean his teeth for him \n(page 18). \n\n\n12 Where There Is No Dentist 2009 \n\n\nWhen you teach, remember that as others learn, they too \nbecome teachers. Each person can teach another. \n\n\nEncourage people to pass along what you have taught. Mothers can teach \nfamily and friends. Students can talk at home with brothers, sisters, and \nolder family members. \n\n\nFROM THE HEALTH CLINIC... \n\n\n...TO THE HOME \n\n\n\n/marie, piease help \n\nME CLEAN BAEV’S \nTEETH AMD THEN \nBROTHERS TEETH, \nW£ WILL DO IT \nEVERY DAY. \n\n\n/ FIRST, I \nMUST CLEAN \nMY OWN \nTEETH PROPERLY, \n\n\n\n\nFROM THE SCHOOL... \n\n\n...TO THE HOME \n\n\n/BROTHER, TRY TO BRUSHN \n/ YOUR BACK. TEETH BETTER, \nj IF YOU DO, THEN THEY \n\\ WILL STAY ST RON & UNTIL \n\n\n\nIf all learners become teachers, a simple message can begin in the health clinic or \nschool and reach many more people at home. \n\n\nWhere There Is No Dentist 2009 13 \n\n\nFINDING THE BEST WAY TO TEACH \n\nDeciding what to teach is important, but just as important is how to teach. \n\n\n\nLearning cannot take place \nwhen you use words that \npeople do not understand. \nThey will learn something \nonly when they see how it \nis related to their lives. \n\n\nRemember this when you teach about eating good food and keeping teeth \nclean. Design your own health messages, but be ready to change them if \npeople are not understanding or accepting what you say. \n\nHere are five suggestions for teaching well. \n\n1. Learn First From the People \n\nGet involved in your community's activities. Learn about people's \nproblems, and then offer to help solve them. People will listen to you \nwhen they know that you care about them and want to help. \n\nSit and talk with people. Learn \nabout their customs, traditions \nand beliefs. Respect them. \n\nLearn about their health habits. \n\nImproving health may require \nchanging some habits and \nstrengthening others. \n\nLearn also about tooth \ndecay and gum disease in \nyour community. \n\n\n\n\nMake people smile — then look into their mouths. \n\nFind out how many children and adults are having \nproblems with their teeth and gums. Do a survey \nsuch as the one on p. 214. \n\n\n14 Where There Is No Dentist 2009 \n\n\n2. Build New Ideas Onto Old Ones \n\nPeople find their own ways to stay healthy. Many traditions are good, \nhelpful, and worth keeping. But some are not. \n\nWhen you teach, start with what people already understand and are \ndoing themselves. Then add new ideas. \n\nThis method of teaching is called 'association of ideas'. It helps people to \nunderstand new ideas because they can compare them with what they \nalready are doing. \n\nIn this way people can more easily accept, remember, and do what you \nsuggest. \n\n\n\nSweeping the compound \nmakes it a clean and \nhealthy place to live. \n\n\nin the \nsame \nway \n\n\nBrushing the teeth and gums \nkeeps them clean and healthy. \n\n\n\n\n\nA small child cannot find \nhis own lice. Mother \nknows she must help him. \n\n\n\nin the \nsame \nway \n\n\nA small child cannot see the \nfood on his teeth. He needs \nhelp with that also. \n\n\n\nDifferent vegetables in the \n\nwhen planted together — same \n\nlike maize and yams — wa y \n\nhelp each other to grow. \n\n\n\nEating different kinds of food \nhelps people to grow. Eating \nthem several times a day makes \nyour teeth and gums, as well as \nyour whole body, grow stronger. \n\n\nWhere There Is No Dentist 2009 15 \n\n\nSTORY TELLING— AN EXAMPLE \n\nPeople everywhere have a tradition of teaching with stories. Many of the \nthings we believe, we learned through stories we heard from parents, \nfriends, and teachers. This is good, except when a story teaches something \nthat isn't true! When a woman gets pregnant, for example, she hears \nmany stories, and she wants to learn whatever she can from these stories. \nUnfortunately, some traditional beliefs about pregnancy are partly \nwrong. An example is the belief that one must always have dental problems \nduring pregnancy. \n\nHere is a story you can tell to help people see that they are partly right about \npregnancy and dental problems, but that there is more to understand. \n\n\nA Story: Bertine's teeth \n\nBertine was the dental worker in her village. She was a young woman, but \nthe villagers respected her because she was such a careful worker, and \nbecause she knew how to fill cavities and pull teeth without hurting people. \nShe also spent a lot of time teaching people how to avoid dental problems. \n\"Clean your teeth every day! \" she often said, at her clinic, at the schools, at \nvillage meetings. \"Eat a mixture of foods, \nespecially a lot of fruits and vegetables! \n\nAvoid candy and sweet, sticky foods! \" \n\nWhen Bertine was 23 years old, she got \nmarried and became pregnant. She also \nbegan to have some tooth problems of \nher own. She saw that her gums were \nbleeding when she cleaned her teeth, \nand she had small cavities in two of her \nteeth. As the dental worker, she was \nembarrassed to have tooth problems, \nbut an older woman told her, \"It's natural \nto lose teeth when you have babies, \n\nBertine. As we say, 'For each child, a \ntooth'.'' \n\nOne day Lucie, a dental worker from a nearby village, came to see her friend \nBertine. Lucie had a young baby, and Bertine asked her a lot of questions \nabout babies and about pregnancy. Then Bertine said, \"Of course, I'm having \nlots of problems with my teeth.\" \"Why do you say 'of course'?\" asked Lucie. \n\"Well,\" Bertine replied, \"For each child, a tooth.\" \n\n\"But that's not true! \" Lucie cried. \"You think you are having tooth and gum \nproblems because you are pregnant, but I bet you are having these problems \nfor all the usual reasons.\" \n\n\n\n16 Where There Is No Dentist 2009 \n\n\n\"The usual reasons?\" asked Bertine. \n\n\"Yes,\" said Lucie. \"How often do you eat now that you are pregnant?\" \"Well, \na lot more than I used to — I have two persons to feed! \" \"And do you still eat \nsweet foods sometimes?\" Lucie asked. \"I guess I do,\" said Bertine, \"and \nmore sweets than before, because I eat more often.\" \n\n\"How about teeth cleaning?\" asked Lucie. \"Do you clean as often as you did \nbefore you were pregnant?\" \"No,\" Bertine admitted, \"I heard I was going to \nhave tooth problems anyway, and I have been so tired lately.... Oh! Do you \nsuppose that these are the only reasons I am having these problems? How \ndo you know so much about this, Lucie?\" \n\n\"Because I had the same problems, Bertine. I learned the truth the hard \nway. I had an infected tooth, and the infection passed to my kidneys. At the \nhealth clinic, they told me it is not necessary to have tooth problems during \npregnancy — and it is even dangerous. I am lucky I did not lose my baby! That \ncan happen, you know, when a tooth problem is not treated. We must fill \nyour cavities right now.\" \n\n\"You mean I can be treated now, before I have my baby?\" \n\n\"Yes, and you should I \" said Lucie. \"And you \ncan take better care of your teeth. It is true \nthat because of the pregnancy, your gums \nare weaker, and they can get infected. But \nthis means you should take even more care \nthan usual to: ( 1 ) clean regularly and ( 2 ) eat \nthe right foods. You need to have strength \nwhen you are pregnant. An infection in your \nmouth does not help that. Because your \ngums are weak, it is also good to ( 3 ) rinse \nyour mouth every day with warm salt water \n(see page 7), and if you cannot get fresh \nfruits and vegetables, then ( 4 ) take a tablet \nof Vitamin C every day.\" \n\nLucie then offered to clean Bertine's teeth and to fill her cavities. When she \ntouched Bertine's gums, they bled, and Lucie said, \"They will bleed at first, \nbut after you clean them regularly for a while, they will be stronger. Bleeding \ngums are dangerous to a pregnant woman. The bleeding can increase \nanemia, which is a serious problem.\" \n\n\"If a pregnant woman's tooth has an abscess, is it safe to pull it before she \nhas the baby?\" asked Bertine. \"Yes,\" said Lucie, \"you just must be gentle. A \nwoman gets tired sitting in a dental chair for a long time, and sometimes you \nmust give some extra anesthetic so she does not feel any pain.\" \n\n\n\n\nWhere There Is No Dentist 2009 17 \n\n\n3. Keep Your Messages Short and Simple \n\nInstead of partially teaching too many things, it is better to discuss a \n\nfew things well. After learning what health problems the people feel are \n\ngreatest, decide what information will help them solve these problems. \n\nThen think of how to share the information. Try to: \n\n• Use simple words (see page 13). If you must use a big word, take \nthe time to explain it. \n\n• Teach people when they are ready to learn. A sick person, for \nexample, usually wants to know how to prevent his sickness from \nreturning. He will remember what you tell him. \n\n• Repeat the most important message many times. Whenever you \nteach about staying healthy, remember to emphasize eating good \nfood and keeping teeth clean. Repetition helps people remember. \n\n• Let people see what you mean. See pages 26 to 34 for ways to use \npictures, puppets, and plays. \n\n\n4. Teach Wherever People Get Together \n\nKnowing where to teach is sometimes as important as how you teach. \nInstead of asking people to come to a class you have organized, go to \nthem. Look for ways to fit into their way of living. You both will gain from \nthe experience. They will ask more questions, and you will learn how to \nwork with people to solve problems. \n\n\nTalk with people where they gather near their homes. \n\n\nTalk to \nwomen at \nhealth clinics \nand in the \nmarket. Talk \nto men at \nbusiness \nand farming \nmeetings. \n\n\n\nTalk to men \n\n\nand women \n\n\nat church \nmeetings, \nin parents' \n\n\ngroups at their \nchildren's \nschool, and \nat community \nmeetings. \n\n\nTeach men and women at reading groups. \n\n\n18 Where There Is No Dentist 2009 \n\n\n5. Teach Something People Can Do Right Away \n\nIt is good to tell a mother to keep her child's teeth clean, but it is \nbetter to show her how to do it. She will remember how if she actually \nwatches you clean her child's teeth. \n\nAn even better way for a mother to learn is to let her clean her child's \nteeth while you watch. A person discovers something for herself \nwhen she does it herself. \n\n\n\nPick out a child and clean his teeth yourself. \nLet his mother watch. \n\nUse a soft brush (or for a baby, a clean cloth). \nGently but quickly brush or wipe his teeth. Do \nthe best you can even if he cries. \n\nIf mothers make this into a habit, the child will \nexpect to have his teeth cleaned and will soon \ncooperate — just the way he does to bathe or \nto have lice removed from his hair. \n\n\n\nNow let each mother clean her \nown child's teeth. Teach her to \nclean on top and on both sides \nof every tooth. \n\n\nAsk her to do the same at home \neach day. At the next clinic, look \nat the children's teeth and see \nhow well the mothers are doing. \nGive further help when needed. \nAlways praise and encourage \nthose who are doing well. \n\n\nTeaching Children \nat School \n\n\nCHAPTER \n\n\nChildren want to learn. The want to know more about things that are real \nto them. Family, friends, and teachers are all important sources of new \nknowledge for the children. \n\n\nIt is important to keep alive their desire to learn, so that \nchildren can continue to ask questions, discover, and \nlearn more for themselves. \n\n\nWhen children are interested in something, they \nwill work hard to learn all they can about it. \n\n\n\nIf you relate your teaching to children's interests and needs, they will learn \nmore easily. New information added to what they already know helps \nchildren to understand your lesson better. As a result, they will want to learn \nmore because the information is both interesting and worthwhile. \n\nTeaching about teeth and gums is important. You must do it well if you want \nchildren to pay attention, learn, and finally act to take care of their own teeth \nand gums. \n\nAs school children continue to learn, they can share their new ideas \nand information at home with brothers, sisters, mothers, fathers, and \ngrandparents. In this way, the circle of teaching and learning described on \npage 12 comes back into the family and is complete. \n\nThis chapter has two parts. Part 1 gives seven guidelines for assuring that \nlearning takes place. Part 2 suggests ways to have fun while learning — with \nstories, games, and pictures. In Chapter 4 there are nine questions on teeth \nand gums with specific activities for learning how to answer them. \n\n\n19 \n\n\n20 Where There Is No Dentist 2009 \n\n\nPARTI: \n\nTEACHING SO THAT LEARNING CAN TAKE PLACE \n\n\nMore children than ever before are having \nproblems with their teeth and their gums. \n\nA tooth that hurts or gums that are \nsore can affect a student's ability to pay \nattention in school and learn. \n\nTreating the problem makes the child feel \nbetter, and that is important. It is equally \nimportant to prevent the same problem \nfrom returning later. \n\n\n\nWorking together, teachers and school children can do much \nto prevent both tooth decay and gum disease. \n\n\nKeeping the mouth healthy involves learning about eating good food and \nkeeping teeth clean. Just giving information is not enough, though. To truly \nlearn, children need a chance to find out things for themselves. \n\n\n\nForcing a person simply to accept what \nyou say does not work very well. \n\nA student learns not to question. What \nyou teach may have no relation to his \nown experiences and needs. \n\nAs a result, he may end up not doing \nwhat you teach — not eating good foods, \nand not cleaning his teeth. \n\n\nLearning happens when a student with a \nquestion or an idea is able to discover more \nabout it himself. \n\nIt also happens when he has a chance to do \nwhatever is necessary to take better care of \nhimself and his family. \n\nHe can learn by doing. Give him a chance to \neat good food and clean his teeth at school. \n\n\nwww. nespcr121n.org \n\n\n'WELL, I WOULD LIKE To\\ \nLOOK AT MY BROTHER’S J \nTEETH FIRST. \n\n\n\nWhere There Is No Dentist 2009 21 \n\n\nLearning about teeth and gums can be fun. When the teaching is real and \npractical, students love to learn. Here are some ideas: \n\nTeaching so that learning can take place \n\n1. Teach and learn together with your school children. \n\n2. Start with what the students already know. \n\n3 . Let students see and then do. \n\n4 . Let children help each other. \n\n5 . Teach about teeth and gums together with other subjects. \n\n6 . Be a good example. \n\n7 . Make the community part of your classroom. \n\n\n1 .Teach and Learn Together with School Children \n\n\n\n\nf(\\ PERMANENT SUCCESSOR UtS' \nAPICAL TO... PAX ATTENTION / \nYOU NEED TO KNOW THIS FOR \nYOUR TSS Tj... EACH PRH^ARY y \n o i \n\n(brother) \n\nwilder 1 yea* *- \n\n1-2 years old \n\nZ-J years old \n\n,/; /> \n\n\n\nMas*' . \n\n- 1 (Sister) \n\n\nn HI l / \n\n/ t:H t / , \n\n/ / 1 / 1 / lb \n\n\nCktn. a. \n\n0 (6 MOnfJlS ) \n\nOld J / \n\nVo \n\n\n\nCcou&ir.) \n\n\n\n///// lill) , \n\nIII'! / \n\n/2o \n\n\nAsk the students what other things they saw inside someone else's mouth. \nThis is a good time for students to discover important things about good \nhealth practices. Encourage them to learn as much as they can from what \nthey see, and then show them how to use a book like this to answer their \nown questions, For example, if students see cavities and red bleeding gums, \nyou can start a discussion on tooth decay and gum disease. Use some of the \nactivities on pages 55 to 60. \n\nFor another example, if the students see a baby who has only a few teeth, \nthey may have some interesting questions. Show them this book and invite \nthem to read pages 63 to 65 to find answers to questions like these. \n\n• Can Chenia, who is 6 months old and has no teeth, eat soft foods? \nShould she have more than just breast milk? \n\n• When Chenia's teeth grow in, will they give her diarrhea and fever? \n\n• Will a 2-year-old girl get more baby teeth? \n\n• Why do we care for baby teeth, when we only need them for a few \nyears? \n\n\no \n\n\n46 Where There Is No Dentist 2009 \n\n\nWhat Makes Teeth Hurt? \n\nTHE IDEA: \n\nA tooth will hurt if it is broken, loose, or if it has a cavity. Cavities are the \nusual cause of toothaches. \n\n\nHealthy teeth are alive. \n\n\nTwo thin strings enter each tooth. One, the nerve, come from the brain and \ncarries the message of pain. The other is the blood vessel. It comes from \nthe heart and carries blood to the tooth. \n\n\nIf you could peel away \nthe gum and look inside \nthe bone, you would see \nthat a nerve and a blood \nvessel go into each one \nof a tooth's roots. \n\nThey give the tooth life \nand feeling. \n\n\n\nThe hard cover of the tooth protects the nerve and blood vessel inside it. But \nwhen tooth decay eats through that cover, the nerve and blood vessel are \nunprotected. A cavity lets food, water and air get closer to the nerve, and \nthat can make the tooth hurt. \n\nThe sugar in food makes tooth decay possible. Sweet food that is also sticky \nis the worst of all because it glues itself to the teeth. Germs inside your \nmouth use the sugar to grow and to work harder at making cavities. \n\n\n\nSee the next section for more discussion of how germs and sugar combine \nto cause cavities. \n\n\nwww. nespenan.org \n\n\nWhere There Is No Dentist 2009 47 \n\n\nA cavity may look small on the outside, but it is much bigger inside. Decay \nspreads more easily in the soft part under the hard cover of the tooth. \n\nA tooth with a cavity may hurt, but it usually does not hurt all the time. This \nis because the bottom of the cavity is close, but not yet on the nerve inside \nthe tooth. \n\n\n\nFill a small cavity and save a tooth. \n\n\nA small cavity that is not treated grows bigger and gets deeper. When the \ncavity finally touches the nerve, it causes a tooth abscess. Infection from \nthe tooth decay going inside the tooth causes the tooth to ache all the time, \neven when you try to sleep. \n\nInfection can pass from the tooth to the bone. As it spreads under the skin, \nthere will be swelling of your face. \n\n\n\n\nA tooth with an abscess must either be taken out \nor have its nerve treated. \n\n\nAn abscessed tooth is dying. When it dies the tooth changes color from \nwhite to dark yellow, grey, or even black. Pus from the end of its root can \npass to the gum, making a sore called a gum bubble. \n\nA tooth is like a light bulb. \n\nWhen the bulb is alive from power inside, it is bright \nand useful. \n\nThe little wires inside the bulb are like the nerves \ninside the tooth. When the bulb burns out, it is dark \nand not useful any more. \n\n\n\no \n\n\n48 Where There Is No Dentist 2009 \n\n\nACTIVITIES: \n\n1. Have each student look inside a partner's mouth. Look for black \nspots that may be cavities, for dark teeth that are dead, and for sores \non the gums, especially near a bad tooth. \n\n2. Discover how sweet food sticks to teeth. \n\n\nCut several different kinds of food with a knife. \n\n\nVegetables and meat do not stick to \nthe knife. \n\nSweet foods, like chocolate and \njam buns, do stick to the knife. \n\nThey stick to your teeth the \nsame way. \n\n\nPour some cola or juice in a dish, and leave it outside overnight. \n\nAs water is lost, the juice left in the dish \nbecomes sticky. It attracts flies. \n\n\n\nThe air you breathe dries the cola and \ncauses a sticky, very sweet coating to \nform on your teeth. It attracts germs. \n\nTry to find some old teeth. Ask the \nstudents to keep their own baby teeth \nwhen they fall out. (Note: in some \ncountries this is not acceptable.) Your \ndental worker can save you some \nteeth that were taken out at the clinic. \n\n\n\n\nScrape the outer cover of the root with a knife. Feel how hard and \nsmooth it is. \n\nThen find out what happens \nwhen the students leave a tooth \nin cola, milk, or plain water. \n\nAfter 3 days scrape each tooth \nagain with a knife. Students will \ndiscover that sweet cola drinks \nmake teeth softer and darker \nin color. \n\n\n\nwww.hesperian.org \n\n\nWhere There Is No Dentist 2009 49 \n\n\n3. Look inside a tooth for the space where the nerve and blood vessel \nused to be. See how close they were to the tooth's hard outer cover. \nLook for a small hole at the end of the root. That is the place where the \nnerve and blood vessel enter the tooth. \n\n\nAsk your dental worker to find an old \ntooth with a cavity and cut it for you. \n\nor ySy \n\n• Take a hammer. I \n\n• Gently break open a tooth. (J \\ \n\n• Look inside. \n\nSee how much bigger the cavity is on the \ninside. It spreads under the hard cover. \n\nCut through a rotten yam. See how the rotten \npart spreads under its skin in the same way. \n\n\n\n4. Do a project in class. \n\n• Count the number of students with cavities. \n\n• Count the number of teeth having cavities. Show the students how \nto look for them on the tops, sides and between the teeth. \n\n• Find out the person's age. \n\nFlave the students write on the blackboard what they counted. Then \nmake a chart or graph. \n\n\n\n• Decide if tooth decay is a serious problem in your school. Ask your \ndental worker to look at your results and to come and treat the \nstudents, and help you prevent the problem from returning. \n\n• Do the same with brothers and sisters at home. Find out if tooth \ndecay is a problem with these young children. Tell your dental \nworker what you find. \n\n\no \n\n\n\n50 Where There Is No Dentist 2009 \n\n\nHow Do Germs Make Holes in the Teeth? \n\nTHE IDEA: \n\nAcid makes holes in the teeth. The acid is made when sweet foods mix with \ngerms in your mouth. \n\nIt is not possible to prevent cavities or gum problems by trying to kill all of \nthe germs in your mouth. There are too many — and some germs are good for \nyou. The important thing is to keep the germs from getting together and \n\nmaking a film or coating on your teeth. \n\nThis film on the teeth is called plaque, but you do not need to use this word. \nEvery morning we can all feel a 'furry film' on our teeth. This film must not \nbe allowed to stay on the teeth! It will mix with sugar and make acid. Worse, \nif it stays in a group (or 'colony') for more than 24 hours, it will mix with \nsaliva, harden, and make tartar (see page 52). \n\nThe main reason for cleaning teeth is to break up these colonies so they \ncannot make acid. Also, if you forget to clean your teeth, tartar will form, and \nyou will need a dental worker to scrape it off. This is why it is important to \nclean your teeth at least every 24 hours, so the tartar can never form on your \nteeth. \n\nTHE ACTIVITY: \n\nHere is a game called \"Scatter!\" that students can play outside. You need: \n\n• Five 'bases' (a tree, rock, or \nthe corner of a house can \nbe a base) in a half circle, \n\n12 meters apart. Each base \nmust have a 'monitor' who \nstays at the base. \n\nNote: children who cannot \nrun can be good monitors. \n\n• One person with a broom. \n\nThis person is the \n\ndecolonizer . Children in Jocuixtita, Mexico, beginning a \n\ngame of \"Scatter!\" The 'decolonizer' is the \ngirl in the center with the broom. \n\n\n\nThe Game: \n\n20 students called 'colonizers' stand facing the decolonizer. When the \ndecolonizer says \"go! \" they try to 'form colonies' around the bases \nbefore the decolonizer can touch them with the broom. \n\n\nwww. nespenan.org \n\n\n\n\nWhere There Is No Dentist 2009 51 \n\n\n\n\nThe 'decolonizer' (with broom) has lost \nthe game. The children behind him have \nformed a 'colony'. \n\n\nThe colonizers win if they make \na colony. There are two kinds of \ncolony: (1) 15 people touching \none monitor at a base, or ( 2 ) a \nchain of 12 people holding \nhands, touching two monitors. \n\nPlay two games: one with \nchildren trying to form the first \nkind of colony, one with the \nsecond kind. These photos are \nfrom the second game. \n\n\nHere the decolonizer stops a boy from \ncompleting a chain. \n\nAfter The Game: \n\nTalk to the students about germs \nin their mouths and how small \nthey are. Can anyone see germs? \nNo, but they can feel them and \ntaste them. Ask the group what \ntheir mouths feel like in the \nmorning when they wake up. You \nmay get these answers: \n\n• My teeth feel mossy. \n\n• My breath is bad. \n\n• I feel a coating on my teeth, \nbut it goes away when I \nbrush them. \n\n\nThe decolonizer tries to stop \nthe others by touching them \nwith the broom. When the \ndecolonizer touches a colonizer \nwith the broom, the colonizer \nmust leave the area for one \nminute. (Give that child a task to \ndo — run around the school-house \nor lie down and sit up 30 times.) \n\nThe decolonizer wins if no \ncolonies form in 5 minutes. \n\n\n\nTo teach about things too small to see, look \nat the suggestion on page 1 1 -29 of Helping \nHealth Workers Learn. \n\n\nTell the students that this coating on the teeth is a 'colony' of germs. They \nare always trying to group together on the teeth or in spaces between the \nteeth — just as the 'colonizers' did in the game! \n\n\no \n\n\n\n52 Where There Is No Dentist 2009 \n\n\nWhat Makes the Gums Feel Sore? \n\nTHE IDEA: \n\nHealthy gums fit tightly around the teeth and help to hold them strongly. \nHealthy gums also cover and protect the bone under them. \n\nHealthy gums are pink in color, or \n\neven blue or dark yellow in some people. \n\nBut healthy gums are never red. \n\nHealthy gums are pointed between \nthe teeth. This lets food slide away and \nbe swallowed. \n\nHealthy gums fold under, making a \nlittle pocket around the tooth. \n\nAs we saw with the last activity (p. 50), when you have 'colonies' of germs \non your teeth, they can make acid that makes holes on your teeth. The same \ncoating of germs can make a different acid that makes the gums sore. This \nalso happens when food mixes with the coating on your teeth. Soft food \nis the worst kind, because when it mixes with spit it sticks more and stays \nlonger on your teeth. Juice from tea, betel nut, and meat color this food, \nmaking the tooth look dark. \n\n\nHealthy gums become sore because of acid. When the coating on the \nteeth (p. 50) becomes hard, it is called tartar. Tartar can hurt the gums. \nAlso, the 'colonies' of germs can make a coating on top of tartar more \neasily than on a clean tooth. When the colonies are new, they make more \nacid which causes tooth and gum problems. After 24 hours, it hardens \nand makes a new layer of tartar. The tartar gets bigger and bigger. \n\nSore gums are infected. \n\nInfected gums are red \nand bleed easily. \n\nInfected gums are round and \nswollen between the teeth. \n\nThey are also loose instead of \ntight against the teeth. \n\nInfected gums have a deep gum pocket which catches even more food. \n\n\nHere is a larger picture of the \nteeth in the box above: \n\n\n\n\n\n\nwww. ncspcri3.ri.org \n\n\nWhere There Is No Dentist 2009 53 \n\n\nInfection in the gums is called gum disease. It is important to treat gum \ndisease early, before it can spread to the root fibers and the bone. \n\n\n\n\n\nACTIVITIES: \n\n\nIf you have sore, bleeding \ngums, you can do much to treat \nthe infection yourself. \n\n1. Clean your teeth with a soft \nbrush gently and more often \n(see page 71). \n\n2. Eat more fresh fruits and \nvegetables. \n\n3. Rinse your mouth with warm \nsalt water. \n\n4. Clean between your teeth \nwith dental floss or string. \n\nAt first your gums may bleed \nwhen you do this. But when \nthe gums are stronger the \nbleeding will stop. \n\n\n1. Have the students look in each other's mouths. \n\nCan they see the coating on the teeth? Usually \nthey cannot. They may see food or 'white stuff', but \nthis is not the coating that makes acid. However, \nif someone has been chewing betel nut or eating \nberries, you will see stains on her teeth and the \nstains will be darkest where she has these \ncolonies of germs on her teeth. \n\n\n\n2. Put something on the teeth to stain the colonies of germs. Try using \nfood dye, betel nut or berry juices. Remember: first wash your hands! \nOlder students can rub berries on the teeth of the younger ones. Have \nthem rinse with a little water and spit it out. After this, the colored areas \non the teeth will show where the colonies of germs are forming. Where \nare they? Usually you will see the dark colors: \n\n• between the teeth \n\n• in the pits or holes in the teeth \n\n• on the tops (biting surfaces) of the teeth. \n\nThe older students can show the younger ones the best way to clean \nteeth (see pages 69-72). Have them use a mirror to see if they are getting \nthe colored juice from their teeth. They will learn that it is most difficult to \nget rid of the color between their teeth. Give them some string, dental \nfloss, or the soft stem from a young palm leaf and show them how to use \nit between their teeth (p. 72). Remind them to be gentle, or they will hurt \ntheir gums. Clean between your teeth every day. \n\n\no \n\n\n\n54 Where There Is No Dentist 2009 \n\n\nWhat Does It Mean if a Tooth is Loose? \n\nTHE IDEA: \n\nBaby teeth become loose when children are between 6 and 12 years old. \nThis is normal. If a loose baby tooth does not have a cavity, and if the gums \naround it are healthy, there is probably a permanent tooth growing under it. \n\nBut a tooth might be loose because it is broken or because it is sick from an \nabscess or gum disease. Either can destroy the bone around the tooth's roots. \n\n\n\nWhen bone is lost, the tooth \nbecomes loose. A loose tooth hurts \nand usually must be taken out. \n\nThere is no medicine to make bone \ngrow back around the roots of \nloose teeth. All you can do is stop \nthe infection from getting worse. \n\n\n\nACTIVITIES: \n\n1. Let the students look into each other's mouth for loose baby teeth. \nLook carefully to see why a tooth is loose. \n\n\nTouch the gum and bone beside the \nloose tooth. You can feel a bump — it is \nthe new permanent tooth growing. \n\nSave the baby tooth after it has fallen \nout. Look to see how the permanent \ntooth has eaten away its root by \npushing against it. \n\n2. Look for teeth that have cavities or gum \ndisease around them. The students can do \nthis with each other, and then later at home. \n(Remember they must wash their hands! \n\nA tooth that has some of its root showing \nis probably loose. \n\nUsing your fingers or the handles of two \nspoons, rock the tooth back and forth \ngently. See how much it moves, and ask \nhow much it hurts. \n\nTell the person what he can do to \nprevent other teeth from becoming \nloose. (See the next section.) \n\n\n\nwww.hespenan.org \n\n\nWhere There Is No Dentist 2009 55 \n\n\nHow Can We Prevent Cavities and Sore Gums? \n\n\nEating good food and carefully cleaning the teeth prevents both tooth decay \nand gum disease. \n\n\nFood from your own garden and local food from the market is best. \n\nThese foods are good for your body, your teeth, and your gums. \n\n\n\n\nVegetables, especially \nthose with dark green \nleaves. \n\n\n\nPeas and beans, like green \nbeans, soybeans, winged \nbeans, and mung beans. \n\n\n\nOil, from palm nut \nkernels, ground nuts, \nand coconut. \n\n\nFruits, like banana, \nguava, oranges, \nand papaya. \n\n\n\nFish, meat and eggs. \n\n\n11^0 0 & \n\nClean water, coconut \nwater, and milk are best \nto drink. \n\n\n\nSoft foods and sweet foods from the store \nare not good for you. Soft foods stick to your \nteeth easily. They can work longer to cause \ncavities and infected gums. Sweet foods have \nmostly sugar in them, and it is 'factory sugar', \nnot the 'natural sugar' that is in the foods in \nthe pictures above. \n\nThis kind of sugar is quick to mix with germs \nand make acid. Remember: natural sugar \nmakes acid slowly; factory sugar makes acid \nquickly. \n\nChildren who eat a lot of sugar lose their \nappetite for other foods — the foods that help \nthem grow strong, stay healthy, and learn well \nin school. \n\nStore foods are also expensive. You can usually \nget better food, and more of it for the same \nmoney, from your garden or in the market. \n\n\no \n\n\n\n56 Where There Is No Dentist 2009 \n\n\nCleaning your teeth carefully every day is another important way to take care \nof both teeth and gums. However, cleaning teeth is like building a house. \nTo do a good job, you need to work slowly and carefully. Once a day is \nenough, if you clean your teeth well every day. \n\n\n\nBuy a brush from the store, or make one yourself (see p. 4). But be sure the \ncleaning end of the brush is soft so that it won't hurt the gums. \n\n\n\nUse your brush to clean all the teeth, especially the back ones with the \ngrooves. Back teeth are harder to reach and so it is easy not to clean them \nwell enough. Cavities start from sweet food and germs left together inside \nthe grooves. \n\n\n\n1 . \n\n\n2. \n\n\n3. \n\n\nScrub the inside, \noutside, and top of \neach tooth. \n\nPush the hairs of \nyour brush between \ntwo teeth. Sweep \nthe food away. \n\nWash your mouth \nwith water, to \nremove any loose \nbits of food. \n\n\n\n\nSmall children are not able to clean their teeth carefully enough by \nthemselves. They need help. Look at the pictures on the cover and p. 1 8 to \n\nsee how you can do this. Older children can care for younger brothers \nand sisters at home. \n\n\n\nWhere There Is No Dentist 2009 57 \n\n\nACTIVITIES: \n\nOne of the best ways to teach is by example. \n\n\n\nSO AT HOME WEN \nPUT BOTH DRIED FISH \\ \nAND DREEN LEAVES \\ \n\n\nINTO THE SOUP. MY \\ \n\n\nJchildren UKE IT VERY) \n\\N\\UCH. YOU WILL TOO [J \n\n\nStudents will believe what their teacher says if they know he eats good food \nand cleans his teeth. \n\nThe reverse is also true. Learning is harder when students know that their \nteacher does not do those things himself. \n\nStudents can be a good example for their community, too. They can: \n\n• draw pictures of foods that are both good and bad for teeth. Use them \nto make posters and flannel-board stories. \n\n• make puppets and plays to discuss ways people can become healthier. \nThere are some other ways to make learning meaningful and fun. \n\n1. Make a garden at school. Divide the ground so that each class has its \nown space to plant a garden. \n\nUse some of the garden's food to prepare a meal for the students, \nperhaps once a week. Students can bring food from home if there is \nnot enough ready in the garden. \n\n2. Organize a school lunch program. Each day the students can bring \nsome good food from home. Cooked yams, or maize, nuts, fruit and \nfresh vegetables are all good. Often the students will exchange food \nand talk about the many different foods that can be grown locally. \n\n\n\n58 Where There Is No Dentist 2009 \n\n\n3. Find the best way to clean teeth. Divide the class into groups. They will \nlearn more easily in a small group of 4 to 8 students. \n\nGive all the students something to eat that is sweet, sticky and dark in \ncolor, such as sweet chocolate biscuits. Ask the students to look in each \nother's mouth, to see how easily the biscuit sticks to the teeth. One or \ntwo of the students in a group can then try to clean away the pieces of \nbiscuit, using a different method. \n\n\n\nWhen they are finished, the students can look at the teeth to decide if \nthey are clean or not. Put your findings on a chart and talk about what you \nhave learned. \n\n\n\nwww. ncspcri3.ri.org \n\n\nWhere There Is No Dentist 2009 59 \n\n\n4. Make cleaning part of a daily health activity. Older students can \nlook after younger students. They can first check their hair for lice, then \nsores for infection, and teeth for old food or germs. (To see the coating \nof germs on the teeth, try the activity on page 53.) One partner can \npoint out to the other where washing and brushing can be done better. \n\n\n\nCLEANLINESS CAN BEGIN AT SCHOOL \n\nAt school, students can wash their hands before lunch and brush their \nteeth afterward. Encourage them to keep a piece of soap and a toothbrush \nor brushstick (p. 4). One day a week, the whole class can treat their teeth \nwith fluoride (p. 205) to prevent cavities. \n\n\n\nThe student \ncan keep the \nbrush at her \nown desk... \n\n\n... or on a \nrack at the \nback of the \nroom. \n\n\no \n\n\n\n60 Where There Is No Dentist 2009 \n\n\nHave the students score each other's progress. Do not make it hard to judge, \nor they will not do it. In the example below, the tooth is either clean or net \nclean. \n\n\n1 \n\n\n\nSCORING TEETH \n\nPick 4 teeth, a back tooth and \na front tooth — two on top and \ntwo on the bottom. \n\nUse the same 4 teeth for each \nperson. Look for food on each \ntooth near the gums. \n\nA clean tooth = 2 points. \n\nA dirty tooth = 0 points. \n\nTotal possible points each day \nis 4 teeth x 2 = 8 points. \n\nIn this example the score is: \nTooth 1 = 2 points \nTooth 2 = 0 points \nTooth 3 = 0 points \nTooth 4 = 2 points \nTotal =4 points \n\n\nHave each student put his daily score on a chart. At the end of the month he \ncan see how much he has improved. \n\n\n\nwww. ncspcri3.ri.org \n\n\nCHAPTER \n\n\nTaking Care of \nTeeth and Gums \n\n\nWe can prevent most tooth and gum problems. This chapter gives more \ninformation about how teeth grow in and how to keep teeth and gums \nhealthy. Share this information and you will prevent problems from starting. \n\nBut remember that people are most interested in the problems they have \nnow. Before listening to what you know about prevention, people will \nwant treatment for the problems that are already causing them pain and \ndiscomfort. \n\n\nEarly treatment is a form of prevention. \nIt can prevent a tooth or gum problem \nfrom becoming more serious. \n\n\nWhen you treat a person's problem, it shows that you care about him. It \nalso shows that you know what treatment he needs. As his confidence in \nyou grows, he will want to learn from you about preventing tooth or gum \nproblems. \n\n\nIn order to help a person it is \nimportant to know what the \nproblem is and what is the \nbest treatment. But just as \nimportant is knowing what \nyou are not able to do, and \nwhen to seek help. \n\nIn this chapter, you will learn \nmore about teeth, gums, and \nproblems affecting them, \nbut you must never be too \nproud to get help from more \nexperienced dental workers. \n\n\n\nKnow your limits. \n\n\n61 \n\n\no \n\n\n62 Where There Is No Dentist 2009 \n\n\nTAKING CARE OF BABY TEETH \n\nA child's baby teeth are being made before birth while the baby is still inside \nthe mother's womb. During the last months of pregnancy and the first few \nmonths after the child is born, the baby teeth take their final form. Pregnant \nmothers and young children need good food and good health in order \nto have strong baby teeth. \n\n\nStrong teeth \n\nare white and their \nfront surface is smooth. \n\n\n\nWeak teeth \n\nhave yellow marks that \nare pitted and rough. \n\n\n\nBaby teeth get marks on them when: 1) the pregnant mother is sick or does \nnot eat good food; 2 ) the young baby is sick or does not eat good food; or, \nsometimes, 3 ) the baby's birth was early or the delivery was difficult. \n\n\nThe marks are rougher than the rest of the tooth. Food \nsticks easily to them and turns the tooth yellow. \n\nThe marks are also soft. They need to be cleaned well \nevery day (p. 63) to prevent them from becoming \ncavities. A tooth with a cavity hurts. When children's \nteeth hurt, they do not want to eat as much. \n\n\n\nCavities in baby teeth can make a child's malnutrition worse. Remember \nthis whenever you see a weak, poorly nourished child. When you examine \na child at the health clinic, lift his lip and look at his teeth. Do this as part of \nyour routine examination. \n\n\n\nYou can fill cavities with cement (Chapter 10). \nCement prevents food and air from going inside \nthe cavity and hurting the child. \n\nA sore on the gums may be a gum bubble. If so, \nit means the tooth has an abscess (page 81). \nThat cavity should not befilled with cement. \nInstead, the tooth needs to be taken out \n(Chapter 1 1) before the infection can get worse. \n\n\n\\ni\\ \n\n\noi \n\n\n\nWhere There Is No Dentist 2009 63 \n\n\nFor baby teeth to grow strong, mother and baby must stay healthy.* Help \nher to understand how important this is. A pregnant mother should: \n\n• Eat enough good kinds of foods, both for herself and her baby growing \ninside (page 68; also see Where There Is No Doctor, Chapter 1 1 , and \nHelping Health Workers Learn, pages 25-39 to 25-44.) \n\n• Attend health clinic each month, so the health workers can examine her \nregularly and she can receive important medicines (see Where There is \nNo Doctor, page 250). \n\n• Not use the medicine tetracycline, because it can cause the teeth \nto turn dark. You, the health worker, must remember — do not give \ntetracycline to a pregnant woman or to a young child. If she needs \nan antibiotic, use a different one. \n\nFor baby teeth to stay strong, and to prevent marks from turning into \ncavities, mother should: \n\n• Continue to breast feed and never feed her \nchild juice or sweet tea from a bottle. Start \nadding soft foods, mashed banana or papaya \nwhen the child is 6 months old. \n\n• Wipe her baby's teeth with a clean cloth after \nthe baby eats. This cleans the baby's teeth, \nand helps the baby get used to teeth cleaning. \n\nLater he will be happy with a brush. \n\nAround 1 year of age, there will be several baby teeth. At that time, mother \nshould start using water — not toothpaste — on a soft brush or brushstick. \n(With toothpaste, you cannot see the child's teeth clearly because of the \nbubbles it makes.) She should scrub the sides and tops of each baby tooth \nas well as she can (page 69). \n\nThe child can also try to clean his own teeth. That should be encouraged. \nHowever, since he is too young to clean properly, mother (or father, or older \nbrother, sister) must clean his teeth once a day for him. Continue helping in \nthis way until the child is old enough to go to school. \n\nYou can make a large brush smaller, \nto fit more easily into a young \nchild's mouth. \n\n\nPull out some of the back hairs, or \ncut them out with scissors. Do not \ncut the hairs in half, because the \ntops are often rounded or softer, and \nthat is better for the gums. \n\n*See the story about pregnancy and dental care on pages 15-16. \n\n\n\n\no \n\n\n64 Where There Is No Dentist 2009 \n\n\nWhy Baby Teeth Are Important \n\nBaby teeth are just as important to children as permanent teeth are to adults. \nThey help a child to eat, talk, and look good. \n\nHowever, many people feel that it is not worth the effort to look after baby \nteeth. Nor is it worth fixing them. After all, parents think, the permanent teeth \nwill take their place. \n\nThis kind of thinking is understandable. The problem is that we are forgetting \none other useful purpose of baby teeth. Baby teeth keep space in the mouth \nfor the permanent teeth to grow in. If there is not enough space, the new \nteeth will grow in crooked, and cavities grow faster around crooked teeth. \n\n\n\nUnder each baby tooth a new \npermanent tooth is growing. \n\nAt the same time, extra \npermanent molars are forming \nat the back of the mouth, \ninside the bone (page 43). \n\nFront baby teeth become \nloose and fall out (usually \n6-7 years, but sometimes as \nyoung as 5 years) ahead of \nback baby teeth (1 0-1 2 years). \nThis is because the front \npermanent teeth are formed \nand ready to grow in first. \n\n\nThe permanent molar (1 PM) is often the first of the permanent teeth to grow \ninto the mouth. That happens at 6 years of age. \n\n\n\nThe first permanent molar grows into \nthe mouth by sliding against the back \nof the second baby molar (2BM). \n\n\nSlowly but steadily the upper and \nlower permanent molars grow until \nthey meet and fit tightly together. \n\n\noi \n\n\nWhere There Is No Dentist 2009 65 \n\n\nBetween the ages of 6 and 1 1 , a child needs healthy baby molars to guide \nthe first permanent molars into position and then to hold them there. When \nthe first permanent molars grow into the right place, this is a good sign. It \nmeans the other permanent teeth will also grow in properly, because they \nwill have enough space. \n\nNote: Some people are born without enough space. But most people are \nnot born with this problem — they lose the spaces when they remove \nbaby teeth instead of fixing them. \n\n\nHEALTHY BABY TEETH . help , — ►STRAIGHT PERMANENT TEETH \n\nto make \n\n\n\n\nSICK BABY TEETH , help , — ► CROOKED PERMANENT TEETH \n\nto make \n\n\n1PM 2B \" \n\n\n\n1 0 years \n\n\n\nTell mothers why baby teeth are important. Good food and regular cleaning \nkeep them healthy. They should know that new teeth coming in do not \ncause diarrhea and fever, but that a child may have diarrhea or fever at the \nsame time. \n\n\nIf there is a cavity, fix it so the tooth can be kept in the mouth to do its \nimportant work (see Chapter 10). \n\n\no \n\n\n66 Where There Is No Dentist 2009 \n\n\nTAKING CARE OF MOLAR TEETH \n\nWe often notice front teeth growing in, but not the back ones. Back teeth \nmolars are not so obvious. Swelling on the face can be either a new molar \ngrowing in or an abscess. So, to help you to decide, look at the tooth for a \ncavity and at the gums beside it for a gum bubble. \n\n\n\nBut if the person is young (16-22 years), it often is not an abscess. The third \npermanent molar tooth may be growing in at the back of her mouth. As the \ntooth grows, it cuts through the skin. Just as a dirty cut on a person's hand \ncan get infected, the cut gum around her new tooth also can get infected, \ncausing a swollen face. \n\n\nSee the red swollen skin on \n\nLook behind her back teeth. top of the new tooth. \n\n\n\nIf there is enough space for the tooth, it will grow in by itself. It only needs \ntime. Before acting, decide how serious the problem is. \n\nIf there is no swelling and she can open her mouth, explain to her what is \nhappening and what she can do herself to reduce infection and toughen the \ngums. The best medicine is to rinse warm salt water over the sore area. A \ngood home remedy is to rinse until the tooth grows all the way into the mouth. \n\nIf it does appear serious (severe pain, swelling, not able to open the mouth), \nsee page 94 for further treatment. \n\n\n\\ni\\ \n\n\noi \n\n\nWhere There Is No Dentist 2009 67 \n\n\nTAKING CARE OF ALL YOUR TEETH \n\nThis book often repeats an important message: eat good food and clean \nyour teeth. It is repeated because this is the most important thing you \ncan learn from this book. Later chapters will discuss what to do when \nproblems occur, but if you follow these two suggestions, you will almost \nnever have problems with your teeth and gums. This is true because good \nfood keeps your whole body healthy, including your teeth. Also, with no \n'colonies' of germs (page 50) or harmful factory sugar (page 55) on your \nteeth, your mouth cannot make the acids that cause both tooth and gum \nproblems. So, remember: \n\n1. Eat Good Food \n\nAn easy-to-remember rule is the same foods that are good for the \nbody are good for the teeth. A healthy body is the best protection \nagainst infection. \n\n\n>d nutrition (eating well) means 2 things: \n\nEat a mixture of different kinds of foods \nevery time you eat. Look at the pictures \non page 55. There are several groups of \nfoods. Every time you eat, try to eat one \nor two foods from each of the groups. This \nway, you will get 3 important kinds of food: \ngrow food (body-building food) to give you \nthe protein you need; glow food (protective \nfood) to give you vitamins and minerals; and \ngo food (concentrated energy food) to give \nyou calories to be active all day. \n\n2) Be sure you eat enough \nfood to give your body the \nenergy it needs. This is even \nmore important than the first \nsuggestion. We get half or \nmore of our energy from our \nmain food. In most parts of the \nworld, people eat one low-cost \nenergy food with almost every \nmeal. Depending on the area, \nthis main food may be rice, \nmaize, millet, wheat, cassava, \npotato, breadfruit, or banana. \n\nThe main food is the central or \n'super' food in the local diet. \n\n\n\nA spoonful of cooking oil \nadded to a child's food \nmeans he only has to eat \nabout 3 A as much of the \nlocal main food in order to \nmeet his energy needs. The \nadded oil helps make sure \nhe gets enough calories by \nthe time his belly is full. \n\n\n\nThe MAIN FOOD is at \nthe center of every meal. \n\n\no \n\n\n68 Where There Is No Dentist 2009 \n\n\n\nBe sure always \nto eat grow \nfoods and \nglow foods \nto get the \nvitamins and \nprotein you \nneed. \n\n\nYour energy \nfoods give \nyou the most \nimportant \npart of your \ndiet — calories. \nHalf or more \nof our \n\ncalories come \nfrom the main \nfood, and most \nof the other \ncalories come \nfrom go foods. \n\n\nWARNING ABOUT GO FOODS: Although go foods give us the energy \nwe need, some go foods are worse than others. Honey, molasses and \nespecially white sugar can be very bad for the teeth, even though they \nhave the calories we need. Fruits, nuts, and oils all give us energy (calories) \nwithout attacking the teeth. \n\n\noi \n\n\n\n\nWhere There Is No Dentist 2009 69 \n\n\n2. Clean Your Teeth \n\nCleaning teeth requires time and care. If you hurry, you will leave food \nand germs behind, and they continue to make cavities and sore gums. \n\nYou may find that different dental workers recommend different ways \nof brushing teeth. Some ways are definitely better, but often they are \nharder to learn. \n\nTeach a method of cleaning that a person can learn and will do at home. \nLet him start by scrubbing his teeth (and his children's teeth) back and \nforth, or round and round. Encourage him to improve his method only \nwhen you think he is ready. \n\nToothpaste is not necessary. Some people use charcoal or salt instead. \nBut it is the brush hairs that do the cleaning, so water on the brush is \nenough. \n\nScrub the outside, inside, and top of each tooth carefully. \n\n\n\nWhen you finish, feel the tooth with your tongue to make sure it is \nsmooth and clean. \n\nFinally, push the hairs of the brush \nbetween the teeth and sweep away \nany bits of food caught there. Do \nthis for both upper and lower teeth. \n\nSweep away in the direction the \ntooth grows: sweep upper teeth \ndown and lower teeth up. \n\n\no \n\n\n\n\n70 Where There Is No Dentist 2009 \n\n\nExplain how important it is to use a brush with soft hairs. A brush that is stiff \nand hard will hurt the gums, not help them. \n\n\n\nYou can make a hard brush softer \nby putting the hairs into hot water \nfor a few minutes. \n\nDo not put the plastic handle into \nthe hot water, or it will melt. \n\n\n\nIf your store has only hard brushes, tell the store keeper that hard \ntoothbrushes do not help the people in the community. Ask him to order and \nsell only soft toothbrushes. \n\n\nNote: Another important way to reduce cavities is by adding \nfluoride to teeth. Fluoride is a substance which, like \ncalcium, makes teeth harder and stronger. \n\nFluoride in drinking water, toothpaste, salt, vitamins, and mouth \nrinses helps to prevent cavities. These methods are sometimes \nexpensive. But treating teeth once a week with fluoride toothpaste \nis effective and inexpensive. See page 205. \n\nFluoride can also be found naturally in food and water. For \nexample, tea leaves and most foods from the sea contain a large \namount of fluoride. \n\nSo, your source of fluoride can be either: \n\n\n\noi \n\n\n\nWhere There Is No Dentist 2009 71 \n\n\nCLEANING BETWEEN THE TEETH IS VERY IMPORTANT \n\nHere are three ways to clean between the teeth: \n\n1. Push the hairs of a toothbrush between the teeth, and sweep the bits \nof food away. \n\n2 . Remove the stem from a palm leaf. Use the thinner end and move it \ngently in and out between the teeth. \n\n\n\n3 . Use some thin but strong thread or string. String can be the best \nmethod of all — but you must be careful with it. \n\n\n\nand use one strand of it. \n\n\n\nBuy and use dental floss.This \nis a special kind of string for \ncleaning between the teeth. \n\n\nBe careful! The string can hurt your gums if you do not use it correctly. \nThe next page shows how to use the string, but the best way to learn \nhow to 'floss' your teeth is to have someone show you. Ask a dental \n\nworker who has experience. \n\n\no \n\n\n72 Where There Is No Dentist 2009 \n\n\nWrap the ends of the \nstring around the middle \nfinger of each hand. \n\n\n\nUse the thumb and finger to guide the string. Go back and forth to slide the \nstring between two teeth. Be careful not to let it snap down and hurt the gums. \n\n\n\nWith your fingers pull the \nstring against the side of one \ntooth. Now move the string \nup and down. Do not pull \nthe string back and forth or \nit will cut the gum. \n\n\n\n\nLift the string over the pointed \ngum and clean the other tooth. \n\n\n\n\nWhen you have cleaned both teeth, release the string from one finger and \npull it out from between the teeth. Then wrap it around your two middle \nfingers once again, and clean between the next two teeth. \n\n\nRemember: clean teeth and good food \nwill prevent almost all dental problems. \n\n\n01 \n\n\nExamination \nand Diagnosis \n\n\nCHAPTER ^ \n\n\nWhenever you do an \nexamination, remember \nto examine the mouth. \n\nYou can prevent much suffering \nand serious sickness when \nyou notice and treat problems early. \nWhenever you hold a health clinic, try \nto find out how healthy each person's \nmouth is. \n\n\nAsk if she is having a problem now, or \nhas had a problem recently. \n\nAlways write down what you find out, \nso you remember what treatment that \nperson needs. \n\n\n(are the teeth healthy? ) ( \n\n(are THE 6U>AS HEALTHY?) 0 \n\n(are THERE AMY sores?) 0 \n\n\n\nWhen you look inside someone's \nmouth, ask yourself these questions. \n\n\n1. Are the teeth healthy? Look for: \n\n\n\nTell the person what is \nhappening and how to \nkeep the skin around it \nhealthy (page 66). \n\n\nThey may be cavities \nwhich should be \nfilled when they are \nstill small (page 47). \n\n\n4. A Dark \nTooth \n\n\nTell the person what is \nhappening and how to prevent \nit from getting worse or \naffecting other teeth (page 54). \n\n\nA tooth that is dark is dead infection from its \nroot can go into the bone (page 47). This can \nmake a sore on the gums (page 74). \n\n\no \n\n\n73 \n\n\n74 Where There Is No Dentist 2009 \n\n\n2. Are the gums healthy? \n\nLook at page 52 and compare the pictures of healthy and unhealthy gums. \n\nUnhealthy gums often are red and they bleed when you touch them. \n\nA bubble on the gums below the \ntooth is a clear sign that the person \nhas an abscess. The abscess may be \nfrom the tooth, or it may be from the \ngums. To decide, look carefully at \nboth the tooth and the gum around it. \n\nA bubble beside a healthy tooth is a sign \nof infected gums. Scale the tooth carefully. \n\nSee Chapter 8. \n\nA bubble beside a decayed tooth is a sign \nof a tooth abscess. (See page 93.) \n\nA sore on the gums from a badly decayed \ntooth appears when a gum bubble breaks \nopen and lets out the pus from inside. \n\n\nx 1 , \n\nv ' /• \n\n\nV 0 \n\n\nGUM BUBBLE \n\n\n\n3. Are there any sores? \n\n\nLook for sores under the smooth skin on the inside of the lips and \ncheeks. Look also under the tongue and along its sides. \n\n\nA \\ \n\ncs* \n\n^7, \n\n\nW <-') J \n\n\nc=6& yol 1 \n\n7Al \n\n\n1. A sore on the \n\n2. Sores on the inside \n\n3. Sores on the \n\ngums may be \n\nof the lip or cheek \n\nlips or tongue \n\nfrom an infected \n\nmay be from a \n\nmay may be \n\ntooth (p. 93). \n\nvirus (p. 104). \n\ncancer (p. 125). \n\n\nAfter your examination, tell the person what you have found. If you notice \na problem starting, explain what to do to prevent it from getting worse. If \nthere are no problems and the mouth is healthy, congratulate the person. \n\n\nShare your knowledge — explain things to people. \nHelp them learn how they can prevent and even \nmanage their own problems with their teeth. \n\n\nWhere There Is No Dentist 2009 75 \n\n\nWHERE TO EXAMINE \n\nExamine people in a light and bright place. It is dark inside a person's mouth, \nso you need light to see the teeth and gums. \n\nUse the sun. Examine outside, or inside a room facing the window. With \nsunlight alone, you will be able to see most places in the mouth well \nenough. If you cannot, set up a lamp or have someone hold a lamp for you. \nReflect the light off a small mouth mirror onto the tooth or gum. \n\n\nIf you have a low chair, lift up the person's \nchin so that you do not have to bend over \nas far when you look into the mouth. An \neven better way is to have the person sit \non some books. The person's head can \nlean back on a piece of cloth. \n\nUse an old chair with a strong back. \n\nAttach two flat sticks to the chair. Then \ntie a strip of clean cloth to the sticks. Tie \nit strong enough to support the head, but \nloose enough to let the head lean back. \n\n\n\nTHE INSTRUMENTS YOU NEED \n\nThree instruments are really enough: \n\n\n\n\n\n\n\n\n\n\n1. A wooden tongue blade to hold back \nthe cheek, lips, and tongue. \n\n2 . A small mirror to let you look more \nclosely at a tooth and the gums \naround it. \n\n3 . A sharp probe to feel for cavities and \nto check for tartar under the gum. \n\n\nIf you have many people to examine, it is helpful to have more than one of \neach instrument. But be sure they are clean. \n\nDirty instruments easily can pass infection \nfrom one person to another. After you finish \nan examination, clean your instruments in soap \nand water and then leave them in a germ-killing \nsolution like the ones described on page 89. \n\n\n\no \n\n\n76 Where There Is No Dentist 2009 \n\n\nA GOOD DIAGNOSIS \n\nYou are making a diagnosis when you decide what a person's problem is \nand what is causing it. To do this, you need information. You need to make a \ncareful examination to make a good diagnosis. \n\n\nLearn all you can about the person's problem: \n\n1. Ask questions about the problem. \n\n2 . Look at the person's face. Think about the person's age. \n\n3 . Examine the mouth more carefully than before. \n\n4 . Touch the place that is sore. \n\n\n1. Ask the person about the problem. \n\nGive a sick person a chance to \ndescribe how he is feeling. \n\nListen. Think about what possibly is \nhappening in his mouth. \n\nYou may have an idea what the \nperson has. Now try to find out \nmore by asking questions: \n\n• What is the problem? Ask him \n\nto talk about the pain, swelling, \nbleeding, or whatever he is feeling. \n\n• Where does it feel that way? See if he can put his finger on the tooth \nor place that is bothering him. \n\n• When do you have the most pain? Find out if it happens all the time \nor only some of the time (for example, when he drinks something very \ncold). \n\n• When did it start? Find out if he has already had this problem before. \nAsk how he took care of it. \n\n• Have you had an accident or injury lately? Infection still inside the \nbone from an old injury in the mouth can make a sore on his face, or \nstart swelling. \n\n• Are you having other problems? A head cold or fever can make the \nteeth hurt. \n\n• How old are you? Think about a new tooth coming into the mouth. \nAfter you hear the answers to your questions, decide if your original idea \nis the correct diagnosis. If not, try to think of another possibility and ask \nmore questions. This is the scientific method of making a diagnosis. \n\nFor a good explanation of scientific method, see Chapter 17 of Helping \nHealth Workers Learn. \n\n\n\nWhere There Is No Dentist 2009 77 \n\n\nWhen you talk to a woman, find \nout if she is pregnant. A pregnant \nwoman's gums can easily become \ninfected. The gums may bleed and \nshe may have more tooth decay. \n\nBut this does not have to happen. \n\nIf a pregnant woman takes extra \ncare of her teeth and gums, she can \nprevent most dental problems. But \nif she already has a problem, do not \nwait for the baby's birth before you \nhelp her. You can treat a pregnant \nwoman's mouth problems now. In \nfact, this may be an important way of \nprotecting her baby as well (see pages \n15 to 16). \n\n\n\nTrain midwives to examine \nwomen's mouths. When \nthey send women to you for \ndental care, they can give \nyou helpful information \nabout the women's health. \n\n\nCaring for a pregnant woman — a guide for dental workers \n\n1. Ask her how many months she has been \npregnant and find out if she has high blood \npressure. Any person with blood pressure over \n1 50/1 00 may bleed excessively after extraction \nTo get this information, encourage all women \nto have regular check-ups with a midwife or a \ntrained health worker who has equipment for \nmeasuring blood pressure. \n\n2 . Do not take X-rays of teeth unless absolutely \nnecessary. X-rays are dangerous to the unborn \nbaby inside. Before an X-ray, always cover the \nmother's chest, belly, and thighs with an apron \nlined with lead. \n\n3 . Always give a careful and complete mouth examination. Tell her \nwhat treatment she needs and how to prevent tooth problems. \n\n4 . Be gentle. Show the woman that you care, that you want her to \nbe comfortable, and that you can treat her without hurting her. \n\n\n\no \n\n\n78 \n\n\nWhere There Is No Dentist 2009 \n\n\n2. Look at the person. \n\nPeople have some problems more often at certain ages. When a person \nfirst comes in to see you, notice his age. Then, before you ask him to \nopen his mouth, look at his face for a sore or swollen area. \n\n\n\nSWELLING \n\n\n\nA A\\) \n\n\nQ *1 \n\nJjkjL \n\n) \n\n\n\nCHILD \n\nYOUNG PERSON \n\nADULT \n\nSwelling can come from: \n\nSwelling can come from: \n\nSwelling can come from: \n\n• mumps \n\n• a new tooth growing \n\n• a tooth abscess (p. 93) \n\n• an infection in the spit \n\nin (p. 100) \n\n• a broken jaw (p. 1 1 3) \n\ngland (p. 1 19) \n\n• a tooth abscess (p. 93) \n\n• a tumor (p. 125) \n\n• a tooth abscess (p. 93) \n\n\n\n\nWhere There Is No Dentist 2009 79 \n\n\n3. Examine inside the mouth. \n\nRemember what the person said, the person's age, and what you saw. \nNow look more closely at the problem area. \n\n\n\nLook at the teeth: \n\n• Is a new one growing in? \n\n• Is a tooth loose? \n\n• Is there a dark (dead) tooth? \n\nLook at the gums: \n\n• Are they red? \n\n• Is there any swelling? \n\n• Do they bleed? \n\n• Are the gums eaten away \nbetween the teeth? \n\n\nLook also for sores on the inside of the cheek or lips, and on the tongue. \n\n\n4. Touch the sore place. \n\nTouching is a good way to find out how serious the problem is. This will \nhelp you decide which treatment to give. \n\n\nPush gently against each tooth in the area of pain to see if a tooth is \nloose. Rock the loose tooth backward and forward between your fingers, \nto see if it hurts when you move it. \n\n\nUsing the end of your mirror, tap against \nseveral teeth, including the one you suspect. \n\n\nThere is probably \nan abscess on a \ntooth that hurts \nwhen you tap it. \n\n\n1 MUST TAKE OUT \nYOUR TOOTH. IT \nHAS AN ABSCESS. \n\n\n\nMo.p_ \n\n\n\nPress against the gums with cotton gauze. Wait a moment, and then look \nclosely to see if they start bleeding. Then use your probe gently to feel \nunder the gum for tartar. Carefully scrape some away. Wait and look again \n\nto see if the gums bleed. When gums bleed, it is a sign of gum disease. \n\n\no \n\n\n80 Where There Is No Dentist 2009 \n\n\nLEARN TO TELL SIMILAR PROBLEMS APART \n\nIf a person comes to you with a toothache or a sore \nor a loose tooth, there are many possible causes for \neach problem. The first thing you notice — the \ntoothache, sore or loose tooth — is your first step \nto a diagnosis. To this you must add more information \nbefore you can point to the most probable cause. \n\nPut together what you have found with what \nyou already know about teeth and gums. You \ncan make a good diagnosis of a problem without \nknowing a special name for it. \n\nUsually it is easy to make a diagnosis. However, \nsometimes you will not be sure, and these are \nthe times to seek the advice of a more experienced \n\ndental worker. Never pretend to know something you do not. Only treat \nproblems that you are sure about and have supplies to treat properly. \n\nSee Where There Is No Doctor, p. w4. \n\n\n\nUse the charts beginning here to help you make the diagnosis. For more \npractice using charts to tell problems apart, see Chapter 21 of Helping \nHealth Workers Learn. \n\n\nIF THE PERSON AND YOU FIND OUT \n\nHAS THAT \n\nHE/SHE \nMAY HAVE \n\nSEE \n\nPAGE \n\nt It hurts only after eating or V ^/'WTTT \n\ndrinking. There is a cavity, but the ~‘x ' \\T? \n\ntooth does not hurt when you tap it. ,3y /\\ \n\n\nT \n\na cavity \n\nt \n\n92 \n\nPart of the filling has fallen out, or is \n\ncracked and ready to fall out. Eating ' r \n\nand drinking make the tooth hurt. /V \n\na cavity \nunder an \nold filling \n\n92 \n\nA TOOTHACHE The t0 °th hurts when chewing food. . \n\nIt may hurt when tapped, but there is l X \n\n^T~ no cavity and the tooth looks healthy. \n\nl \n\ntartar \nbetween \nthe teeth \n\n131 \n\n^ ^ It hurts all the time — even when ' * /Q O' \n\n^ ) person tries to sleep. The tooth hurts \n\nz^-nJ v) ^7 when you tap it and it feels a bit \n\n/ y*- y—f loose. ffl/Tw \n\nan abscess \n\n93 \n\n/ x ^ It hurts when person breathes in cold WvA/\"\\/\\/Y \n\nair. The tooth was hit recently. 1/7 Y Y V \\ \n\na cracked \nor broken \ntooth \n\n96 \n\nHe cannot open his mouth properly. \n\nSteady pain and a bad taste are (ferr \n\ncoming, from the back of the mouth. fj^v^ \n\nS' \n\na new tooth \ngrowing in \n\n100 \n\nSeveral top teeth hurt, even when \n\nyou tap them. She had a head cold \n\nand can only breathe through her y \n\nmouth. \n\n; \n\nan infected \nsinus \n\n95 \n\n\nWhere There Is No Dentist 2009 81 \n\n\nIF THE PERSON AND YOU FIND OUT \n\nHAS THAT \n\nHE/SHE MAY \nHAVE \n\nSEE \n\nPAGE \n\n* * ^ \n\nHe had a toothache recently. (//£*■ 7 \n\nThe bad tooth hurts when you (/ \n\ntap it. IvVJS \n\nf \n\na tooth \nabscess \n\nT \n\n93 \n\nSWOLLEN FACE She is young, about 18 years \n\nold, and has trouble opening \n\na new tooth \ngrowing in \n\n100 \n\nJ m 1 } He was hit on the face or jaw. \n\nIf tu* I/ The bone hurts when you otvOlIJ \n\ntouch it. The teeth do not fit \ntogether properly. \n\na broken bone \n\n108 \n\nThe swelling is under or \n\nbehind the jaw. It gets worse S'Sl'i?! \n\nwhen he is hungry and smells \n\nan infection \ninside the spit \ngland \n\n119 \n\nThe swelling has been there for \na long time. It does not seem to 11 's \n\nget better. \n\na tumor \n\n125 \n\n\nFood and tartar are attached \n\nto the tooth. The gums ( \n\naround it are loose and \n\nswollen. r \n\ninfection \ninside the root \nfibers — from \ngum disease \n\n101 \n\nThere was pain in the tooth \nbefore, but it does not hurt \nso much anymore. It has a \ncavity and there may be a \nsore on the gums near it. \n\ninfection in the \nbone — from \nan old tooth \nabscess \n\n99 \n\nand \n\n93 \n\nA 4 \n\nLOOSE TOOTH T . . .. ... u k fH \n\nThe tooth was hit r> vCi-7 = ^A V \n\n^ some time ago. V/f \n\na root broken \nunder the gum \n\n96 \n\n~' V ^v)O00 When the loose tooth \n\nmoves, the bone around it \nand the tooth beside it also \n\nBONE BROKEN \nUNDER THE \n\na broken bone \naround the \ntooth's roots \nOR \n\ninfection inside \nthe bone from \nVincent's \nInfection \n\n108 \n\nto \n\n112 \n\n102 \n\nand \n\n121 \n\n)f \n\nWhen you ask the person to \nslowly close his teeth, one ( ( j JLj) \n\ntooth hits another, before the '/CviT /V \n\nother teeth come together. \n\na tooth is out \nof position and \nbiting too hard \naganist another \n\n99 \n\n\no \n\n\n82 \n\n\nWhere There Is No Dentist 2009 \n\n\nIF THE PERSON AND YOU FIND OUT \n\nHAS THAT \n\nHE/SHE MAY \nHAVE \n\nSEE \n\nPAGE \n\nt t \n\nThe gums are red and (’T'TPTf'**! \n\nswollen. They bleed when the \n\nteeth are cleaned. ^ \n\nt \n\ngum disease \nstarting \n\nt \n\n101 \n\nA SORE MOUTH Between two teeth the gums \n\nfrom are sore anc ' sw °H en ' like a \n\nINFECTED GUMS small tumor. \n\nsomething \ncaught under \nthe gum \n\n133 \n\nThe 9 ums between the teeth _ _ \n\nrNTX\" R m have died and are no longer T^LXj \n\npointed. Pus and blood around \ny the teeth make the mouth \n\nsmell bad. \n\nVincent's \nInfection (a \nmore serous \ngum infection) \n\n102 \n\n\nfever blisters \non the gums — \nfrom Herpes \nVirus \n\n104 \n\nThe gums are bright red and \\ A A A / \n\nsore, but between the teeth \n\nthey are still pointed. oQC^ \n\n\nA sore on the inside of the / . \n\ncheek, lips, or under the /^r~r tv \\ \n\ntongue, is yellow with the \nskin around it bright red. Y\\, ' \\ \n\nFood touching it makes the \nsore hurt more. \n\na canker sore \n\n106 \n\nA sore spot around or under \nor a denture hurts when you \n\nA SORE MOUTH touch it. \n\nfrom a \\ \\ \n\nSMALL SORE \n\na sharp place \non a denture, \nor an old \ndenture that \nneeds to be \nrefitted \n\n106 \n\nin another \n\nplace A kind of white cloth seems \n\nto be stuck to the top of the \nmouth or tongue. It may \n, stop a baby from sucking. \n\nn \\ £?> / / \n\nthrush \n\n105 \n\nThe sore is near the root of \na bad tooth. \n\ngum bubble \n\n74 \n\nand \n\n93 \n\nThe corners of the mouth \\ / \n\nare dry. The lips crack and \nare sore. \n\nmalnutrition \n\n107 \n\nSmall painful blisters on the c— . ) \n\nlips soon break and form dry \nscabs. \n\nfever blisters — \nfrom Herpes \nVirus \n\n104 \n\nA SORE THAT DOES NOT HEAL PROPERLY MAY BE CANCER (See page 125). \n\n\nWhere There Is No Dentist 2009 83 \n\n\nIF THE PERSON AND YOU FIND OUT \n\nHAS THAT \n\nHE/SHE MAY \nHAVE \n\nSEE \n\nPAGE \n\nt T \n\nInside his mouth, he has a \n\ntooth abscess or a broken fc&rsl £ _ 40 \n\ntooth near the sore. <.^3 jC* S. \n\nT \n\nabscessed tooth \ndraining pus to \nthe outside of \nthe face \n\nt \n\n120 \n\nON THE FACE \n\nA dark sore is eating through \nthe cheek. Her gums are \\| \n\n^ badly infected. A bad smell is y >|L)1 \n\n4/6 *^1 coming from the dying skin on T \n\nthe face, and from inside the \n\na condition \ncalled Noma — \nstarting from \nVincent's \nInfection of the \ngums \n\n121 \n\nA 1 -month-old sore on the lips v I \n\nis not healing with medicine. / \n\ncancer \n\n125 \n\n\nHe is young, between a \n\n16-24 years, with some 4* \n\nswelling behind his jaw. \n\na new tooth \ngrowing in \n\n100 \n\nTROUBLE yf\\ h (j} ^ \n\nOPENING THE He recently had an accident. ' \n\nMOUTH \n\na broken \njaw — probably \nin front of the \near \n\n108 \n\n/f^’ \\ He had a toothache before \n\nin a back tooth with some \n\nan abscess in a \nback tooth \n\n93 \n\n) i can not\\ When she tries to open ^1^. \n\n[ open any j her mouth, there is clicking \n\n\\ °thi! HAN J sound from in front of her \n\nV THS lx ear. It also hurts in that place \n\nwhenever she tries to open \nher mouth or chew food. ' ‘ \n\npain in the \njoint — where \nthe jawbone \njoins the head \n\n114 \n\nSwallowing is difficult and ^‘hc^ 60 A\\ \nthe jaw grows stiff. Germs (i»\\\\ \\ -/> \n\nhave gone into the body Vv v \n\nfrom dirty instruments or an y / \ninfected wound. \n\ntetanus \n\n118 \n\n\nTROUBLE After opening wide to eat \n\nCLOSING THE or yawn, his mouth became \n\nMOUTH stuck there. He was many \n\nmissing back teeth. \n\n\na dislocated \njaw \n\n113 \n\n\"IcJ He had an accident and now j \n\nj \\ something is stopping the € \n\ny ' y_ teeth from coming together. r* \n\n\na broken jaw \n\n108 \n\n\no \n\n\n84 Where There Is No Dentist 2009 \n\n\nWWW. \n\n\nhesperian \n\n\n• org \n\n\nTreating Some \nCommon Problems \n\n\nCHAPTER \n\n\n7 \n\n\nYou must make a good diagnosis to treat a problem so it goes away and \ndoes not return. Why treat a sore on the face by cleaning it when the sore \nis from pus draining from a tooth with an abscess? You need to know the \ncause of the sore to give the best kind of treatment. \n\nAfter you make the diagnosis, you must decide whether you or a more \nexperienced dental worker should provide the treatment. \n\n\nIn the following pages, we describe the kinds of problems you as a health \nworker may see, and we also give the treatment for each problem. \n\nBefore you touch the inside of anyone's mouth, learn how to keep clean. \n\nThe next 6 pages explain how you can prevent infections by washing your \nhands, wearing gloves, and sterilizing your instruments. \n\nGerms in the mouth \n\nThe mouth is a natural home for germs. They usually do not cause problems \nbecause the body is used to them. In fact, many germs are helpful. For \nexample, when we eat, some germs break down chewed food into parts \nsmall enough for the body to use. \n\nThere are problems when the number of these ordinary germs increases \ngreatly, or when strange, harmful germs come into a healthy body from \noutside. Fever and swelling follow. It is an infection. \n\nWhen we regularly clean the mouth, the number of germs stays normal. \n\nYou can teach others to clean teeth and gums, but cleaning is each person's \nresponsibility. \n\nHowever, dental workers have one serious responsibility. You must not \nspread germs from a sick person to a healthy person. You must do \neverything you can to make sure your instruments are clean. An instrument \nwith blood on it can spread hepatitis (a serious liver disease) or HIV, which \ncauses AIDS. \n\n\nKnow your limits. Do only \nwhat you know how to do. \n\n\nWWW. \n\n\n\n86 Where There Is No Dentist 2009 \n\n\nTHE FIRST RULE FOR TREATMENT: STAY CLEAN! \n\nNo matter what problem you are treating, be sure that your workplace, your \ninstruments, and you are always clean. For example, prevent infection by \nalways washing your hands before you examine or treat someone. \n\nWash your hands in front of the person, in the same room. You will show \nthat you are a careful and caring health worker. Also, you will demonstrate \njust how important cleanliness really is. \n\n\n\nWear gloves \n\nLatex or plastic gloves protect the people you \ntouch from germs that may be stuck under your \nfingernails or on your skin, even after you wash \nyour hands. They also protect you from getting \ninfections. Wear clean gloves whenever you touch \nsomeone's mouth or any blood. \n\nIf you are filling or removing a tooth, or if you are touching any \ninstruments that have been sterilized, you must wear sterile gloves. \n\nIf you do not have gloves, use plastic bags that \nhave been washed in disinfectant soap instead. \nBags are harder to use than gloves, but they are \nbetter than nothing. \n\n\nfjnpi \n\n\n\nWhere There Is No Dentist 2009 87 \n\n\n\nGerms hide inside bits of old food, cement, or \nblood on an instrument. There they can continue \nto live, even in boiling water. \n\nThis is why you must be sure to scrub the working \nend of each instrument carefully with soap and \nwater. Rinse, and then look carefully to see that it \nis clean and shiny. \n\n\nRemember that 'clean looking' is not necessarily 'clean'. Truly 'clean' means \nfree of germs. Unless you sterilize, that instrument may still have germs, the \nkind that cause infection in the next person that it touches. \n\nSterilizing means killing germs. The best way to sterilize is with heat. High \nheat kills almost all harmful germs — especially those that cause hepatitis, \ntetanus, and mouth infections. Wet heat (steam) is always more effective \nthan dry heat from an oven. \n\nHere is a simple rule to use in \ndeciding when to sterilize: \n\nBoil or sterilize with steam \nany instrument that has \ntouched blood. \n\n\nThat means always sterilize \nall syringes, needles, and \ninstruments you use when \nscaling teeth (Chapter 8) \nor when taking out a tooth \n(Chapter 1 1). \n\nInstruments left in boiling water need 30 minutes to become sterile. A pot \nwith a cover to trap the steam can act faster. The inside becomes hotter and \n20 minutes is enough. But remember that water can rust metal instruments. \nTo prevent rust: \n\n• Add 5 spoonfuls (20 ml) of oil to every liter of water you boil. \n\n• Then lay the hot instruments on a dry, clean (sterile, if possible) cloth, \nso the water can evaporate. \n\nNever put an instrument away while it is wet. \n\n\n\noi \n\n\n88 Where There Is No Dentist 2009 \n\n\nSterilizing with steam under pressure is the fastest and surest method. It \nkills harmful germs in 1 5 minutes. You need a strong pot with a tight fitting \n\nlid. But be sure to make a small hole in the lid so steam can escape \nwhen the pressure becomes too great. \n\nA special pot called a pressure cooker is perfect for this. It even has a safety \nhole on it to release extra steam. \n\n\n1. Put 2 cups of water and \n2 spoonfuls of cooking \noil into the pot. \n\n\n\n2 . Place the handles together. \nPut on high heat until a loud \nhissing noise begins. \n\n\n\n3 . Put on lower heat. Begin \ntiming now. Leave the hissing \npot on the low flame for \n1 5 minutes. \n\n\n\nDO NOT LET \nTHE COOKER \nBOIL DRY! \n\n\n4 . Cool the pot under water, open, \nand lay the instruments on a \nclean towel to dry. \n\n\n\nThe next time you use the pot, \nyou can use the same water that \nwas left inside it. \n\n\noi \n\n\nWhere There Is No Dentist 2009 89 \n\n\nSterilizing with heat is not necessary for instruments that do not touch blood. \nFor example, after you examine a person or place a temporary filling, you can \nclean your instruments and then soak them in a solution of alcohol or bleach. \n\n\nAlcohol solution \n\n1. Mix in a large container each week: \n7 parts alcohol (95%) with 3 parts \nclean water. Keep the container \ntightly covered to prevent \nevaporation. \n\n2. Keep a covered pan half filled with \nthis mixture. You will have to add \nsome more of the mixture from the \nlarge container to the pan each day. \n\n3. Leave your clean instruments in the \npan, completely covered with the \nliquid, for 30 minutes. \n\n\n\n\ntight fitting \nlid \n\n\n\nBleach solution (sodium hypocholorite) \n\nFind the cheapest brand name in your area for bleach. \nExamples are Javex, Clorox, Purex, and Cidex. Make \n1 liter of solution with a mixture of Vi cup \n(125 ml) of bleach and 31/2 cups (875 ml) \nof clean water. \n\n\n\n\nBLEACH & WATER \n\n\nV2 CUP \n\n\n\n\n3+ V 2 CUPS \n\n\nUnfortunately, bleach rusts metal \ninstruments. To reduce rust, \nadd 1 large spoonful of baking \nsoda (sodium bicarbonate) to \nthe solution, and leave your \ninstruments in the solution for only \n30 minutes. \n\nWipe each instrument with alcohol \nto remove the film of bleach. Then \nstore it dry inside a clean cloth or in \nanother covered pan. \n\n\n\nChange the solution each week. \n\n\n01 \n\n\n90 Where There Is No Dentist 2009 \n\n\nKeep your sterile instruments together in a clean place. \n\nWrap them in a clean cloth OR Leave them in disinfectant \n\n(p. 89) \n\n\n\nMark with tape the names \nof the instruments inside. \n\n\n\nBefore you use any instrument \nagain, wash it with clean water — to \nremove the taste of the disinfectant. \n\n\nGerms living in dirty cotton can easily go inside the socket and start an \ninfection. It is important, therefore, to keep the cut pieces in a container that \nis clean and has a cover. Use clean tweezers to remove the cotton gauze \nwhen you need some. \n\n\n\nAlso, keep your room and work area clean. Sweep or mop the floor one or \ntwo times a day, and wipe down the chair and tables after every patient. \n\n\nStaying clean is a part of staying healthy. \n\n\noi \n\n\nWhere There Is No Dentist 2009 91 \n\n\nNEEDLES \n\nMany people get sick with serious illnesses like hepatitis or HIV/AIDS from \nusing unsterilized needles. \n\nReusable syringes and disposable syringes \n\nReusable syringes can be used again and again. Reusable syringes make \nless waste and can save money, but they must be washed very carefully and \nsterilized after every use. \n\nUse each disposable needle only one time and then throw it away in a box \nlike the one on pages 199-200. If you must reuse a needle, replace the cap \nvery carefully and put the needle in a safe place (such as a pan full of bleach \nsolution) until you are ready to clean and sterilize it (p. 138). \n\n\nHOW TO WASH AND STERILIZE A SYRINGE AND \nNEEDLE FOR REUSE: \n\n\n1. Put on a pair of heavy gloves \nto protect your hands from \ngerms and from sticking \nyourself with the needle. \n\n\n\n2 . Draw 5% bleach solution (see page 89) up \nthrough the needle into the syringe barrel. \n\n3 . Squirt out the bleach solution. \n\n4 . Repeat several times. Rinse everything \nseveral times with clean water. \n\n5 . Take the syringe and needle apart and boil or \nsteam them. (See page 138.) \n\n\n\nNever reuse a needle or syringe without \ncleaning and sterilizing it first. \n\n\n\noi \n\n\n92 Where There Is No Dentist 2009 \n\n\nPARTI \n\nPROBLEMS YOU WILL SEE MOST OFTEN \n\n\nCAVITIES AND LOST OR BROKEN FILLINGS \n\nA cavity can occur in any tooth. A cavity can also start around an old filling, \nespecially if it is dirty. The deeper a cavity gets inside the tooth where the \nnerve lives, the more the tooth hurts. \n\nSIGNS: \n\n• Pain when drinking water or eating \nsomething sweet. \n\n• A hole (or black spot) on the tooth, or \nbetween two teeth. \n\n• Pain if food gets caught inside the hole. \n\n• No pain when you tap the tooth. \n\n\nTREATMENT (when there is no abscess): \n\nTry to remove any loose piece of filling with a probe. Then, following the \nsteps in Chapter 10, put in a temporary filling. \n\nNow: \n\n1. Fill the hole with cement. If you have no cement, put some cotton into \nthe hole to keep food out. \n\n2 . Look for cavities or broken fillings in the other teeth. Fill each one with \ncement before it gets worse and starts to hurt. \n\nSoon (within a few months): \n\n3 . Arrange for someone to replace the temporary filling with a permanent \none. You will need a person who has experience using a dental drill (see \np. 151). \n\nA groove on the neck of a tooth is a more difficult \ncavity to fill. For the temporary cement to hold \nproperly, you need to shape the groove with \na drill. To help temporarily, you can put a little \nfluoride toothpaste on the groove (page 205). Do \nthis once each week until the inside part of the groove is stronger and the \ntooth hurts less. Or, you can paint the inside of the groove with oil of cloves \n(eugenol) to reduce the pain. \n\nTo avoid making the problem worse, (1) do not use a hard toothbrush; \n\n( 2 ) do not brush back and forth along the gums; and ( 3 ) do not chew tobacco \nor betel nut and do not hold them against the teeth. \n\n\n\n\nWhere There Is No Dentist 2009 93 \n\n\nTOOTH ABSCESS \n\nA cavity that is not filled grows bigger and deeper until it touches the nerve. \nGerms travel inside the tooth's root and start an infection called an abscess. \n\nPus forms at the end of the root, inside the bone. As the pus increases, it \ncauses great pressure. This is why an abscess causes severe pain. \n\n\nSIGNS: \n\n• Pain all the time, even when trying \nto sleep. \n\n• Tooth often feels longer, and even \na bit loose. \n\n• Tooth hurts when it is tapped. \n\n• A sore on the gums near where \nthe root ends (gum bubble). \n\n• Swelling of the gums around the \ntooth, or swelling of the face on \nthe same side as the bad tooth. \n\n\n\nTREATMENT: \n\nIf there is no swelling, take out the tooth immediately (unless you are able \nto give root canal treatment). This allows the pus to escape and relieves the \npain. See Chapter 1 1 . \n\nIf there is swelling, treat the swelling first. Take out the tooth only after the \nswelling goes down. This is necessary because an anesthetic (see Chapter 9) \nwill not work if there is swelling. \n\nTo treat the swelling, give an antibiotic. Penicillin by mouth is best. Use an \ninjection only when the person is in immediate danger. For example, inject \npenicillin when the person has a fever or if the swelling is pressing against \nthe throat. But remember you can treat most serious infections with simple \npenicillin by mouth. For the doses for serious infections, look below the box \non the next page. If you still think an injection is necessary, look at the \nsection on 'aqueous procaine penicillin' on page 204. \n\nAdults and children over 25 kg (60 pounds) of weight should take the same \namount of oral penicillin. Children under 25 kg should take 1 h as much. For \nmost infections, penicillin by mouth is taken 4 times a day for 5 to 7 days. \n\nThe first dose is double and then the regular dose is taken every 6 hours. The \n\nperson should take all of the penicillin, even if the pain or swelling goes \ndown. For the correct doses, see the next page. \n\n\noi \n\n\n94 Where There Is No Dentist 2009 \n\n\nTHE BEST CHOICE \n\nSECOND CHOICE \n(for those allergic to penicillin) \n\nPenicillin: 1 tablet = 250 mg \n\nGive enough tablets for 5 to 7 days \n\nErythromycin: 1 tablet (or capsule) = 250 mg \n\nGive enough tablets for 5 days \n\nFirst Dose (take all at once) \n\nAdults 4 tablets \n\nand children over 25 kg (1000 mg) \n\nChildren under 25 kg 2 tablets \n\n(500 mg) \n\nThen every 6 hours for 5 to 7 days \n\nAdults 2 tablets \n\nand children over 25 kg (500 mg) \n\nChildren under 25 kg 1 tablet \n\n(250 mg) \n\nFirst Dose (take all at once) \n\nAdults 4 tablets \n\nand children over 25 kg (1000 mg) \n\nChildren under 25 kg 2 tablets \n\n(500 mg) \n\nThen every 6 hours for 5 days \n\nAdults 2 tablets \n\nand children over 25 kg (500 mg) \n\nChildren under 25 kg 1 tablet \n\n(250 mg) \n\nIMPORTANT: to allow it to best fight infection, \ntake penicillin before eating. \n\nIMPORTANT: to avoid upset stomach, take \nerythromycin with meals. \n\n\nNote: If you do not have penicillin tablets, try to get ampicillin or amoxycillin \nand follow directions for using them in Where There Is No Doctor. \n\nFor many infections, taking penicillin for 5 days should be enough. For \nserious infections, it may be necessary to take the antibiotics for 7 days. For \nhowever long you take them, always take the double dose the first time, and \nthen the regular dose 4 times a day (every 6 hours). If the infection does not \nheal, you may need another medicine.* Usually you can take out the tooth \n1 or 2 days before the end of the antibiotic treatment, but the person must \ncontinue to take all of the tablets, even after you have taken out the \ntooth. If not, the infection might come back even stronger than before. \n\nIf the swelling is 'pointing', open it with a sharp sterile knife to release the \npus. Cover the wound with a sterile dressing to keep it clean. If you are not \nable to do that, explain how to reduce the swelling with heat. As often as \npossible until the swelling goes away: \n\n• soak a cloth in warm water and hold it against the face. \n\n• hold warm water inside the mouth near the swelling. It is not \nnecessary to add salt to the water. \n\nFinally, give the person medicine for pain. A 2-day supply will be enough, \nbecause the penicillin and the heat will reduce the pressure and that will \nreduce the pain. The best medicines for pain are aspirin, which comes in \n300 mg tablets, and acetaminophen (paracetamol), which comes in \n500 mg tablets. Aspirin is usually cheaper, but acetaminophen does not cause \nstomach pain and it is safer than aspirin for children. (To avoid stomach pain, \ntake aspirin with food, milk, or water.) See doses at the top of the next page. \n\n\n* If the infection does not heal, penicillin may not be the right antibiotic to use. Take some pus \nfrom the infection and have it tested, to see which antibiotic is best. \n\n\nwww. nCSpCri3Tl.org \n\n\nWhere There Is No Dentist 2009 95 \n\n\nEVERY 6 HOURS (4 times a day): aspirin or acetominophen \n\n\nadults \n\n\n600 mg \n\n1000 mg \n\nchildren \n\n8 to 12 years \n\n300 mg \n\n500 mg \n\n\n3 to 7 years \n\n150 mg \n\n250 mg \n\n\n1 to 2 years \n\ndo not use \n\n125 mg \n\n\nINFECTED SINUS \n\nA sinus is a hollow place inside the bone. There is a sinus under the eyes, on \neach side of the nose. Because the sinus is very close to the roots of the top \nteeth, these teeth may hurt if the sinus becomes infected. \n\nSIGNS: \n\n• Toothache in several top teeth. The teeth \nlook healthy, but hurt when you tap them. \n\n• A head cold, and plugged nose. She can \nonly breathe through her mouth. \n\n• Hurts when you press against the bone \nunder her eyes. \n\n• Tooth feels different when patient bends over forward \n\n\n\nTREATMENT: \n\nDo not take out any teeth. They will feel better after you treat the sinus \n\ninfection. \n\n1. Give penicillin for 5 days (page 94). \n\n2 . Explain to the person that she should \n\n• drink lots of water. \n\n• breathe steam from boiling water \nher nose. \n\n• hold a warm wet cloth against her \noften as possible. \n\n• not try to blow her nose, or else h> \nhurt. Wiping the nose is better. \n\n3 . See the person again after 3 days, and \n\n• examine her teeth closely, tapping them to be sure they are strong \nand healthy. \n\n• if she is not better, get help from a more experienced health worker. \n\n\n\noi \n\n\n96 Where There Is No Dentist 2009 \n\n\nTOOTH INJURIES \n\n1. Broken tooth \n\nIt is possible to save a broken tooth. It depends on where the tooth is \nbroken and whether its nerve is still covere \n\nSIGNS: \n\n• Pain when breathing air or drinking \nwater. \n\n• Blood from the gums around the tooth \n\n• Tooth moves when you touch it. \n\nTREATMENT: \n\nTake out the broken tooth if: \n\n• its nerve is not covered. If no one can give special root canal \ntreatment, the tooth must come out. Germs from the saliva have \nalready gone inside the tooth and started a small infection. \n\n• its root is broken. To see if it is broken, push gently against the tooth \nas you feel the bone around its roots. The tooth's root probably \n\nis broken if the tooth moves but the bone does not. The root \nprobably is not broken if both the tooth and bone move. However, \nthe bone around the roots may be broken (page 109). \n\nYou can save a broken tooth if the nerve is still covered and the \nroot is not broken. To do this, use a file on the sharp edges around the \nbreak. This makes them smooth so they do not cut the tongue. Later, an \nexperienced dental worker who has the equipment can cover the broken \npart with a cap or a filling. Until this is possible, tell the person how to \nprotect the tooth: \n\n• Give the tooth a rest. Use other teeth to eat. \n\n• Do not drink things that are very hot or cold, and do not eat spicy \nfood. \n\n• Watch the tooth. See if it changes color (gets darker). Also watch \nthe gums near the root. See if a sore (gum bubble) develops. \n\nA dark tooth and gum bubble are signs that the tooth is dying. Take it out, \nunless you can give special nerve treatment. \n\n\naH \n\n\n\nor \n\n\nWhere There Is No Dentist 2009 97 \n\n\n2. Tooth knocked out \n\nWhen a tooth is knocked out of the mouth, you should ask two questions: \n\n(1) Was it a baby tooth? (2) How long ago did it happen? \n\nBaby tooth. There is no reason to try to put a baby tooth back into the \nsocket. Tell the child to bite on some cotton to stop the bleeding. Then wait \nfor the permanent tooth to replace it. Warn the mother that the permanent \ntooth may take more time than usual to grow into the mouth. \n\nSimilarly, there is no need for \ntreatment if the baby tooth is \npushed up under the gum. \n\nThe tooth may grow back into the \nright place later, or it may turn dark \nand die. if you see a darkened tooth \nor a gum bubble (p. 74), take out \nthe baby tooth before it hurts the \npermanent tooth that is growing \nunder it. \n\nPermanent tooth. A permanent tooth is worth saving. How long ago was \nit knocked out? If it was less than 1 2 hours ago, you can put a permanent \ntooth back into the socket. The sooner you do this the better, so do not wait. \n\nIf you replace the tooth in the first hour, it has a much better chance of \njoining with the gum and bone. In order to heal and to join the bone, the \ntooth must be held firmly. \n\na) Wash the tooth \ngently with saline, \nmilk, or clean water. \n\nThere should not be \nany bits of dirt on the \nroot of the tooth. \n\nKeep the tooth \ndamp with wet \ncotton gauze. \n\n\n\n\nDo not scrape away any skin from the \nroot or from the inside of the socket. \n\n\noi \n\n\n98 Where There Is No Dentist 2009 \n\n\nb) If you can not use anesthetic, tell the patient that it will hurt \n\nsomewhat. Gently push the tooth up into the socket. As you push it \nup, use a slight turning movement \nback and forth. \n\n\nThe biting edge of the loose \ntooth should be at the same \nlevel as the teeth beside it. \n\nHold it in place with your \nfingers for about 5 minutes. \n\nc) Soften some beeswax and form \nit into 2 thin rolls. Place 1 roll \nnear the gums on the front side \nof five teeth: the loose tooth \nand the two teeth on each side \nof it. Press the wax firmly, but \ncarefully, against these teeth. \n\nDo the same with the second \nroll of wax on the back side of \nthe same teeth, again near the \ngums. \n\nIt is good if the wax on the \nback side is touching the wax \non the front side. This helps \nthe wax hold the teeth more \nfirmly. To do this, you can \npush the wax between the \nteeth with the end of your \ncotton tweezers. \n\n\n\nKeep the wax in its position \nfor at least 3 weeks. \n\n\nTell the person with the injured tooth to return to see you several times. \n\nThe tooth may die several months or even several years later (see page 47). \n\nIf that happens, you must take out the tooth, unless you can do root canal \ntreatment. \n\nIf it is possible, take an X-ray of the tooth 6 months later and then again each \nyear. Look at the X-ray picture of the root to be sure an infection is not eating \nit away. To do this, compare the root with the roots of the teeth beside it. \n\n\noi \n\n\nWhere There Is No Dentist 2009 99 \n\n\nLOOSE TOOTH \n\nA tooth may be loose for one of several reasons. Decide the reason before \ngiving the treatment. \n\n\nIF THE TOOTH IS LOOSE BECAUSE \n\nTHE BEST TREATMENT \n\nt \n\n' J - \n\na new permanent tooth is \ngrowing under it. \n\n1 . tell the mother and child what is happening. \n\n2. pull out the loose baby tooth, if it is hurting the \nchild. \n\ngum disease or an old abscess has \neaten the bone around its roots. \n\n1 . take out the tooth, especially if it also hurts. \n\n2. explain to the person what to do to prevent this \nproblem in other teeth. (See Chapter 5.) \n\nits root has been broken. \n\ntake out both parts of the tooth. If you have trouble \ntaking out the broken root, leave it and try again a \nweek later. \n\nthe bone around its root is cracked. \n(The bone moves when you push \nagainst the tooth.) \n\nDo not take out the tooth. If you do, the bone will \ncome out with it. Instead, hold the tooth with wires \n(page 110). \n\n\nA tooth may also be loose because another \ntooth is biting too hard against it. \n\nSIGNS: \n\n• You can feel the tooth move when \nthe upper and lower teeth meet. \n\n• That tooth hurts. \n\n\nTREATMENT: \n\n\n\nYou need to remove a bit of each of the teeth that are biting too hard. Use \neither a dental worker's drill, a small file, or a hard stone. \n\n\n1. Smooth the inside edge \nof the upper tooth. \n\n2. Smooth the outside edge \nof the lower tooth. \n\n\n\n\noi \n\n\n100 Where There Is No Dentist 2009 \n\n\nNEW TOOTH GROWING IN \n\nA new tooth cuts through the gums when it grows into the mouth. Germs \ncan easily go under the gums in that place and cause an infection. When the \nopposite tooth bites against the sore gum it can make an infection worse. \n\n\nSIGNS: \n\n• Toothache at the back of the jaw. \n\n• Mouth cannot open properly. \n\n• A bad taste coming from the back \nof the mouth. \n\n• Sore throat. \n\n• Skin over the new tooth is sore \nand hurts when you touch it. \n\n• The age of the person is the right \nage for growing a new molar \ntooth (page 66). \n\n\n\nInfection in the gums and pressure \nfrom the new tooth are painful, notice \nthe 'flap' of skin over the new tooth. \n\n\nTREATMENT: \n\nDo not take out a new tooth while there is still infection and pain. Wait \nfor the infection to finish. Then decide if there is room for the tooth to grow \nin. A dental X-ray can help you make that decision. New molar teeth are \noften difficult to take out. Ask an experienced dental worker to take out the \ntooth, if it must be done. \n\nWhat you can do \n\nFirst, treat the infection. Then wait for the new tooth to grow more into the \nmouth. Tell the person what is happening. Tell him what he can do to keep \nthe gums healthy while the tooth grows in: \n\n• Rinse the area with warm salt water (page 7). Make 4 cups each day \nuntil the mouth opens normally again. Then make 1 cup each day to \nprevent the problem from returning. Keep rinsing this way until the \ntooth grows all the way in. \n\n• Hold a warm wet cloth against the jaw as often as possible each day. \n\n• Take aspirin for pain (page 94). \n\nGive penicillin (pages 93-94) if there is fever, a swelling, or if he is only able \nto open his mouth a little. \n\n\noi \n\n\nWhere There Is No Dentist 2009 101 \n\n\nTEETHING \n\nWhen babies and small children first get their teeth, it is called teething. This \ncan make the child unhappy, because his gums are sore. \n\n\nTREATMENT: \n\n\n\nTeething does not cause fever, \nhead colds, or cough. \n\nBut a child can have any of \nthese problems at the same \ntime as he gets a new tooth. \n\n\nIf the child has another sickness, do not blame it on teething. Look for \nanother cause and treat it separately. Also, do not cut the gum over the \nnew tooth. Let the tooth grow through the gum by itself. \n\n1. Give acetaminophen for pain and fever (page 94). \n\n2. Give the child something hard to bite against. This will help the tooth to \ngrow through the gums faster. For example, let him chew on a dry hard \nbiscuit. \n\n\nGUM DISEASE STARTING \n\nInfection can start in the gums whenever the teeth near them are not clean. \nFor example, there may be swelling between only 2 teeth or between many \nteeth. In addition, gums that are weak from poor nutrition are not able to \nresist the infection. This is why pregnant women and people living with HIV/ \nAIDS must take special care to eat well and clean their teeth carefully. When \na person has HIV, his body cannot fight infections well, so a gum infection \ncan quickly get worse (page 183). \n\nSIGNS: \n\n• Gums are red instead of pink. \n\n• Gums are loose instead of \ntight against the tooth. \n\n• Between the teeth, gums are \nround instead of pointed. \n\n• Gums bleed when the person \nbrushes or flosses. \n\n• Gums bleed when you press \nagainst them, or when you scrape away food from under them. \n\n• The person has bad breath and a bad taste inside the mouth. \n\n\n\nFeel for tartar under the gum — or \neven a piece of fishbone. \n\n\n\noi \n\n\n102 Where There Is No Dentist 2009 \n\n\nTREATMENT: \n\nExplain to the person the cause of her gum problem and what she can do \nto help herself. The only way to stop gum disease is to remove plaque and \ntartar from the teeth and then to keep them clean. \n\n1. Show her how to clean her teeth better near the gums (page 69). \n\n2 . Tell her to rinse her mouth with warm salt water (page 7). Make 4 cups \neach day until the bleeding stops. Then make 1 cup each day to keep \nthe gums strong and tough. \n\n3 . Tell her to eat fresh fruits and vegetables. Guavas, oranges, pineapples, \npapayas, tomatoes, peas, and green leaves give strength to gums. \n\n4 . Gently reach under the gums and remove tartar (or loose piece of \nfishbone) that is caught there (see Chapter 8). \n\nSometimes a pregnant woman's gums become swollen, and the swelling \ndoes not go down even after cleaning with a soft brush and rinsing with salt \nwater. These swellings must be cut away. But she should wait to have this \nsmall operation until after the baby is born. \n\nMORE SERIOUS GUM DISEASE \n\nVincent's infection of the gums, also called trench mouth, affects both \nadults and children. In its worst form, it can eat a hole through the cheek of a \nweak child (page 121). \n\nA person with Vincent's Infection may not want to eat because his teeth \nhurt when he chews food. That can make a child's malnutrition worse. \n\nYou must prevent this problem from starting, especially in a child who is \nweak from sickness. Teach mothers to clean their children's teeth and to get \ntheir children to rinse their mouths with warm salt water. \n\nSIGNS: \n\n• Gums between the teeth are dying \nand turning gray. \n\n• Pus and old blood collect around \nthe teeth. \n\n• Burning pain from the gums. \n\n• Bleeding from the gums. \n\n• The mouth smells bad. \n\n\nTREATMENT: \n\nYou will need to see the person over a 2-week period. Start some \ntreatment now: \n\n1. If the person is already sick, give penicillin for 7 days (page 94). \n\n\n\nWhere There Is No Dentist 2009 103 \n\n\n2 . Clean away the pus, old food, and big pieces of tartar. Then: \n\n• Tell the person to rinse his mouth with warm water. \n\n• Wipe his gums with cotton soaked in a 3% solution of hydrogen \nperoxide. Rinse with warm water. For a child, use a weaker solution. \nMix 1 part hydrogen peroxide with 5 parts water and wipe the child's \ngums with it. \n\n• Scrape away the bigger pieces of tartar. Do not try to remove all of it. \nYou can do that later. Put topical anesthetic on the gums if you have \nsome (first dry the area with cotton so the topical anesthetic will stay \nlonger). Rinse away any loose bits of tartar with warm water. \n\n3 . Give Vitamin C (ascorbic acid), 2 tablets a day for 7 days. \n\n(1 tablet= 500 mg) \n\n4 . Teach the person how to care for the gums at home: \n\n• Rinse at home for 3 days with a weak solution of hydrogen peroxide \n(page 8). Try to hold the solution in the mouth for several minutes. The \nlonger the solution touches the gums, the better it is for the gums. \nRinse once every hour. After 3 days, change to salt water, 4 cups a \nday. If you have no hydrogen peroxide, rinse with salt water from the \nbeginning. \n\n\n\nFor a young child who is not able \nto rinse, Mother or Father can wipe \nhis gums with the weak solution of \nhydrogen peroxide 4 times a day. \n\nShow parents how to do this. \n\nGive them some cotton gauze and \nhydrogen peroxide to take home. \n\n\n• Clean the teeth with a soft brush. Parents can clean children's teeth. \nShow them how (page 1 8), and ask them to do it even if the gums bleed. \n\n• Cook food that is soft (like pounded yam) and not spicy (no pepper). Eat \nfresh fruits and vegetables that give strength to the gums (page 102). \n\n• Stop smoking and stop chewing betel nut. \n\nOne week later, scrape away the rest of the tartar from the teeth. Then \nuse the person's own brush and show him how to do a better job of \ncleaning his teeth. \n\n\n\noi \n\n\n104 Where There Is No Dentist 2009 \n\n\nFEVER BLISTERS \n\nHerpes virus is a kind of germ that causes fever blisters. Fever blisters are sores \nthat can form inside the mouth on the gums or outside on the lips. Blisters on \nthe cheeks only are not from herpes virus (see canker sores, page 1 06). \n\n\nSores inside the mouth are a serious problem that usually affect children \nbetween 1 and 5 years old. A child with fever blisters in his mouth can become \nvery sick. Fie will not be able to eat properly. If he does not drink enough fluids, \nhe can become dehydrated (lose his body water). This is dangerous! Fever \nblisters are also a problem for people living with HIV/AIDS. See pages 186 to 187. \n\n\nInside the mouth \n\n\nSIGNS: \n\nSore throat. \n\nFever. \n\nCrying, stops sucking 2-3 days before sores appear. \nSpit spills from the mouth because it hurts to swallow. \nPainful swelling under the jaw. \n\n\n\nBright red blisters on the gums, but not between the teeth. Blisters also \nmay be on the roof of the mouth. \n\n\nTREATMENT: \n\nMedicine cannot kill the Flerpes virus. The sores will go away by themselves in \nabout 1 0 days. The treatment is to help the person feel more comfortable and \nto be sure he gets enough to eat and drink. \n\n1. Give aspirin or acetaminophen for fever (page 94). \n\n2. Wipe milk or yogurt over the sores to protect them before eating. Wash \nyour hands before touching the inside of someone's mouth! (See \npage 86.) Then give food that is soft and not spicy. If the person cannot \neat, prepare a special milk-oil drink, as on page 1 \n\n3. Give lots of fluids to drink. \n\nSores on the lips usually occur after the age of 5. \n\nThey often appear when the person is weak and \nsick (for example, with diarrhea or pneumonia.) \n\nUsually there is no fever. The blisters soon break \nopen and release water. When they dry, a crust \nforms. The blisters often return. When sores leak \nwater they can pass infection. If you or anyone else \ntouches them, wash your hands immediately. \n\nTo prevent the blisters from becoming infected, put an antibacterial cream or \npetroleum jelly (Vaseline) on them. If you hold ice against the sores for several \nminutes each day, it may help them heal faster. See page 187 for more options. \n\n\n\nWhere There Is No Dentist 2009 105 \n\n\nTHRUSH \n\nThrush is an infection caused by a yeast fungus called Candida. It often \nappears when a person is weak and poorly nourished, or sick and taking \nmedicine like tetracycline or ampicillin. In a baby, thrush usually appears on \nthe tongue or top of the mouth. It can stop the baby from sucking. In an \nadult, thrush often occurs under a denture. Thrush is a very common proble \nfor people living with HIV/AIDS (see pages 180 to \n\nSIGNS: \n\n• White patches on the tongue, cheek, or \ntop of the mouth. Wipe the white area: If \nthere is no bleeding it is old milk. If there \nis bleeding, it is thrush. \n\n• The child may not want to suck or eat. \n\n\nTREATMENT: \n\nThere is usually something else present which is helping thrush to grow. Try \nto find what it is and deal with it. For example, treat the malnutrition, change \nor stop the antibiotic medicine, or leave the denture out of the mouth for a \nwhile. Then: \n\n1. Cover the white patches with nystatin drops. Use a full dropper 4 or 5 \ntimes a day until the patches are gone. If you do not have nystatin you \ncan soak a piece of cotton in gentian violet and use it to paint the white \npatches 2 times a day. \n\nIf the baby's mother has sore, painful nipples, she may also have thrush \nin her breasts. She should treat her nipples the same way she treats \nthe baby's mouth. \n\nDo not use penicillin or any other antibiotic unless you need to \ntreat something different. Thrush can get worse when a person uses \nan antibiotic for a long time. \n\n2 . Continue breastfeeding. For older persons, make their food soft and \neasy to chew. \n\nIMPORTANT: Sometimes white lines appear on the inside of an adult's \ncheek or on the roof of the mouth. If these lines become sore, they can \nchange into a cancer (page 125). To prevent this cancer, ask the person \n\nto stop smoking (especially pipes), stop chewing betel nut, and get \ndentures adjusted if they do not fit properly. \n\n\n\n\noi \n\n\n106 Where There Is No Dentist 2009 \n\n\nCANKER SORES \n\nThe exact cause of canker sores is not known. Unlike fever blisters, canker \nsores usually affect adults rather than children. \n\nOne or more sores can appear at any time. These sores hurt, especially \nwhen pieces of food touch them. \n\n\nSIGNS: \n\n• A sore can appear on the cheeks, \ninside the lips, on the tongue, or below \nthe gums on the smooth skin. \n\n• The sore is white or yellow with the \nskin around it bright red. \n\n• The person may have had a similar kind \nof sore before. It tends to come back. \n\n\n\nNote: a sharp edge of a denture rubbing against the gums can \nmake a similar kind of sore. \n\nTREATMENT: \n\nA canker sore goes away by itself in about 10 days. Medicine does not \nmake that happen any faster. (However, smoothing a denture does help.) \n\nThe treatment is simple. Tell the person how to feel more comfortable while \nwaiting for the 1 0 days to pass: \n\n• Eat foods that are soft and not likely to hurt the sore. \n\n• Do not eat food with a lot of pepper. \n\n• Drink lots of water. \n\n• Chew food on the other side of the mouth, away from the sore. \n\nA denture which does not fit \nshould be remade. \n\nIn the meantime, leave the \ndenture out of the mouth for \n2 or 3 days. \n\nAsk the person to rinse with \nwarm sait water, 4 cups each \nday until the sore is better. \n\nIf the sore continues after 1 0 days, it may be infected. Give penicillin (page 93). \n\nA sore that does not heal after antibiotic treatment may be cancer. See \na doctor immediately. \n\n\n\nWhere There Is No Dentist 2009 107 \n\n\nSORES AT THE CORNERS OF THE MOUTH \n\nTeeth support the lips. When they come together for chewing, the teeth stop \nthe person's chin from moving any closer to the nose. \n\nA person without many teeth looks old. A person with a poor fitting denture \nalso looks old. \n\nThe distance from his chin to his \nnose is shorter than normal. \n\nHe must close his jaw further to \neat. That causes lines to form at \nthe corners of his mouth. \n\nPoor health can make lines at \nthe corners of the mouth crack \nand become sore. These cracks are \n\noften infected with thrush and can be treated with nystatin (see page 105). \n\nA person with missing teeth needs dentures. Dentures will help him \nchew more food and make him look younger. They support his lips and \nopen his mouth more. (See page 164). \n\n\n\nA child who has had a fever or measles often has dry lips. The corners of her \nmouth can crack and become sore. \n\n\nCracks and sores appearing at the \ncorners of a child's mouth are signs of \ndehydration and malnutrition. \n\n\n\nThe child needs to eat the kind of foods that give strength, energy, and \nprotection. Feed her beans, milk, eggs, fish, oils, fruits, and green leafy \nvegetables (see page 67). \n\n\nTREATMENT (when sores occur): \n\n1. Wash the sores with soap and hot water. \n\n2 . Mix 1 part sulfur with 10 parts of petroleum jelly (Vaseline). \n\n3 . Smear some on the sores 3-4 times a day. \n\n\n\noi \n\n\n\n108 Where There Is No Dentist 2009 \n\n\nPART 2 \n\nSOME SPECIAL PROBLEMS \n\n\nYou will find some problems that are too serious for you to treat. If you can, \nsend the sick person to a more experienced dental worker as soon as possible. \n\nSometimes, however, it is better to start some of the treatment yourself. \nEarly treatment can prevent some problems from becoming more serious. \nAlso, if you know what to do when someone returns from the hospital, you \ncan help that person to get well faster. \n\nSometimes, you will find it impossible to get help. Therefore, we will discuss \neach of these more serious problems in detail, so you can give as much help \nas necessary. \n\nBROKEN BONE \n\nThree main bones form the face and lower jaw. \n\n\n\n\nA bone can break completely, or part of it can crack. In either case, the teeth \nare usually pushed out of position. Look for this as a sign of a broken bone. \n\nSIGNS of a broken bone: \n\n• The person has had an injury. \n\n• When teeth are closed, some upper \nteeth do not meet lower teeth. \n\n• The person cannot open or \nclose the mouth properly. \n\n• There is bleeding from between 2 teeth. \n\n• There is swelling or a bruise on the face or jaw. \n\n• There is bleeding into the eye. \n\n\n\noi \n\n\nSIGNS of a cracked bone \naround the tooth's roots: \n\n\nWhere There Is No Dentist 2009 109 \n\n\n• When you move one tooth, \nthe tooth beside it also moves. \n\n• When you move the loose \ntooth, the bone moves with it. \n\n• Blood is coming from \n\nunder the gums. (5) \n\nTREATMENT: \n\n\n\nPUSH GENTLY \nAGAINST ONE \nTOOTH \n\n\n(D AND the other \n\nf TOOTH ALSO MOVES \n\n\nBECAUSE THE \nBONE AROUND \nTHEIR ROOTS \nts cracked. \n\n\nWhen a bone is broken or cracked, the treatment is to hold the broken \nparts together so that the parts can rejoin. The usual way to do this is to put \nwires around the teeth. An experienced dental worker should do this. There \nare two things you can do. First, provide emergency care. Later, show the \nperson how to eat and how to keep his mouth clean. \n\n\nEmergency care (pages 109-110): \n\n1. Be sure the person can breathe. \n\n2 . Stop the bleeding. \n\n3. Put a bandage on the person's head. \n\n4. Give penicillin to stop infection. \n\n5. Give aspirin or acetominophen for pain. \n\n\n1. Be sure the person can breathe. \n\n\n\nLater, carry him to the hospital in that position. If he goes in a car, be sure \nhe sits with his head forward. His jaw and tongue will be forward and he \nwill breathe more easily. \n\nLook inside the mouth to see if any tooth is broken and very loose. A \nbroken piece of tooth can fall out and block the person's airway, so take \nout the broken part now. You can leave in the root, but if you do, tell the \ndental workers at the hospital (p. 213). They will remove the root when \nthey put on the final wires. \n\n2. Stop the bleeding. \n\nWipe away the dried blood from his face and from inside his mouth. Look \nfor the place that is bleeding. Sew any deep cuts on his face (see Where \nThere Is No Doctor, p. 86). If you gently press cotton gauze against the \nbleeding gums, it will usually control the bleeding. \n\n\noi \n\n\n110 Where There Is No Dentist 2009 \n\n\nBleeding inside the mouth, from between the broken parts of the \nbone, is more difficult to stop. You must pull the two sides together and \nhold them in that position. To do this, you need wire that is thin, strong, \nand bends easily. 'Ligature wire' (0.20 gauge) is best. \n\n\nPlace a piece of wire around 2 teeth, \none on each side of the break. Choose \nthe strongest tooth on each side — the \nones with the longest or the most roots. \nTighten the wire around the two strong \nteeth with pliers or a hemostat. \n\n\n\nAsk the person to close his teeth. Lift up the broken part of the jaw \nand hold it so the lower teeth meet the upper teeth properly. This is the \nnormal way the jawbone holds the teeth. \n\n\nNow join the wires. Twist and tighten \nthem together. This may be painful. \n\nYou can inject local anesthetic — see \nChapter 8. You must twist the wire tight \nenough to hold the broken parts together. \n\n\n\nBend the end of the twisted wire toward the teeth. Now it cannot poke \nthe person's lips or cheek. \n\n3. Put on a head bandage. \n\nGently close the person's jaw so that his teeth come together. Support it \nin this position with a head-and-chin bandage. \n\n\n\nTie the bandage to support the jaw, not to pull it. \nDo not make it too tight. It is all right if his mouth \nstays partly open with the teeth slightly apart. \n\nBe sure not to let the bandage choke the person. \n\n\n4. Give penicillin by injection (page 204) for 5 days to stop infection inside \nthe bone. \n\n5. Give something for pain. Aspirin (p. 94) may be enough. Give 600 mg \nby mouth, 4 to 6 times a day, as needed. For children, see doses on \npage 165. If there is a lot of pain and the person cannot sleep, give \ncodeine. The dose for an adult is 30 mg, 4 to 6 times a day as needed. \n\n\nWhere There Is No Dentist 2009 111 \n\n\nSend the person to the hospital as soon as possible. The person must have \nwires placed on his teeth within a week of the accident. The wires must \nremain there for 4 to 6 weeks. Every week, the person must return to the \nhospital to have the wires tightened. During this time he cannot open his \nmouth to chew food or brush his teeth. \n\n\nCARING FOR A PERSON WHO CANNOT EAT PROPERLY \n1. Give liquid foods for strength and energy. \n\nPrepare food in two ways: (a) First, a milk-oil drink to build strength and \nthen (b) a special soup to keep him strong and give him energy. \n\nTo build strength: Milk-oil drink \n\nMix for him each day at your clinic: \n\n• 9 cups of water • 1 50 ml of peanut oil or coconut milk \n\n• 3 cups of milk powder • 14 cup of honey or 1 cup of sugar \n\n\nLeave some near his bed, and keep the rest in a cool place. \n\n\nTo keep strength and give energy: Special vegetable soup \n\nCut into small pieces and cook together in a pot of water: \n\n\n\n14 tin of fish or a handful of dried fish \n4 small spoonfuls of peanut oil or palm oil \n6 sweet potatoes or small yams \n1 large handful of green leaves \n1 small spoonful of salt \n\n\n\n\nPour the soup into an empty tin with small holes made in the bottom. \n\nUse the back of a spoon to press as much of the cooked food as you can \nthrough the holes. The person can suck the soup between the teeth to the \nthroat and then swallow it. Clean the tin and set it in boiling water, so you \ncan use it again the next day. \n\n2. Keep the teeth clean and the gums tough. \n\nThe person must learn to clean teeth and gums or the gums can quickly \nbecome infected and the mouth will feel sore. So: \n\n• Scrub both the wires and the teeth with a soft brush after drinking soup. \n\n• Rinse with warm salt water (page 7), 2 cups every day. \n\n\n\noi \n\n\n112 Where There Is No Dentist 2009 \n\n\nLOOSE TEETH \n\nIf the bone around the roots of the teeth is cracked, those teeth will be \nloose. Do not take the teeth out until the bone is healed. Otherwise, \nbone will come out with the teeth and there will be a big hole in the jaw. \nInstead, support the teeth, in order to hold both sides of the bone steady. \n\n\n1 . \n\n\n2. \n\n\n3 . \n\n\n4 . \n\n\nWith your thumb and finger, gently \nmove the loose teeth and bone back \ninto normal position. \n\nCut a hypodermic needle and use it \nas a splint. Make it long enough to fit \naround two strong teeth on each side of \nthe loose teeth. Curve the needle so it \nfits the curve of the teeth. To make the \nsharp ends smooth, use a file or rub the \nends against a stone. \n\nTie each tooth to the needle. Use short \npieces of 0.20 gauge ligature wire (page 1 10). \n\nPut one end of the wire under the needle. \nBring it around the back of one tooth and \nout to the front again over the needle. \n\nUse the end of a small instrument to \nhold down the wire at the back of the \nteeth. Then twist the ends together. \nTighten the wire around each one of \nthe 6 teeth. \n\nCut the ends of the ligature wire. Turn \nthem toward the teeth, so they will not \ncut the lip. \n\n\n\nBEND THE NEEDLE \nAROUND THE TOOTH \nSO IT DOES NOT \n\n\n\n\nNEEDLE HOLDER \n\n\n\n5 . Tighten the wires the next day, and then once each week. But be \ncareful. Only Vz a turn usually is needed. More, and the wire will break. \nAlways twist in the direction a clock moves. With this habit, you will \nremember which way tightens the wire and which way loosens it. \n\n\n6 . Explain to the person that it takes 4 weeks for the bone to heal. The \nwires must remain on the teeth for this time. To help the teeth to heal, \nask the person to: \n\n• give these teeth a rest. Use other teeth for chewing. \n\n• clean both the teeth and the wires with a soft brush. \n\n• rinse with warm salt water, 2 cups every day (p. 8). \n\n• return to have the wires tightened every week. \n\n\n7 . After 4 weeks, cut and remove the wires. Ask the person to watch \nthose teeth. A dark tooth and gum bubble are signs that the tooth is \ndying. Take it out, unless you can give special nerve treatment. \n\n\nWhere There Is No Dentist 2009 113 \n\n\nDISLOCATED JAW \n\nIf a person opens her mouth wide and then is unable to close it, we say her \njaw is dislocated. It is stuck in the open position. This problem often happens \nto a person who does not have several of her back teeth. When she opens \nwide to yawn or shout, the part of her jaw that joins her head moves too far \nforward inside the joint. It is then unable to return to its normal position. You \ncan also dislocate the lower jaw by accident while extracting a tooth. \n\n\nSIGNS: \n\n\n\n\nTREATMENT: \n\n\nShe is unable to close her \nteeth together. \n\nShe cannot close her lips \neasily. \n\nHer lower jaw looks long \nand pointed. \n\nIt hurts when you press on \nthe joint in front of her ear. \n\nShe cannot speak clearly. \n\n\nThe treatment is to try to move the lower jaw back where it belongs. Then \nhold it in that position until the muscles can relax. \n\n\n1. Find a way to support the person's head. For example, have the person \nsit on the floor with her head against a wall. \n\n2 . Kneel in front of her. Put your fingers under her jaw, outside the mouth. \nPut your thumbs beside her last molar tooth on each side. Do not put \nyour thumbs on the molars. The person may bite them! \n\nPress down hard with the ends of your \nthumbs. Force the jaw to move quickly \nclown and back into position. Be sure \nto press down before you press back. \n\nIf the jaw will not move, perhaps the \nmuscles are too tight. A doctor or \ndentist can put the person to sleep, \nwhich will relax the muscles. \n\n3 . Support the jaw with a head-and-chin \nbandage for 3 to 4 days (page 110). \n\n4 . Give aspirin or acetominophen for pain (page 94). \n\n5 . Explain the problem to the person and tell her how to care for her \njaw: (a) eat mostly soft foods for 2 weeks; (b) hold a warm wet cloth \nagainst the jaw; (c) remember not to open the mouth wide anymore. If \n\npossible, replace the missing back teeth with dentures (page 107). \n\n\nCO \n\n\n\n\nor \n\n\n114 Where There Is No Dentist 2009 \n\n\nPAIN IN THE JOINT \n\nA joint is the place where one bone joins another. The jawbone has two \njoints, for it joins the head in front of each ear. \n\nThe mouth opens and closes because: \n\n• muscles pull the jawbone; and \n\n• the jawbone slides against the head \nbone, inside the joints. \n\nPain in these joints may be because: \n\n(1) The muscles are tight because the \nthe person is tense or nervous. \n\n(2) The jawbone is fractured in the area \nof the joint. (Also check the lower \njaw on the other side since a fracture \nnear the joint is often caused by a \nblow to the other side of the face.) \n\n(3) The teeth do not fit together properly. \n\nTREATMENT: \n\nBefore you treat, decide what is causing the pain. We will discuss the three \ncauses mentioned above. \n\n1. Tension. \n\nTalk with the person and help, if you can, to find a solution to her \npersonal problems. This can do much to help her and her muscles relax. \nIn addition, explain how to care for the sore joint: \n\n(a) Eat only soft foods until it no longer hurts to chew. \n\n(b) Hold a hot, wet cloth against the jaw, to help relax the muscle. \n\nDo this as often as possible, but be careful not to burn the skin. \n\n(c) Take aspirin or acetominophen (page 94) to reduce the pain. \n\n2. Fracture. \n\nIf an X-ray shows a fracture, the person needs expert help. A dentist \ncan wire the teeth in a way that will allow the bone to heal. \n\n3. Teeth do not fit together properly. \n\nImagine a line that passes between the two middle upper teeth and \nthe two middle lower teeth in the person's closed mouth (see the next \npage). When the person opens the mouth, this line becomes longer, but \nit is still a straight line. If it is not, this condition can, after a long time, \ncause pain in the joint. \n\n\n\noi \n\n\nWhere There Is No Dentist 2009 115 \n\n\n\n\ntwo middle teeth does not shift when the mouth opens. \n\n\nWhen you see teeth that do not fit properly: \n\n• Warn the person not to open his \nmouth wide. Suggest, for example, \nthat he take his food in small bites. \n\n• Tell the person what can be done \nto help. Often a dentist can grind \nthe teeth in a special way and this \ncan end the pain. \n\n\n\nThese teeth do not fit properly. Because the \nline shifts, this means the jaw is also shifting. \nThis shift can cause pain in the joint. \n\n\nSWOLLEN GUMS AND EPILEPSY \n\nMany persons who suffer from epilepsy \n(see Where There Is No Doctor, page \n178) have a problem with swollen \ngums. In severe cases, the gums are so \nswollen that they cover the teeth. This \nproblem is caused not by epilepsy but by \ndiphenylhydantoin (Dilantin), a drug used \nto control epilepsy. \n\nWhen you see swollen gums, find out what medicines the person is taking. \n\nIf possible, change to a different drug. If the person must continue using \ndiphenylhydantoin, explain how to prevent this swelling of the gums. Show \nthe person this book, especially pages 69 to 72. Persons who take this drug \nmay be able to prevent the swelling by brushing the teeth carefully after \neach meal, and taking special care to clean between the teeth (page 71 ). \n\n\n\noi \n\n\n116 Where There Is No Dentist 2009 \n\n\nBLOOD IN THE MOUTH \n\nUse wet cotton gauze to wipe away the old blood from inside the mouth. \nThen you can see where it is coming from. Treat the cause of the bleeding. \n\n\nIF YOU SEE: \n\nTO STOP THE BLEEDING: \n\nSEE PAGE \n\nt \n\na large red clot growing \nout of a socket where you \nhave taken out a tooth \n\n1 . \n\n2. \n\nt \n\nRemove the clot with \ncotton tweezers. \n\nAsk the person to bite \non a piece of cotton. \n\nt \n\n118 \n\nsore and bleeding gums \nand the mouth smells \n\n1 . \n\nRinse with a mixture of \nhydrogen peroxide and water. \n\n8 \n\nbad (Vincent's infection) \n\n2. \n\nRemove as much tartar as you can. \n\n127 \n\na red, bleeding growth \ninside the cavity in a tooth \n\n\nTake out the tooth; \nit has an abscess. \n\n93 \n\na loose tooth with \nbleeding gums around it \n\n\nHold the tooth with wires, or if the \nroot is broken, take out the tooth. \n\n112 \n\n157 \n\ntorn gums with broken \nbone and bleeding \n\n1 . \n\n2. \n\nWith wire, hold the broken \nparts of the bone together. \nSend the person to an \nexperienced dental worker. \n\n110 \n\n\nPROBLEMS AFTER YOU TAKE OUT A TOOTH \n\n\nProblems like swelling, severe pain, and bleeding can occur after you \ntake out a tooth. Tetanus (p. 1 18), a more serious problem, can also occur, \nespecially if your instruments were not clean. \n\n\nSwelling of the Face \n\nYou can expect some swelling after \nyou take out a tooth. But if the \nswelling continues to grow, and it is \npainful, this is not normal. Probably an \ninfection has started. The treatment \nis the same as for a tooth abscess: \npenicillin for 5 days to fight infection, \nheat to reduce the swelling, and \naspirin or acetominophen for pain. \nSee page 94 for the proper doses. \n\n\n\n\noi \n\n\nWhere There Is No Dentist 2009 117 \n\n\nPain from the Socket \n\nThere is always some pain after a tooth is taken out. Aspirin is usually \nenough to help. \n\nHowever, sometimes a severe kind of pain starts inside the tooth's 'socket' \n(the wound) 2 to 3 days after you take out the tooth. This problem is called \ndry socket and it needs special care. \n\nTREATMENT: \n\n1. Place a dressing inside the socket. Change it each day until the pain stops. \n\n\n\nFirst, clean out the socket. \n\nSquirt warm water inside the socket with \na clean syringe. After the person spits out \nthe water, squirt water inside once more. \nUse a blunt needle so that it does not \nhurt the gums or bone if it touches them. \n\n\n\nSecond, prepare the dressing. \n\nSoak 1-2 small pieces of \ncotton in eugenol (oil of \ncloves.) \n\nSqueeze each piece so that it \nis damp but not wet. \n\nNote: There may be local \nmedicine in your area that \nrelieves pain. Use it instead of \neugenol. \n\n\n\nThird, place the dressing \ngently inside the socket. \n\nPlace one piece of dressing \ninto each root space. Push \nit down into the root space \ngently. \n\nCover the socket with plain \ncotton gauze, and send \nthe person home bitting \nagainst it. He can remove \nthe plain cotton in an hour. \nThe dressing should remain \ninside the socket. \n\n\n2 . Give aspirin or acetominophen for pain (page 94). \n\n\noi \n\n\n118 Where There Is No Dentist 2009 \n\n\nBleeding from the Socket \n\nWhen you take out a tooth it leaves a wound, so you can expect some \nblood. However, if the person bites firmly against a piece of cotton, it usually \ncontrols the bleeding. To help the wound heal (from a clot), tell the person \nnot to smoke, rinse with salt water, or spit for 1 or 2 days after you take out \nthe tooth. \n\nWhen the first bleeding occurs, put a new piece of cotton on top of the \nwound and ask the person to close her teeth against it for an hour. Keep \nher there with you, to be sure she continues to bite on the cotton. (If it is \ntoo painful, you may want to inject anesthetic. See Chapter 9.) Change the \ncotton if it becomes soaked with blood. \n\nTREATMENT (if the bleeding continues): \n\n1. Take her blood pressure (see Helping \nHealth Workers Learn, page 19-13). If it \nis high, you may need medicine to bring \nit down. That can help slow the bleeding. \n\n2. Look carefully at the wound. \n\nIf the gum is torn or loose, \nput in a suture (pages 161-163). \n\n3. Wrap tea leaves in cotton gauze. Soak the bundle in water and then \nput it on the socket. Have the person bite against it. Or, have her bite \nagainst cotton gauze soaked with cactus juice. \n\nLet the person go home only when the bleeding stops. Give her \nsome clean cotton to use in case the bleeding starts again later \n(see page 161). \n\nTETANUS \n\nThis is a very serious infection. Tetanus germs enter the body when a \nwound, like a wound on the bottom of the foot, gets dirty. Germs can also be \ncarried to the socket when you use a dirty instrument to take out a tooth. To \navoid this, carefully read pages 86 to 89. \n\nSIGNS: OLD, DRY BLOOD \n\n• the jaw becomes stiff and tight \n\n• it is hard to swallow \n\n• the whole body becomes tight, \nwith sudden spasms \n\nTREATMENT: \n\nA person with signs of tetanus requires immediate medical help. See \nWhere There is No Doctor, pages 182 to 184, if you cannot get help \nimmediately. \n\n\n\n\nWhere There Is No Dentist 2009 119 \n\n\nINFECTION INSIDE THE SPIT (SALIVA) GLAND \n\nSpit glands are places where the spit or saliva is made. They are located in front \nof the ear and under the jaw, on each side of the head. If there is an infection \ninside a spit gland, the face will become swollen and the area will hurt. \n\nSpit is sent from the gland to the mouth through a thin pipe called a duct. \nDucts open into the mouth in two places: on the inside of each cheek and \nunder the longue. \n\nA small stone can often block a duct and cause an infection in the spit gland \nand swelling of the face. You may be able to feel the stone near where the \nduct enters the mouth. \n\nSIGNS: \n\n• swelling in the area of the spit gland. \n\n• pain which gets worse when the person is hungry, and when he sees \nor smells food. \n\n• the opening of the duct is red, swollen, and hurts when you touch it. \n\n\n\nspit from \nthis gland \nenters on \nthe inside of \nthe cheek \n\nspit from \nthis gland \nenters under \nthe tongue \n\n\n\nTREATMENT: \n\nReduce the infection and swelling first. Later try to remove the stone. \n\n1. Give penicillin for 5 days (page 94). If the swelling is large and the \ninfection serious, start with short-acting crystalline penicillin (see \npage 204). \n\n2. Give aspirin or acetominophen for pain (see page 94). \n\n3 . Apply a wet hot cloth to the swelling as often as possible. \n\n4 . Give enough soft food to prevent the person from feeling hungry. \nThe pain will be less then. \n\n5 . When the person feels better, a dentist or doctor can remove the \nstone that is blocking the duct. \n\n\noi \n\n\n120 Where There Is No Dentist 2009 \n\n\nSORES ON THE FACE \n\nWhenever you see a sore on a person's cheek or under his chin, remember \nthere may be a tooth or gum problem. If it is a gum problem, it may be \nNoma. See the following pages. \n\n\nA bad tooth: \n\nAsk him to open his mouth. \nLook for an infected tooth in \nthe area of the sore. There \nmay be a large cavity and the \ntooth may be loose. \n\n\n\n\nOr the tooth may be darker \nin color than the others. \nThis is because it is dead. \n\nThe pus is draining onto \nthe skin, so the pressure \nis reduced and the person \ndoes not complain of pain. \n\n\nTREATMENT: \n\n1. Take out the tooth (see Chapter 1 1). \n\n2. Give penicillin for 7 days (see page 94). \n\n3 . After the penicillin treatment, check the sore. If it has healed, there is \nno longer infection inside. The treatment is finished. \n\nBut if the sore is still open and you can squeeze out pus, you will need the \nhelp of experienced health workers who can: \n\n• test the pus to see if it is resistant to penicillin. The person may \nneed to take a different antibiotic. \n\n• take an X-ray to see if there are dead pieces of bone which are \nkeeping the infection alive. If there are, they must be removed. \n\nIf infected gums (and not a bad tooth) are the cause of a sore on the cheek \nor chin, the problem is more serious. See the next 4 pages. \n\n\noi \n\n\nWhere There Is No Dentist 2009 121 \n\n\nNOMA \n\nWhen a child is sick, a simple gum infection can get out of control and \nspread through the cheek to the face. When that happens the condition is \ncalled Noma orCancrum Oris. Noma is a complication of Vincent's Infection \nof the gums (page 102). \n\n\n\nYou will usully see Noma in children. It will only \ndevelop if these 3 things are true: \n\n(1) The child's general resistance is low. \nUsually, he is undernourished and anemic \n(lacks iron). He may have tuberculosis. \n\n( 2 ) The child has Vincent's Infection. \n\n( 3 ) The child has recently had a serious \nillness like measles or malaria. \n\n\nNoma can also be a problem for adults living with HIV/AIDS. See page 185. \n\n\nSIGNS: \n\nThe infection starts in the mouth. \n\nThen it passes to the gums. \n\n1. Sore mouth with itching gums. \n\n2 . Swollen, sore gums. \n\n3 . Gums bleed when eating or \nwhen teeth are cleaned. \n\n4 . Bad breath, spits a lot. \n\nThen it reaches the jaw. \n\n5 . Loose teeth. \n\n6 . Loose pieces of bone \naround the teeth. \n\nFinally, it affects the cheek. \n\n7 . Skin is tight with dark red \nswelling. \n\n8 . Black spot on the cheek \nbreaks open, leaving a hole \ninto the mouth. \n\n9 . A line separates dead \ntissue from healthy tissue. \n\n\n\n\n\noi \n\n\n122 Where There Is No Dentist 2009 \n\n\nTREATMENT: \n\nYou must start treatment for Noma immediately in order to prevent the hole \nfrom getting bigger. The bigger the hole, the tighter the scar that forms after \nyou close the hole. A tight scar will prevent the child from opening his mouth \nand chewing the food he needs to grow stronger. \n\n1. Give fluids. \n\nThe child needs to overcome both \nthe lack of body water (dehydration) \nand his lack of resistance to disease. \n\nStart giving the milk-oil drink \ndescribed on p. 1 1 1 . \n\nIf he cannot drink by himself, help \nhim. Use a spoon or syringe. \n\nPlace the fluid on the inside of the \nhealthy cheek and ask the child to \nswallow. \n\n2. Treat the anemia. \n\nStart giving iron now. The child should continue taking the tablets or \nmixture for 3 months. \n\n\n\n\nFerrous Sulfate Tablets \n\nover 6 years \n\n200 mg (1 tab) 3 times a day \n\n3-6 years \n\n1 00 mg ('A tab) 3 times a day \n\nunder 3 years \n\n50 mg (V* tab) 3 times a day \n\n\nYou can also use ferrous fumarate. Advise the mother that the iron \nwill make the child's stool black. \n\nAlso give food rich in iron: meat, fish, eggs, dark green leafy \nvegetables, peas and beans. \n\nNote: A child may have anemia because he has worms. It is a good \nidea to do a stool analysis to find out. If he has worms, give him \nmedicine right away. Mebendazole and Albendazole and Thiabendazole \ntreat many different worm infections. Piperazine treats roundworm and \npinworm infections, and there are other medicines for tapeworm and \nblood flukes. Also give folic acid. For doses, see Where There Is No \nDoctor, pages 374 to 377, and page 393. \n\n\noi \n\n\nWhere There Is No Dentist 2009 123 \n\n\n3. Start antibiotics. \n\nMetronidazole is the best medicine to use. Give 200 mg by mouth 3 times \na day for 1 0 days. You can also use clindamycin. To decide how much to \ngive, weigh the child. For adults, see the medicines and doses on page 1 85. \n\n\nWeight \n\nDose for clindamycin (give 3 times a day for 5 days) \n\n5 to 1 0 kg \n\n50 mg by mouth or 60 mg by injection \n\n1 0 to 1 7 kg \n\n100 mg by mouth or 130 mg by injection \n\n17 to 25 kg \n\n1 50 mg by mouth or 225 mg by injection \n\nover 25 kg \n\n250 mg by mouth or 333 mg by injection \n\n\n4. Treat the other illness that helped Noma to develop. \n\nIt is wise to assume that the child has malaria and to begin treating \nwith antimalarial drugs (see Where There Is No Doctor, pages 365 to \n368). \n\nLook for any other illnesses and treat them, too, especially measles and \ntuberculosis. \n\n\n5. Clean the sore. \n\nGently pull away any dead skin with tweezers. Wash the inside of the \nsore with hydrogen peroxide. (Be sure you measure the hydrogen \nperoxide carefully. See page 8.) Then put in a wet dressing. (You can also \nclean the sore with an iodine solution.) \n\nThe dressing: \n\n• Soak cotton gauze in salt water. Squeeze out the extra water so that it \nis damp but not wet. \n\n• Put it in the hole and cover it with a dry bandage. \n\n• Every day, remove the bandage, wash the hole with hydrogen \nperoxide, and put in a new dressing. Do this until the hole does not \nsmell anymore and there is no more dark dead skin. \n\n6. Remove the loose teeth and dead bone. \n\nYou can use a local anesthetic (Chapter 9). Usually there is not much \nbleeding. If gums are loose, join them with a suture (see pages 161 to \n163). \n\n\nwww. nespenan.org \n\n\n124 Where There Is No Dentist 2009 \n\n\n7. Keep the mouth clean. \n\n• Use a soft brush gently to clean the remaining teeth. Do this 3 times a \nday for the child. \n\n• Wipe the gums with a weak solution of hydrogen peroxide. Use cotton \ngauze that is damp with the solution. Do this every 2 hours for 5 days. \n\n• Then after 5 days, start rinsing with warm salt water 3 cups a day. \n\n8. Get advice on whether surgery is needed. \n\nUnfortunately, the child will probably need surgery, to release the \nscar. Without this surgery, the child will not be able to open his mouth \nproperly. \n\n\nSend the child for medical help when the \ninfection is finished and the wound starts \nto close. \n\nYou may also need a dentist's help at this \ntime. The child's jaws may need to be \nwired. The wires are put on the healthy \nteeth in a way that holds the mouth open \nwhile the tight scar is forming. When the \nwires are removed, the child will be able to \nopen and close his mouth to chew food. \n\n\nNoma need not occur. We can prevent it. Always give special attention \nto the mouth of a sick child, to be sure to keep his teeth clean. \n\nWhenever someone is nursing or caring for a sick child, that person \nshould clean the child's teeth as a normal activity. This is especially \ntrue for a child who is weak, undernourished, and with little body water \n(dehydration). \n\nSuch a child should always: \n\n• have his teeth carefully cleaned \neach day with a soft brush. \n\n• rinse his mouth with a warm salt \nwater solution (page 7), 2 times \na day. \n\n• eat fresh fruits and vegetables, \nespecially the kind that have \nVitamin C: guavas, oranges, \npineapples, papayas, tomatoes, \npeas, and dark green leaves. \n\n\n\n\nPREVENTION OF NOMA: \n\n\nWhere There Is No Dentist 2009 125 \n\n\nTUMOR \n\nA tumor is a lump that grows under the skin or inside the bone. It grows \n\n\n\nIf the swelling does not get better after 5 days of antibiotics and heat \ntreatment (page 94), it may be a tumor. \n\nTREATMENT: \n\nDo not waste any more medicine or any more time. A tumor may be \ncancer. Send for medical help. Surgery is needed to remove a tumor. \n\n\nCANCER \n\n\nAny sore that does not heal may \nbe cancer. The lips and tongue are \nthe two places in the mouth where \ncancer starts most often. \n\nCancer is deadly. \n\n\nMedicine cannot help. \nIt wastes time to use it. \n\n\n\nCancer can spread quickly to the inside of the person's body where you \ncannot see it. This can lead to the person's death. \n\n\nTREATMENT: \n\nWhenever you treat a sore and it does not ge better, send the person for \nmedical help immediately. A doctor can cut out a piece from the sore, look at \nit under a microscope, and decide if it is cancer. \n\n\noi \n\n\n126 Where There Is No Dentist 2009 \n\n\nWWW. \n\n\nhesperian \n\n\n-org \n\n\nCHAPTER \n\n\nScaling Teeth \n\n\nScaling means 'scraping away.' You can scale old food, tartar, or even a fish \nbone caught under the gum. You usually scale teeth to remove tartar. \n\n\nClean teeth keep our gums healthy. Scaling a person's teeth gives infected \ngums a chance to become normal again. \n\nHowever, gums remain healthy only when we keep the teeth beside \nthem clean. If we are not careful about cleaning our teeth after they are \nscaled, tartar will soon return. Instead of being healthy, the gums will \nbecome sore and infected again. \n\n\nScale a person's teeth, but also teach how to keep teeth clean. \n\n\nYou must remove something caught under the gums (page 133) before it \ncauses more pain and swelling. Remove a piece of fish bone or piece of \nmango string now. \n\nIf the person has a mild gum problem (gums that bleed), wait a week or so \nbefore scaling. If the person uses this time to clean his teeth better and to \nrinse with warm salt water (page 7), the gums will improve. The person's teeth \nwill be easier for you to scale, and he will learn that he can do much by himself \nto care for the gums. \n\nUse a mirror to show the person gum infection inside his own mouth. \n\nLater he can see the improvement he has made. He can learn about how to \nkeep gums healthy as he follows his own progress. \n\nScale a person's teeth only when he really wants to try to keep them \nclean. If he does not want to clean his teeth, the tartar will soon return. Do not \nwaste your time scaling the teeth of a person who does not want to learn. \n\n\n\nWe get tartar when the coating \nof germs on our teeth (p. 50) \nbecomes hard. \n\n\nGums that press against tartar \nbecome sore and infected. \n\n\n127 \n\n\n128 Where There Is No Dentist 2009 \n\n\nTHE INSTRUMENTS YOU NEED FOR SCALING \n\nWe scale teeth with special instruments called scalers. There are many \ndifferent kinds of scaler\n…[truncated]", "summary": "Where There Is No Dentist by Murray Dickson updated and expanded with information about hiv/aids by Richard Bebermeyer, Martin Hobdell and Gene Stevenson Introduction by David Werner, author of Where There Is No Doctor Hesperian encourages others to copy, reproduce, or adapt to meet local needs any or all parts of this book, including the illustrations, provided that the parts reproduced are distributed free or at cost - not for profit. Any organization or person who…", "source_url": "https://archive.org/details/WhereThereIsNoDentist-MurrayDickson", "pdf_url": "https://archive.org/details/WhereThereIsNoDentist-MurrayDickson", "case": "hesperian", "sub_case": "MURRAY DICKSON", "tags": ["hesperian", "RADICAL MEDICINE; PEOPLE'S HEALTH."], "page_count": 0} {"title": "Antibiotics: What they are and How to use them. Lesson from Book \"Where there is no doctor\"", "content": "COMMUNITY HEA - . aCe 5 ae, \n&7/%, (Bivet Fleer) Si. Marks nooe, . \noe aenqalora - 6609 001, \n\n\nCHAPTER \n\n\n| ANTIBIOTICS: WHAT THEY ARE \n\", AND How To USE THEM \n\n\nte teeeneenrereten \n3. Chew one end to make it 4. Sharpen the other end so \nstringy like a brush. it can clean between the \n\n\nteeth (see pages 71-72). \n\n\nWhere There Is No Dentist 2010 \n\n\nYou can twist the fiber from inside a coconut husk into a kind of brush. First \nrub it and shake away the loose bits. Then use the end to clean your teeth. \n\n\nWhatever kind of brush you use, be sure to clean your back teeth as well as \nyour front teeth. Scrub the tops and sides where the grooves are. Then push \nthe hairs between the teeth and scrub (page 69). \n\n\nToothpaste is not necessary. \nCharcoal or even just water is \nenough. When your teeth are \nclean, rinse away the loose \npieces of food. \n\n\n5 \n\n\n6 \n\n\nWhere There Is No Dentist 2010 \n\n\nCAVITIES, TOOTHACHES AND ABSCESSES \n\n\n‘Cavities’ are holes in teeth. Cavities are made by the infection called tooth \ndecay. If you have a black spot on your tooth, it might be a cavity. If that \ntooth hurts some of the lime, such as when you eat, drink, or breathe cold \nair, it probably has a cavity in it. \n\n\nYou will get cavities in your teeth if you eat sweet food and then do not \nclean your teeth. If you see a cavity starting in your mouth or feel a \ntooth hurting you, get help right away. If you do not fill a cavity, it grows \nbigger and deeper. A dental worker knows how to fill the cavity so you can \nkeep that tooth. Do this before the pain gets worse. \n\n\nEach tooth has roots When decay When infection \nthat hold it in the touches the nerve reaches the \njaw bone. Inside inside the tooth inside of a root, \neach root is a nerve. aches, even when it is called a \n\n(p. 39 to 40 and 45) you try to sleep. tooth abscess. \n\n\nA tooth with an abscess needs treatment at once, before the infection \ncan go into the bone (page 93). In most cases the tooth must be taken \nout. If it is not possible to do this right away, you can stop the problem from \ngetting any worse if you follow these steps: \n\n\n1. Wash the inside of your mouth with warm \nwater. This removes any bits of food \ncaught inside the cavity. \n\n\n2. Take aspirin or acetominophen for pain. \nSee page 95 for amount. \n\n\n3. Reduce the swelling: \n\n\ne hold warm water inside your mouth \nnear the bad tooth. \n\n\ne Weta cloth with hot water and \nhold it against your face. Do not \n\n\nuse water hot enough to burn \nyourself! A tooth abscess can cause \nswelling like this. \n\n\nWhere There Is No Dentist 2010 \n\n\nSORE BLEEDING GUMS \n\n\nHealthy gums fit tightly around the teeth. Gums are infected if they are \nloose, sore, and red, and if they bleed when the teeth are cleaned. Infection \nin the gums is called gum disease. \n\n\nGum disease, like tooth decay, happens when acid touches the teeth and \ngums. This acid is made when sweet and soft foods mix with germs (see \npage 50). \n\n\nf f £, y 4 7 \na4 oF \n1 \nWi el Aa ha \nHEALTHY TEETH AND GUMS CAVITIES AND GUM DISEASE \n\n\nInfection from gum disease can spread into the root fibers and bone (see \npage 42). But you can stop gum disease and prevent it from coming \nback. There are two things to do: clean your teeth better and strengthen \nyour gums. \n\n1. Even if your gums are sore and they bleed, you must still clean the \nteeth beside them. If more food collects on the teeth, the gum \ninfection will get even worse. Get a soft brush (see p. 4) and use it \ngently. This way you will not hurt the gums when you clean. \n\n2. To make your gums stronger and more able to fight the infection: \n\ne Eat more fresh fruits and green leafy vegetables, and fewer soft \nsticky foods from the store. \n\ne Rinse your mouth with warm salt water. Do this every day, even \nafter your gums feel better. \n\n\n(1) Mix some salt with a cup of warm water. (2) Take a mouthful \nand rinse. (3) Spit it out. Repeat until all of the salt water is finished. \n\n\n8 \n\n\nWhere There Is No Dentist 2010 \n\n\nMORE SERIOUS GUM DISEASE \n\n\nPainful gums that bleed at the slightest touch need special treatment. If \nyou have this problem, ask for help. A dental worker can explain what is \nhappening and what needs to be done. A dental worker can also scrape the \nteeth and remove the tartar that is poking the gums, making them sore. \n\n\nAt home, you can do some things to help. \n\n\nTake some into your mouth and hold it there for \nabout 2 minutes. Then spit it out and repeat. Do \nthis every hour you are awake. \n\n\nUse hydrogen peroxide for only 3 days. Then \nchange and start rinsing with salt water (page 7). \n\n\nClean your teeth near the gums with a soft brush. Gently push the \nbrush between the tooth and the gum. It may bleed at first, but as the \ngums toughen, the bleeding will stop. \n\n\nMake your food soft, so it is easier to chew. Pounded yam and soup \nare good examples. \n\n\nEat plenty of fresh fruits and vegetables. If it is difficult for you to bite \ninto fruit, squeeze it and drink the juice. \n\n\nStart rinsing your mouth with a mixture of hydrogen peroxide \nand water. You can get hydrogen peroxide from your clinic or your \npharmacy (chemist). \n\n\nThe strength of hydrogen peroxide is important. Ask for a 3% \nsolution, and mix it evenly with water—that is, % cup of hydrogen \nperoxide with % cup of water. \n\n\nWARNING: Read the label to be sure the solution \nis 3%. A mixture with more than 3% \nhydrogen peroxide can burn the mouth. \n\n\nIf you take care, you can keep your teeth for a lifetime. \n\n\nCHAPTER 2 \n\n\nTeaching Family and \nFriends in Your Community \n\n\nOld people can remember when there were fewer problems with teeth and \ngums. Children’s teeth were stronger and adults kept their teeth longer. \n\n\nTimes are changing. Today there are more tooth and gum problems than \never before. In many countries, tooth decay and gum disease are two of the \n\n\nfastest growing health problems. \n\n\nThis unhealthy situation is getting worse, for two reasons: changes in the \nkind of food people now are eating, and not enough cleaning after they eat. \n\n\nBEFORE, the food people ate \nwas their own, grown and \nprepared by themselves. \n\n\nEven sugar cane was not as bad \nas the sticky candy children eat \ntoday. The sugar was bad for the \nteeth, but the fiber in the cane \nhelped rub them clean. \n\n\nNOW, more people are buying \nsofter and sweeter food from \nthe store. This kind of food \nsticks to the teeth more easily \nso it has more time to attack \nthe teeth and gums. \n\n\nEveryone must be more careful \nto clean away soft, sweet \nfood. But many people do not \nknow how. Some, especially \nchildren, do not even try. \n\n\n10 Where There Is No Dentist 2010 \n\n\nMany people do not understand that tooth and gum problems are caused \nby certain kinds of food, and poor cleaning of the teeth. In fact, some have a \ncompletely different belief. \n\n\nTHERE MAY BE ANOTHER \nREASON. EATING SWEET FOOD \nAND NOT CLEANING YOUR \nTEETH CAN HURT \nTHEM AND MAKE \n\n\nHIM ANGRY À \nBEFORE HE DIED. \n2 << \n\n\nN \n\n\nDo not attack a belief because it is traditional. Many traditions are more \nhealthy than ‘modern’ things. Often, instead of telling people that their belief \nis wrong, you can remind them of a different tradition that is healthy. \n\n\nHelp your family and friends to recognize their \n\n\nhealthy traditions. Then help them find new ways \nto use these same traditions for better health. \n\n\nBUT WE CAN MAKE \nFOR OURSELVES MANY \nOF THE THINGS THE \nSTORE SELLS. \n\n\nYES, AND WE CAN \nMAKE OUR OWN \nTOOTHBRUSHES FROM \nTHE TWIG OF A TREE! \n\n\nOUR PEOPLE DO NoT \nUSE TOOTHBRUSHES. \nWE DO NOT HAVE MONEY \nTo BUY SUCH THINGS \nAT THE STORE. \n\n\nWhere There Is No Dentist 2010 \nBE A GOOD EXAMPLE \n\n\nOther people like to watch what you do before they try something different. \nFirst show members of your family and then they will be an example to \nothers in your community. For example: \n\n\n1. Instead of buying all your foods from the store, buy fresh fruits and \nvegetables from the market. It is even \nbetter to grow food in your own garden. \n\n\nLearn to use several different kinds of \nfoods in each meal. Mixing foods is a \nhealthy idea. Invite friends to share your \nmeals and see the number of different \nfoods you have at each meal. \n\n\n2. Do not buy fizzy drinks like Coca-Cola or Fanta. \nThey have a lot of added sugar which quickly \nmakes children’s teeth rotten. \n\n\nAlso, do not sweeten your child’s milk or tea. \n\n\nWhen she is young she can learn to enjoy \ndrinks that are not sweet. \n\n\nClean, cool water, tea with little sugar, milk, or \nwater from a young coconut are best to drink. \nFresh fruits are delicious when you are thirsty. \n\n\nMost important: do not give your child feeding bottle, \nespecially one with a sweet drink inside. (See page 3.) \n\n\n3. Keep your children’s teeth clean. \nYour friends will notice clean \nteeth or teeth that are dirty or \nhave cavities. Remember, clean \nteeth are healthy teeth. \n\n\nAn older child can clean his own \nteeth if you show him how. \n\n\nA younger child cannot. He needs \nhelp. Each day someone older \nshould clean his teeth for him \n(page 18). \n\n\n11 \n\n\n12 Where There Is No Dentist 2010 \n\n\nWhen you teach, remember that as others learn, they \n\n\ntoo become teachers. Each person can teach another. \n\n\nEncourage people to pass along what you have taught. Mothers can teach \nfamily and friends. Students can talk at home with brothers, sisters, and \nolder family members. \n\n\nFROM THE HEALTH CLINIC... ... TO THE HOME \n\n\nKEEP YOUR TEETH MARIE, PLEASE HELP \n\n\nAND YOUR ME CLEAN BABY’S Fins. T \nCHILDREN’S TEETH TEETH AND THEN Must CLEAN \nHEALTHY BY BROTHER’S TEETH. \n\n\nMY OWN \nTEETH PROPERLY. \n\n\nWE WILL DO IT \nEVERY DAN, \n\n\nCLEANING THEM, \n\n\nTHEN MAYBE MY \nTEETH WON'T HURT \nLIKE VINCENT’S, \n\n\nFROM THE SCHOOL... ... TO THE HOME \n\n\nUSE A SOFT TOOTHBRUSH. \nA SOFT BRUSH 15 BEST \nBECAUSE IT WON'T \nHURT YOUR GUMS. \nTELL YOUR \nFAMILY THAT. \n\n\nBROTHER, TRY TO BRUSH \nYOUR BACK TEETH BETTER. \nIF YOU DO, THEN THEY \n\nWILL STAY STRONG UNTIL \nYOU GROW OLD. \n\n\nWHAT SHOULD \nI DO IF MY \nGUMS BLEED? \n\n\nWISH L HAD \nKNOWN ABOUT \nTHAT BEFORE. \n\n\nIf all learners become teachers, a simple message can begin in the health clinic or \nschool and reach many more people at home. \n\n\nWhere There Is No Dentist 2010 \nFINDING THE BEST WAY TO TEACH \n\n\nDeciding what to teach is important, but just as important is how to teach. \n\n\nIMPROVING ORAL HYGIENE CAN \nSIGNIFICANTLY REDUCE THE \nINCIDENCE OF DENTAL CARIES, \n\n\nLearning cannot take place \nwhen you use words that \npeople do not understand. \nThey will learn something \nonly when they see how it \nis related to their lives. \n\n\nRemember this when you teach about eating good food and keeping teeth \nclean. Design your own health messages, but be ready to change them if \npeople are not understanding or accepting what you say. \n\n\nHere are five suggestions for teaching well. \n\n\n1. Learn First From the People \n\n\nGet involved in your community's activities. Learn about people's \nproblems, and then offer to help solve them. People will listen to you \nwhen they know that you care about them and want to help. \n\n\nSit and talk with people. Learn . oth =A m \nabout their customs, traditions RRN i LE ŽA \nand beliefs. Respect them. i Ra SMR RY ie Ñ \n\nERA \nLearn about their health habits. i Re oe \nImproving health may require : \n\n\nchanging some habits and \nstrengthening others. \n\n\nAa \n\n\nLearn also about tooth \ndecay and gum disease in \nyour community. \n\n\nMake people smile—then look into their mouths. \n\n\nFind out how many children and adults are having \nproblems with their teeth and gums. Do a survey \nsuch as the one on p. 214. \n\n\n13 \n\n\n14 Where There Is No Dentist 2010 \n\n\n2. Build New Ideas Onto Old Ones \n\n\nPeople find their own ways to stay healthy. Many traditions are good, \nhelpful, and worth keeping. But some are not. \n\n\nWhen you teach, start with what people already understand and are \ndoing themselves. Then add new ideas. \n\nThis method of teaching is called ‘association of ideas’. It helps people \nto understand new ideas because they can compare them with what \nthey already are doing. \n\n\nIn this way people can more easily accept, remember, and do what you \nsuggest. \n\n\nA HEALTHY TRADITION— builds —> NEW IDEAS AND WAYS \n\n\nBe, \n\n\nSweeping the compound in the Brushing the teeth and gums \n\n\nmakes it a clean and same —» keeps them clean and healthy. \nhealthy place to live. way 7 \n\n\nat C \n\n\nA small child cannot find in the A small child cannot see the \nhis own lice. Mother same — food on his teeth. He needs \nknows she must help him. way. help with that also. \n\n\nEating different kinds of food \n\n\nDifferent vegetables in the helps people to grow. Eating \nwhen planted together — same —» them several times a day makes \nlike maize and yams— way your teeth and gums, as well as \n\n\nhelp each other to grow. your whole body, grow stronger. \n\n\nWhere There Is No Dentist 2010 \nSTORY TELLING—AN EXAMPLE \n\n\nPeople everywhere have a tradition of teaching with stories. Many of the \nthings we believe, we learned through stories we heard from parents, \nfriends, and teachers. This is good, except when a story teaches something \nthat isn't true! When a woman gets pregnant, for example, she hears \n\nmany stories, and she wants to learn whatever she can from these stories. \nUnfortunately, some traditional beliefs about pregnancy are partly \nwrong. An example is the belief that one must always have dental problems \nduring pregnancy. \n\n\nHere is a story you can tell to help people see that they are partly right about \npregnancy and dental problems, but that there is more to understand. \n\n\nA Story: Bertine’s teeth \nBertine was the dental worker in her village. She was a young woman, but \nthe villagers respected her because she was such a careful worker, and \nbecause she knew how to fill cavities and pull teeth without hurting people. \nShe also spent a lot of time teaching people how to avoid dental problems. \n“Clean your teeth every day!” she often said, at her clinic, at the schools, at \nvillage meetings. “Eat a mixture of foods, \nespecially a lot of fruits and vegetables! \nAvoid candy and sweet, sticky foods!” \n\n\nWhen Bertine was 23 years old, she got \nmarried and became pregnant. She also \nbegan to have some tooth problems of \nher own. She saw that her gums were \nbleeding when she cleaned her teeth, \nand she had small cavities in two of her \nteeth. As the dental worker, she was \nembarrassed to have tooth problems, \nbut an older woman told her, “It's natural \nto lose teeth when you have babies, \nBertine. As we say, ‘For each child, a \ntooth’.” \n\n\nOne day Lucie, a dental worker from a nearby village, came to see her friend \nBertine. Lucie had a young baby, and Bertine asked her a lot of questions \nabout babies and about pregnancy. Then Bertine said, “Of course, l'm having \nlots of problems with my teeth.” “Why do you say ‘of course’?” asked \nLucie. “Well,” Bertine replied, “For each child, a tooth.” \n\n\n“But that’s not true!” Lucie cried. “You think you are having tooth and gum \nproblems because you are pregnant, but | bet you are having these problems \nfor all the usual reasons.” \n\n\n15 \n\n\n16 Where There Is No Dentist 2010 \n\n\n“The usual reasons?” asked Bertine. \n\n\n“Yes,” said Lucie. “How often do you eat now that you are pregnant?” \n“Well, a lot more than | used to—l have two persons to feed!” “And do you \nstill eat sweet foods sometimes?” Lucie asked. “| guess | do,” said Bertine, \n“and more sweets than before, because | eat more often.” \n\n\n“How about teeth cleaning?” asked Lucie. “Do you clean as often as you did \nbefore you were pregnant?” “No,” Bertine admitted, “| heard | was going to \nhave tooth problems anyway, and | have been so tired lately.... Oh! Do you \nsuppose that these are the only reasons | am having these problems? How \ndo you know so much about this, Lucie?” \n\n\n“Because | had the same problems, Bertine. | learned the truth the hard \nway. | had an infected tooth, and the infection passed to my kidneys. At the \nhealth clinic, they told me it is not necessary to have tooth problems during \npregnancy—and it is even dangerous. | am lucky | did not lose my baby! \nThat can happen, you know, when a tooth problem is not treated. We must \nfill your cavities right now.” \n\n\n“You mean | can be treated now, before | have my baby?” \n\n\n{ “Yes, and you should!” said Lucie. “And \n\n' me you can take better care of your teeth. \n\nIt is true that because of the pregnancy, \nyour gums are weaker, and they can get \ninfected. But this means you should take \neven more care than usual to: (1) clean \nregularly and (2) eat the right foods. You \nneed to have strength when you are \npregnant. An infection in your mouth does \nnot help that. Because your gums are \nweak, it is also good to (3) rinse your mouth \nevery day with warm salt water (see page \n7), and if you cannot get fresh fruits and \nvegetables, then (4) take a tablet of Vitamin \nC every day.” \n\n\nLucie then offered to clean Bertine’s teeth and to fill her cavities. When she \ntouched Bertine’s gums, they bled, and Lucie said, “They will bleed at first, \nbut after you clean them regularly for a while, they will be stronger. Bleeding \ngums are dangerous to a pregnant woman. The bleeding can increase \nanemia, which is a serious problem.” \n\n\nZi \n\n\n\"If a pregnant woman's tooth has an abscess, is it safe to pull it before she \nhas the baby?” asked Bertine. “Yes,” said Lucie, “you just must be gentle. \nA woman gets tired sitting in a dental chair for a long time, and sometimes \nyou must give some extra anesthetic so she does not feel any pain.” \n\n\nWhere There Is No Dentist 2010 \n\n\n3. Keep Your Messages Short and Simple \n\n\nInstead of partially teaching too many things, it is better to discuss a \nfew things well. After learning what health problems the people feel are \ngreatest, decide what information will help them solve these problems. \nThen think of how to share the information. Try to: \n\n\ne Use simple words (see page 13). If you must use a big word, take \nthe time to explain it. \n\n\ne Teach people when they are ready to learn. A sick person, for \nexample, usually wants to know how to prevent his sickness from \nreturning. He will remember what you tell him. \n\n\ne Repeat the most important message many times. Whenever you \nteach about staying healthy, remember to emphasize eating good \nfood and keeping teeth clean. Repetition helps people remember. \n\n\ne Let people see what you mean. See pages 26 to 34 for ways to use \npictures, puppets, and plays. \n\n\n. Teach Wherever People Get Together \n\n\nKnowing where to teach is sometimes as important as how you teach. \nInstead of asking people to come to a class you have organized, go to \nthem. Look for ways to fit into their way of living. You both will gain \nfrom the experience. They will ask more questions, and you will learn \nhow to work with people to solve problems. \n\n\nTalk with people where they gather near their homes. \n\n\nTalk to men \nTalk to and women \nwomen at at church \nhealth clinics meetings, \nand in the in parents’ \nmarket. Talk groups at their \nto men at children’s \nbusiness school, and \nand farming at community \nmeetings. meetings. \n\n\nTeach men and women at reading groups. \n\n\n17 \n\n\n18 Where There Is No Dentist 2010 \n\n\n5. Teach Something People Can Do Right Away \n\n\nIt is good to tell a mother to keep her child's teeth clean, but it is \nbetter to show her how to do it. She will remember how if she actually \nwatches you clean her child’s teeth. \n\n\nAn even better way for a mother to learn is to let her clean her child's \nteeth while you watch. A person discovers something for herself \nwhen she does it herself. \n\n\nPick out a child and clean his teeth yourself. \nLet his mother watch. \n\n\nUse a soft brush (or for a baby, a clean cloth). \nGently but quickly brush or wipe his teeth. Do \nthe best you can even if he cries. \n\n\nIf mothers make this into a habit, the child will \nexpect to have his teeth cleaned and will soon \ncooperate—just the way he does to bathe or \nto have lice removed from his hair. \n\n\nNow let each mother clean her Ask her to do the same at home \nown child's teeth. Teach her to each day. At the next clinic, look \nclean on top and on both sides at the children’s teeth and see \n\nof every tooth. how well the mothers are doing. \n\n\nGive further help when needed. \nAlways praise and encourage \nthose who are doing well. \n\n\nTeaching Children \"3 \nat School \n\n\nChildren want to learn. The want to know more about things that are real \nto them. Family, friends, and teachers are all important sources of new \nknowledge for children. \n\n\nIt is important to keep alive their desire to learn, so that \nchildren can continue to ask questions, discover, and \nlearn more for themselves. \n\n\nWhen children are interested in something, they \nwill work hard to learn all they can about it. \n\n\nIf you relate your teaching to children’s interests and needs, they will learn \nmore easily. New information added to what they already know helps \nchildren to understand your lesson better. As a result, they will want to learn \nmore because the information is both interesting and worthwhile. \n\n\nTeaching about teeth and gums is important. You must do it well if you want \nchildren to pay attention, learn, and finally act to take care of their own teeth \nand gums. \n\n\nAs school children continue to learn, they can share their new ideas \n\nand information at home with brothers, sisters, mothers, fathers, and \ngrandparents. In this way, the circle of teaching and learning described on \npage 12 comes back into the family and is complete. \n\n\nThis chapter has two parts. Part 1 gives seven guidelines for assuring that \nlearning takes place. Part 2 suggests ways to have fun while learning—with \nstories, games, and pictures. In Chapter 4 there are nine questions on teeth \nand gums with specific activities for learning how to answer them. \n\n\n19 \n\n\n20 Where There Is No Dentist 2010 \n\n\nPART 1: \nTEACHING SO THAT LEARNING CAN TAKE PLACE \n\n\nWHAT 15 THE MATTER, LI? \nYOU ARE NOT \n\nKEEPING UP WITH \nTHE OTHERS. \n\n\nMore children than ever before are having \nproblems with their teeth and their gums. \n\n\nA tooth that hurts or gums that are \nsore can affect a student's ability to pay \nattention in school and learn. \n\n\nTreating the problem makes the child feel \nbetter, and that is important. It is equally \nimportant to prevent the same problem \nfrom returning later. \n\n\nWorking together, teachers and school children can do much \nto prevent both tooth decay and gum disease. \n\n\nKeeping the mouth healthy involves learning about eating good food and \nkeeping teeth clean. Just giving information is not enough, though. To truly \nlearn, children need a chance to find out things for themselves. \n\n\nForcing a person simply to accept what \nyou say does not work very well. \n\n\nA student learns not to question. What \nyou teach may have no relation to his \nown experiences and needs. \n\n\nAs a result, he may end up not doing \nwhat you teach—not eating good foods, \nand not cleaning his teeth. \n\n\nRIGHT SIR, \n\n\nWHAT DO YOU THINK \nABOUT THAT? \n\n\nLearning happens when a student with a \nquestion or an idea is able to discover more \nabout it himself. \n\n\nWELL, I WOULD LIKE TO \nLOOK AT MY BROTHER'S \nTEETH FIRST. \n\n\nIt also happens when he has a chance to do \nwhatever is necessary to take better care of \nhimself and his family. \n\n\nHe can learn by doing. Give him a chance to \neat good food and clean his teeth at school. \n\n\nWhere There Is No Dentist 2010 \n\n\nLearning about teeth and gums can be fun. When the teaching is real and \npractical, students love to learn. Here are some ideas: \n\n\nTeaching so that learning can take place \n. Teach and learn together with your school children. \n. Start with what the students already know. \n. Let students see and then do. \n. Let children help each other. \n. Teach about teeth and gums together with other subjects. \n. Be a good example. \n\n\n. Make the community part of your classroom. \n\n\n1.Teach and Learn Together with School Children \n\n\nShare ideas \ninstead of always \ngiving information. \nChildren learn \nmore when they \nare involved. \n\n\nA PERMANENT SUCCESSOR LIES \n\n\nAPICAL To... PAY ATTENTION / \nYOU NEED TO KNOW THIS FOR \n\n\nYOUR TEST/... EACH PRIMARY \n\n\nA lecture transfers \nyour own notes \n\nto the children’s \nnotebooks without \never passing \nthrough their minds. \nA discussion draws out \ninformation and opinions. \n\n\nIt helps you | A LOOSE TOOTH \nto learn more | aki T know À \nf 00D WAY \nabout the To TAKE OUT \nschool children, epic \nOOTH. \nwhat they \n\n\nalready know \nand believe to \nbe true. \n\n\nBut it also allows \nyou to introduce \nimportant \ninformation that \nis related to the \ndiscussion. \n\n\n21 \n\n\n22 Where There Is No Dentist 2010 \n\n\n2. Start with What the Students Already Know \n\n\nTo have meaning, learning should be a part of daily living. Talk with your \nstudents. Find out what they know about teeth and gums, and what \nquestions they might have. \n\n\nAdd information by building upon \nwhat a person already knows. \n\n\nDo not use big words. Scientific names and textbook explanations are \nconfusing, and you usually do not need them. Talk about teeth and \ngums using words that a school child can understand and use later at \nhome. \n\n\nDEGLUTITIO \nATN, \nThis way \nmakes students \nfeel stupid. \n\n\nAAA ESOMAYS \n\n\nEATING Food \n\n\nThis way lets the yaa To Gaw ? \nstudents feel good, \nbecause it makes \nsense and they know \n\n\nsomething about it. \n\n\nWhen you can understand new information, you gain confidence and \nyou look forward to learning more. \n\n\nWhere There Is No Dentist 2010 23 \n\n\n3. Let Students See and Do \n\n\nStudents learn best when they can take part and find out for themselves \nabout something new. \n\n\nAN OLD CHINESE SAYING: rr \n\n\nCAN MAKE A \nTOOTHBRUSH \n\n\nIFLHEAR IT, o \n\n\n| FORGET IT. | Twie. \n\n\nIF 1 SEE IT, \n| REMEMBER IT. \n\n\nNOW, CHEW \n. ONE END \nTO MAKE IT \nTee tie T, SOFT AND \nSTRINGY. \n\n\nA lecture about brushing teeth is usually not interesting at all. \n\n\nLearning is more interesting when students can see how to make a \nbrush and how to clean teeth properly. \n\n\nIf students can actually make their own brushes and clean their own \nteeth, it is not only interesting but fun. \n\n\nA student who takes part will not forget. What he learns by doing \nbecomes part of himself. \n\n\n24 Where There Is No Dentist 2010 \n\n\n4. Let Children Help Each Other* \n\n\nIn most families, older children have important work to do—taking care \nof their younger brothers and sisters. These older children can do much \nto teach the younger ones about care of teeth and gums. For example: \n\n\ne When they feed their younger \nbrothers and sisters they can \nencourage them to eat good food, \nlike fruit instead of candy. \n\n\ne They can do a play or puppet show \nabout care of teeth and gums. \n\n\ne They can check the teeth and \ngums of the younger children and \n‘score’ them on how healthy they \nare (see p. 60). \n\n\ne Best of all, they can actually clean \nthe teeth of the younger ones, \n\n\nHere a group of school children \nin Ajoya, Mexico is putting a \nhigh-fluoride paste (see p. 205) \n\n\non the teeth of the younger \nchildren. \n\n\nand show them how to clean their \nown teeth when they are able. \n\n\n5. Teach About Teeth and Gums \nTogether with Other Subjects \nTeeth and gums are part of a bigger health picture. Teach about them in \nclass at the came time. \n\n\nEating good food can be part of a discussion on nutrition, teeth, \nfarming methods, and the politics of who owns the lands. \n\n\nCleaning the teeth can be part of a \ndiscussion on hygiene, clean water, and \n\n\ntraditions and customs. \n\n\n“STORE FOOD \nA good way for school children to learn \n\n\nthe community. \n\n\nThe results will tell the children \nsomething about health problems in \ntheir community. For an example of a \nsurvey of health problems, see page \n3-14 of Helping Health Workers Learn. \n\n\npat | | Number selli \n$ = 2 OyBundnsts \nabout using numbers is to do a survey in \"Y y WV Ry A \niv) \n\n\ndumber selling Cola \nÀ arink \nA HT UY JT Ieee Lo \nj ee — \n\n\n*For more ideas on how school children can help each other, write to CHILD-to-child Trust, \nInstitute of Education, 20 Bedford Way, London, WC1H OAL, UK. Tel: 44-207-612-6649. \nFax: 44-207-612-6645. E-mail: ccenquiries@ioe.ac.uk. Website: www.child-to-child.org \n\n\nWhere There Is No Dentist 2010 \n\n\n6. Be a Good Example \n\n\nChildren watch people around them. They pay attention to what you do, \nas well as to what you Say. \n\n\nBe a good example. \nTake care to do \nyourself what you \nare teaching to your \nstudents. \n\n\nYour family can be \na good example for \nothers. \n\n\ne Clean your teeth carefully every day. Also, help your children keep \ntheir teeth clean. \n\n\ne Make a garden near your house and plant a variety of vegetables and \nfruits in it. \n\n\ne Buy only good, healthy food from the store. Do not buy sweet foods \nand drinks for yourself or your children. \n\n\n. Make the Community Part of Your Classroom \n\n\nA child's home and his community are really more important to him \nthan his school. Learning will be more interesting for a student if the \nday-to-day needs of his home and his community are part of school \ndiscussion. \n\n\nLet students find out more about problems \nat home and in their community. \n\n\nFor example: \n\n\ne How many small children have \ncavities or red, bleeding gums? \n\n\ne How many stores have mostly \nsweet snack foods on their \nshelves? \n\n\ne Why do the people not grow \nand eat more local food? \n\n\nBack in the classroom, students can record what they find. Ask the \nchildren to think of ways to solve the problems they found. If they can \nthink of a program to help solve a health problem, let them go back into \ntheir community and try it. \n\n\n25 \n\n\n26 Where There Is No Dentist 2010 \n\n\nPART 2 \nMAKING LEARNING EXCITING, VISUAL, AND FUN \n\n\nHere are some ideas to help students see what you are teaching, and to \nhave fun while they learn. Students can also show these things to others. \nTeaching others is an excellent way to learn. \n\n\nTell a story about food or teeth. For example, tell a story about why a wild \ncat's teeth are different in shape from a goat's teeth (page 40). Stories are \nan excellent way to learn, both for the storyteller and for those listening. \nLeave time at the end to discuss the story and to introduce new information. \nSee the example of storytelling on pages 15 to 16. \n\n\nMake up a play or drama about good food or clean teeth. Show it later to \nthe community. \n\n\nThe play should be about looking for an answer to a real problem. If the \nchildren invent the play, they will have to think, plan, and solve problems. A \nplay also helps children learn how to talk with and teach others. \n\n\nThese school children in Nicaragua are doing a play about cavities. On the left, germs \nand sweet food are combining and trying to make a hole in the ‘tooth’. But a giant \ntoothbrush (right) beats them away! \n\n\nDo a demonstration using local resources. \n\n\nTry, for example, the \n‘tooth in the Coca-Cola’ \ntest on page 48. \n\n\nWhere There Is No Dentist 2010 27 \n\n\nPuzzles can help school children discover answers for themselves. You can \nmake your own. The best puzzles are with words that the students know \nand can use easily. \n\n\nEXAMPLE (for younger children just \nlearning to read) Try to find these words: \n\n\nVNUTS \n\n\nONIN \nTOOTH GUMS G55 \n\n\nAs you find each word, put a J beside it. \n\n\nAn older child can try to find important words that are more difficult. \n\n\nVILLAGE \nCO-OP STORE \n\n\nbefrisvtesvyv \n\ngasprqxoami \n\nuvsofeaorsn abscess cola \nmisg steof \n\ndtentéuhvye v sugar toothache \niyc@eolaobc cavity Vv maize \nscG/smpscu(r\\t \n\nrae eons ee es V sore green leaf \nafaelneerl|glo infection gum disease \nscbpnusntluln \n\neĝa izor t d\\s/b \n\n\nSpell some of the words diagonally (slanted). It will make the puzzle harder. \n\n\n28 Where There Is No Dentist 2010 \nYou can use pictures on posters, flip charts, and on flannel-boards. \n\n\nPictures that school children draw themselves are best. They learn simply \nby drawing them. Also, school children will draw local people and local \nexperiences, and the people will understand their pictures better than the \nones sent from a central office far away. \n\n\nPhotographs of local people and events are also good. If there is a \nphotography club in a local secondary school, have them take some pictures \nfor you. They may even print the photographs larger so that you can use \nthem as posters. \n\n\nAsk the children to make pictures big enough so that a person can stand far \naway and see them easily. \n\n\nLet each child carry her \nposter home to show her \nfamily and friends. \n\n\nBK \n\n\nHang up other posters in = i \nthe store, church, or other T O W \nplaces where people will on \nsee them. —] \n\nU \nPictures can be made to = \n\n\nstick to cloth and then used \nto tell a story. Cover a board \nwith a piece of flannel cloth 4 \nor a soft blanket, to make a \nflannel-board.* aS \n\n\nMix some flour and water to \nmake glue. Then glue a strip \nof sandpaper to the back of \neach picture. The sandpaper \nsticks to the cloth and lets you \nplace the picture where you \nwant on the cloth. \n\n\nLet the child use her pictures \nand cloth outside of the \nschool, to show her story to \nfamily and friends. \n\n\n*For more ideas on flannel-boards, see pages 11-15 to 11-19 of Helping Health Workers \nLearn. \n\n\nWhere There Is No Dentist 2010 29 \n\n\nFlip charts are excellent for telling a story with pictures. Often, people can \nguess what the story is about just from the pictures. When showing the \npictures on a flip chart, ask as many questions as you can, to get the people \nto tell you the story. \n\n\nHere a health worker from \nMozambique is holding a flip chart \nwith pictures about care of teeth \nand gums. There are no words \nwith the pictures. \n\n\nBut he can read a short message \nwritten on the back of the page \n\nbefore. There are \nalso examples of \nquestions to ask. \n\n\nThis way, \n\nanyone who can \nread can tell the \n‘flip chart story’ \n\n\nto others. \nThis is part of a flip chart presentation on There is also a \nmothers’ and children’s health. Notice small copy of the \nthe rings at the top that hold the flip big picture on the \nchart together. They are made from old back of the page \nelectrical cords. before. \n\n\nwith 2 thin pieces of wood with metal or wire rings \n\n\n30 Where There Is No Dentist 2010 \n\n\nFLIP CHARTS—AN EXAMPLE \n\n\nDental workers in Mozambique created this flip \nchart presentation for teaching in schools. \n\n\n1) Here is a healthy, happy schoolboy. In the circle \nyou see the inside of his mouth. His teeth are \nwhite and clean. Look at his gums. What color \nare they? Are they tight or loose? Between the \nteeth, are the gums pointed or flat? \n\n\n2) This is an unhappy, sick boy. What color are \nhis teeth? Not only are they yellow, there are \nblack spots. These are cavities. \n\n\nWhat color are his gums? Are they pointed? \n\n\nLoose, red, swollen gums are signs of gum \ndisease. \n\n\nBoth cavities and gum disease can be treated. \n\n\n3) What happens if tooth and gum \nproblems are not treated? \n\n\na) The black hole grows bigger on \nthe tooth and a sore forms on the \ngums near the root. The tooth hurts \nwhenever you touch it. \n\n\nb) The red, loose gums pull away from \nthe tooth. Infection gets to the bone \nand eats it. The tooth loses the bone \nand the gum around it. \n\n\nThe first problem is a tooth abscess. The second is advanced gum \ndisease. |f either of these things happens, the tooth must be taken out. \n\n\n4) Why does the boy have cavities and gum disease? \nThere are 2 reasons. \n\n\na) He eats too many sweet foods. \nWhat foods do you see here? \nWhat other foods hurt the teeth? \n\n\nb) He does not clean his teeth regularly. \nThe germs in his mouth eat sugar from \nhis food and make acid. Acid causes \nboth cavities and gum disease. \n\n\nWhere There Is No Dentist 2010 31 \n\n\n5) What foods can the boy eat to keep his teeth and \ngums healthy? What do you see in this picture? \n\n\nNatural foods, with no sugar added, are the best. \n\nThe foods you grow yourself and local foods from \nthe market are better than sweet foods from the \n\nstore. \n\n\n6) How can we clean our teeth? \n\n\nCarefully is the = \nimportant word to \nremember. Clean your \nteeth at least once a day, carefully brushing every \npart of every tooth—outside, inside, and top. Be \nvery careful to push your brush between your \nteeth. That is where the germs and food collect \nto make acid. \n\n\nIf you do not have a toothbrush, you can make \none from a stick. Toothpaste is not necessary. \nClean water is enough. \n\n\nChapter 12 in Helping Heath Workers Learn is full of ideas on how to make \nand use pictures effectively. Once you have a good original, you do not need \nto be an artist to make a good copy. Here is an easy method that can involve \nevery student. \n\n\nPlace thin see-through paper over the original drawing. Carefully trace a copy. \n\n\nNow place the copy on a new sheet of heavy paper. Pressing firmly with a \npencil, retrace all of the fines on the thin copy paper. \n\n\nRemove the tracing \npaper. Pressure from \nthe pencil has made \nfines on the poster \npaper. Redraw them \nwith a pencil so they \nstand out clearly. \n\n\nYour copy is now \nready for coloring. \nAnd you can use your \ncopy paper again to \nmake another copy. \n\n\n32 Where There Is No Dentist 2010 \n\n\nUse puppet shows to act out the \nmessages of eating good food and \nkeeping teeth clean. \n\n\nMr. Lyam, you should \nfeel shame for selling \nthat kind \nof food/ \n\n\nStudents can make their own \npuppets to look like people or \nanimals. \n\n\nUsing puppets, it is often \n\neasier to say things that people \nthemselves cannot. For example, \nthey can talk openly about the bad \nfood sold at the village store. \n\n\nChildren can make puppets easily from paper bags. They are good for \nshowing teeth because you can make a wide-open mouth. \n\n\nOpen and close \nyour hand to make \nit eat or speak. \n\n\nTo make a \nbigger puppet, \nattach a \ncardboard face \nto the bag. \n\n\nA puppet made from a sock looks alive. \n\n\n1. Fit the sock over your hand. \n\n\n2. Make the mouth by pushing in the \ncloth between your thumb and \nfingers. \n\n\n3. Add eyes, nose and hair to the \nsock or to a box that fits over it. \n\n\nLoosely fill a cloth bag with old cotton or paper. Put the end of a stick inside, \nand tie the bag to it with tape or string. Make a sad or happy face to fit the \nstory. Dress the puppet with an old piece of cloth. \n\n\nWhere There Is No Dentist 2010 33 \nPUPPET SHOWS—AN EXAMPLE* \n\n\na \n\n\nAbove, school children in Ajoya, Mexico are holding puppets they made \nthemselves. On the left, you see them in front of the stage and at right, the \nchildren show how they hold the puppets behind the stage. \n\n\n1) They called their puppet show “Rotten \nTeeth—And A Friend's Advice.” \n\n\nLOS CONSEJOS \nDE UN AMIGO \n\n\n2) Pedro, a schoolboy, is sad. His friends \nlooked into his mouth and saw two \nteeth with big holes in them. He tells \nhis brother he wants to walk home \nalone. \n\n\n3) On the way, Pedro meets Maria, a \nfriend who is a dental worker. “I’m not \nsad because the others are laughing,” \nsays Pedro.” | know the real problem. \nThe holes in my teeth will get bigger. \nMy teeth will rot and fall out, and \nmaybe my permanent teeth coming in \nwill rot, too.” \n\n\nnity \n\n\nMaria thinks she knows what to do. “We \nwill talk to your father,” she says. \n\n\n* For another example of a puppet show, and more suggestions for making puppets, see pages \n27-35 to 27-39 of Helping Health Workers Learn. \n\n\n34 Where There Is No Dentist 2010 \n\n\n4) One day later. \n\n\n(Note how the scene behind the \npuppets changes. It is a flipchart with \npictures to show the different places \nthe puppets ‘go’.) \n\n\n“lam a poor farmer,” Pedro’s father \ntells Maria. “I only go to the city two \ntimes a year to sell my crops. | cannot \ntake the boy to the city and pay for \nfillings in his teeth.” \n\n\nMaria answers, “But we can save his \nteeth with a temporary cement filling.”* \n\n\n“Then, when you have time and \nmoney, you can go to the city. | know \na dental worker who will put in a \npermanent filling. | trust him. | will \nsend a note with you, and it will not \ncost much. \n\n”Good!” says the father. “Come on, \nPedro,” says Maria, “l'Il put some \ncement in those holes!” \n\n\nFour months later, Pedro visits the \ndental worker in the city. “Maria’s \ngood fillings saved your teeth,” he says. \n“These permanent fillings will last for \nyears.” \n\n\n“Terrific!” says Pedro. \n\n\nAfter the show, the puppets played \n\na game. Throwing a ball into the \naudience, they asked questions like \n“How do you keep cavities from \nhappening?” Each child who caught \nthe ball answered the question and \nthrew it back. Then the children in \nthe audience began asking questions \nfor the puppets to answer. “Why did \nyou get rotten teeth?” one child asked \nPedro. The puppet looked down and \nsaid, “Too much candy!” \n\n\n* To learn how to make a temporary filling, see Chapter 10. \n\n\nAitaa dET. \nwww. hesperian .org \n\n\nCHAPTER 4 \n\n\nSchool Activities for Learning \nAbout Teeth and Gums \n\n\nWe can help school children in two ways. First, they need treatment now \nfor problems they already have. Second, they need to learn how to prevent \nproblems from hurting them (and their families) later. \n\n\nTreatment and prevention go together. It is a mistake to emphasize only \nprevention and to forget about treatment. In fact, early treatment is the \nfirst step to prevention because it usually meets a person’s most \nstrongly felt, immediate need. \n\n\nAs a community dental worker, you can visit a school and find out what the \nfelt needs are. Begin with the teacher. Examine for cavities, bleeding gums, \nor other problems. Then look at the students. \n\n\nChapter 6 tells you how to examine a person. It also helps you decide what \ntreatment to give, and who should give it. \n\n\nThen teach how to prevent dental problems. Give the teacher ideas to \nhelp students learn why they have problems, and how to keep the problems \nfrom returning. The best way to learn is by doing—through activities, not \nlectures. This chapter has many suggestions for activities. \n\n\nThe best health practice is to prevent cavities and gum disease from even \nstarting. With these activities, children can do something to guard their \nhealth. \n\n\nBY — \n|. EATING ONLY GOOD \nHEALTHY FOODS \n\nAND \n2. CLEANING MY \n\n\nTEETH CAREFULLY \nEVERY DAY, \n\n\nTeacher, each day at school: \n\n\nSuggest ways genie, \n\n\nfor your \nstudents to eat \ngood healthy \nkinds of food. \n\n\nAND \n\n\nGive your \nstudents time \nto clean their \nteeth. \n\n\n35 \n\n\n36 Where There Is No Dentist 2010 \n\n\nA Note To Teachers: \n\n\nDo not wait for a dental worker. This book, and especially this chapter, is \nwritten to help you learn and do things yourself. But do ask your dental \nworker to work with you. He probably has suggestions that would fit your \nsituation. After examining the children, he can help you follow their progress. \nYou can then find out how much they are learning and how healthy they are \nbecoming. \n\n\nTo begin, talk with your students to find out what they think and what they \nalready know. What are their traditional beliefs? Some may be helpful, and \nothers may need changing. At first it is best simply to discuss. \n\n\nAsk the kind of questions that get students talking. Later they will take part \nin discussions more easily. \n\n\nAdd new information as you go along, changing some ideas but usually \nbuilding upon what the students already know. \n\n\nThis chapter asks nine questions: \n\n\ne Why do we need teeth and gums? \ne Why do some teeth look different? \ne What holds the teeth? \n\ne How often do teeth grow in? \n\ne What makes teeth hurt? \n\n\ne How do germs make holes in the \nteeth? \n\n\ne What makes the gums feel sore? \n\n\ne What does it mean if a tooth is \nloose? \n\n\ne How can we prevent cavities and \nsore gums? \n\n\nFor each question, there is an activity to help students discover answers \nfor themselves. The questions are not in any particular order, nor are they \nwritten for any particular grade level. Make your own lesson plan, using the \nmain idea to help you. Shorten the lesson and make it easier for younger \nchildren. Add more information for older students and let them do more \nactivities. \n\n\nWhere There Is No Dentist 2010 \n\n\nWhy Do We Need Teeth and Gums? \n\n\nTHE IDEA: \n\n\nYour teeth and the gums around \nthem help you in many ways. \n\n\nTeeth are important for: \n\n\nGood Health. Infection from a bad \ntooth can spread to other parts of \nyour body. \n\n\nGood Looks. Healthy teeth that \nlook good help you feel good. \n\n\nGood Speech. Your tongue and \nlips touching the teeth help you \nmake many sounds. \n\n\nGood Eating. Your teeth break food into small pieces so that you can \nswallow and digest it better. \n\n\nGood Breath. If you leave food around your teeth, your breath will smell bad. \n\n\n= Your gums are important too. \n\nThey fit tightly around the teeth, and \n\nhelp to keep them strong. Without \n\nstrong gums, your teeth are of no \n\n) use. Most old people lose teeth \nbecause of bad gums, not bad teeth. \n\n\na \n\n\nCon =a e i rot I~ \nO EE S E \n\n\nACTIVITIES: \n\n\n1. Draw or cut pictures of people from magazines. Make posters to \nshow that healthy teeth make a person happy, while bad teeth make a \nperson sad. Use the posters for discussion. \n\nHang up a picture of a person the FEKIS NE \nstudents know and like. Put black on \none of her front teeth. Talk about it. n : \n\n\nOR \n\n\nLeave the picture for a few days. Then \nput black on some of her teeth before \nthe students come to school. See who \nnotices first. \n\n\nWhen someone sees the difference, \ntalk about how the person looks, how \nteeth can be lost, how to prevent that, \nand what she can do now. \n\n\n37 \n\n\n38 Where There Is No Dentist 2010 \n\n\nMake a picture of a person who has \nlost all of his teeth. He looks old. \n\n\nTalk about how hard it is for him to \neat properly or speak clearly. \n\n\n2. Have the students say words that use teeth to make sounds. \n\n\n“v\" and “f\" — friend, fever — the lower \nlip touches the top teeth. \n\n\n[EICD\\ “th” — the, teeth — the tongue touches \nin ~_\\\\ the top teeth. | \nOsa) “s\" — sun — air goes between the teeth. \n\n\nNow, try saying the same words again, \nbut do not let the tongue or lips touch the \nteeth. \n\n\n3. Have students draw pictures of good foods we use our teeth to eat. \nThen draw foods that we can eat if we lose our teeth. \n\n\nNeed Teeth No Teeth Needed \n\n\nand but not \nmany more! much more! \n\n\nTalk about this together. Try to eat a mango or some maize without \nusing your teeth, or using only your front teeth. \n\n\nWhere There Is No Dentist 2010 39 \n\n\nWhy Do Some Teeth Look Different? \n\n\nTHE IDEA: \nWe need two different kinds of teeth to help us eat our food. \n\n\nFront teeth. Another name for \nthem is incisors. Their sharp \nedge cuts food into pieces. \n\n\nBack teeth are called molars. \nThey chew and grind pieces \nof food into bits small enough \nto swallow. \n\n\nThe outside of a tooth is the hardest and strongest part of your body. When \n\na tooth is healthy, it can chew hard food, even bone. The shape of a tooth \nallows us to swallow food when the small pieces can slide down its smooth \nsides. \n\nFood that is not \ncleaned away \nfrom the grooves \ncan make a cavity \n(hole) in them. \n\n\nSmall bits of food \noften get caught \ninside deep lines, or \ngrooves, in a tooth. \n\n\nA tooth with a \ncavity is weak and \noften hurts. \n\n\nLook for them on \nthe top and the sides \nof back teeth. \n\n\n40 Where There Is No Dentist 2010 \n\n\nACTIVITIES: \n\n\n1. Ask the students to bring different kinds of food to class. Bring \nsome yourself. \n\n\nWHICH TEETH DID YOU USE \nTO EAT THE MANGO? \n\n\nEat the food using first the front and \nthen the back teeth. \n\n\nBite a guava using only the back teeth. \n\n\nChew completely a mango or piece of \nmaize, using only the front teeth. \n\n\n2. Collect teeth from different animals. Let the students discover from \nthe shape of an animal's teeth the kind of food it usually eats. For \ninstance, a wild cat needs sharp pointed teeth to tear meat, but a goat \nneeds flat teeth to chew grass. \n\n\nMake a poster to show the animal, its teeth, and the kind of food it \nlikes to eat. \n\n\n3. Have each student take a partner. Let each look at the shape of the \nfront and back teeth in the other's mouth. \n\n\nTalk about the many different kinds of food we need to stay healthy. \nDiscuss which teeth we use to chew meat, fish, mango, and other \ngood foods in your area. (For most foods, the answer is both front and \nback teeth!) \n\n\nWhere There Is No Dentist 2010 \n\n\nWhat Holds the Teeth? \n\n\nTHE IDEA: \n\n\nWhen you look inside someone’s mouth, you see only the top part of each \ntooth. The bottom part, its root, is inside the bone under the gum. \n\n\nThe roots of the \ntooth hold it in the \nbone just like the \nroots of a tree hold it \nfirmly in the ground. \n\n\nThe roots of the tooth \ndo not actually touch \nthe bone. Root fibers \nconnect the root and \nbone, holding the \ntooth in place. \n\n\nWZ \nA \n\n\nbone \n\n\nThe gums do not hold the teeth, but healthy gums will keep harmful germs \nfrom getting to the bone and root fibers. When the gums are not healthy, \nthey form deep ‘pockets’ which collect germs. Soon, these germs will reach \nthe root fibers and bone. The bone pulls away from the tooth in order to get \naway from the germs. With no bone to hold it, the tooth is lost. This is the \nmost common reason why teeth fall out. \n\n\nACTIVITIES: \n\n\n1. Have the students look for \nan old jaw bone from a dog \nor other animal. Notice that ‘ \nbone goes around every root \nof every tooth and holds it \n\n\nSS \ntightly. Break away some Ay A A we \nf ull A \n\n\n+ \n\n\nof the bone and look at the ik \nroots of the teeth. \n\n\n2 Front teeth need only one root \nae because they are used for biting. \n\n\nBack teeth have 2, 3, or even 4 \nroots. That makes them strong \nenough to chew tough meat and \neven break hard bone. \n\n\n41 \n\n\n42 Where There Is No Dentist 2010 \n\n\n2. Show your students how infected gums can cause teeth to fall out. \n\n\nC \n\n\nbone \npulling \naway \n\n\nbone \n\n\nA. When gum disease is beginning, a small red `pocket’ forms where the \ntooth meets the gum. Germs and food collect in the gum and make acid. \nThis makes the gums sore. \n\nB. As a result, the gum pulls away and the pocket becomes deeper. \n\nC. The bone moves away from the infection and no longer holds the tooth. \n\n\nTry to think of other ways to teach how gum disease pushes the \nbone away from the tooth. In Jamaica, dental workers ask, “What do \nyou do if someone attacks you with a machete (long knife)?” “| run \naway!” most people answer. “Exactly,” say the dental workers, “and \nwhen you have a lot of germs attacking the root of your tooth, the \nbone ‘runs away’ and leaves the tooth with nothing to hold it.” \n\n\nTell a story to show how, when the gum moves away from the top of \nthe tooth, the root and bone are open to attack. For example: \n\n\nOne day, a hen was sitting on the eggs in her nest. The hen was \nhungry, and when she saw a worm, she left the nest to catch the \nworm. Just then, a possum came along, saw the fresh, warm eggs, \nand ate them all up. \n\n\nExplain to the students that the gums protect the teeth the way a \n\nhen protects her eggs. When she leaves the eggs unprotected and \nexposed, an animal can attack and destroy them. When gums around \na tooth are red and sore, the tooth is exposed to germs that can attack \nnot only the top of the tooth, but also the bone and root. \n\n\nWhere There Is No Dentist 2010 43 \n\n\nHow Often Do Teeth Grow In? \n\n\nTHE IDEA: \n\n\nA child gets two sets of teeth. The first set, baby teeth, \nstarts to grow when the child is a baby. The second and \nlast set grows in at school age. They are the permanent \nteeth. Permanent teeth should last a lifetime. \n\n\nA child grows his first baby tooth at about 7 months of \nage. It is usually a front one. \n\n\nA baby who is poorly nourished, however, may not grow his first tooth until \nlater. Do not wait for the first tooth before giving him the extra soft food he \nneeds to grow and stay healthy. \n\n\nThe remaining baby teeth grow in over the next 24 months. By the time the \nchild is 30 months old, there will be a total of 20 baby teeth in his mouth, \n10 on top and 10 on the bottom. \n\n\nMost permanent teeth form under the baby teeth. When the child is \nbetween 6 and 12 years old, the permanent teeth push against the roots \n\nof the baby teeth, making them fall out. Not all of the baby teeth fall out at \nonce. One tooth at a time becomes loose, falls out, and then is replaced with \na permanent tooth. The new tooth may not grow in immediately. Sometimes \n2 or 3 months pass before the new tooth grows into the space. \n\n\nIn the 6 years between ages 6 and 12, the 20 permanent teeth replace the \n20 baby teeth. In addition, 8 other teeth grow in behind the baby teeth. \n\n\nAt 6 years the 4 first permanent \nmolars start to grow in at the back of \nthe mouth. This means an \n8-year-old child should have \n\n24 teeth, or spaces for them. \n\n\nAt 12 years, the 4 second \npermanent molars grow in behind \nthe first molars. This means a \n14-year-old child should have \n28 teeth, or spaces for them. \n\n\nBetween 16 and 22 years, the 4 third \npermanent molars grow in. This \nmeans that an adult usually has a \ntotal of 32 permanent teeth: 16 on \ntop and 16 on the bottom.* \n\n\n*(Note: the third molars often do not grow in correctly. This is a very common cause of tooth \npain. See page 66.) \n\n\n44 Where There Is No Dentist 2010 \n\n\nTHE ACTIVITY : \n\n\nHave the students examine each other.* Help them learn which are baby \nteeth and which are permanent teeth. Look for the important 1st permanent \nmolars at the back. \n\n\nShow the students Caa \n\n\nPERMANENT TOOTH \nhow to count the \n\nteeth and the spaces ) \n\nthat are ready for new LOOSE BABY TOOTH \n\n\nteeth to grow in. \n\n\nSPACE FOR NEW TOOTH \nThen have them count \n\n\ntheir friends’ teeth, to find \nout how many teeth should \nbe growing in different age \ngroups. Later, they can do this with their brothers and sisters at home. \ne Wash your hands. \ne Count the teeth. \ne Count the spaces where new teeth have not yet grown in. \nTOTAL = teeth + spaces \ne Find out the person's age. \n\n\nHave the students first write their totals on the blackboard. Then make a \nchart for the children to remember and discuss the results. \n\n\nLesson: Number of Teeth We Should Have \n\n\nTOTAL = teeth now present (T) + spaces (S) \n\n\nAmbun (giri) \n\n\n22 ; \nPNE. 2y \nMichael (bey) 25 Tatai \n\n\n* Here the children are only counting the teeth. They can also learn to check for cavities and \ngum disease (see p. 49). \n\n\nWhere There Is No Dentist 2010 45 \n\n\nDiscuss the number of teeth children have at different ages. Young children \n6 to 12 years old, for example, have 24 teeth; older students, 28 teeth; and \nmost adults, 32 teeth. \n\n\nAt home, students can count brothers’ and sisters’ teeth to learn how many \nteeth small children have. Count only the teeth and not the spaces. \n\n\nLésson: Number of Teeth ina Small Che led \nDeboi \n\n\nunder 1 year | 1-2 years old | 2-3 years o \n21 \n\n(brother) \n\nae seed’ if ? fw \n\n\nO ($ “aie I \nsister) \n\n\nSthed Jiili \nEEA \n\n\nERREI 29 \n\n\nAsk the students what other things they saw inside someone else's mouth. \nThis is a good time for students to discover important things about good \nhealth practices. Encourage them to learn as much as they can from what \nthey see, and then show them how to use a book like this to answer their \nown questions, For example, if students see cavities and red bleeding gums, \nyou can start a discussion on tooth decay and gum disease. Use some of the \nactivities on pages 55 to 60. \n\n\nFor another example, if the students see a baby who has only a few teeth, \nthey may have some interesting questions. Show them this book and invite \nthem to read pages 63 to 65 to find answers to questions like these. \n\n\ne Can Chenia, who is 6 months old and has no teeth, eat soft foods? \nShould she have more than just breast milk? \n\ne When Chenia’s teeth grow in, will they give her diarrhea and fever? \n\ne Will a 2-year-old girl get more baby teeth? \n\n\ne Why do we care for baby teeth, when we only need them for a few \nyears? \n\n\n46 Where There Is No Dentist 2010 \n\n\nWhat Makes Teeth Hurt? \n\n\nTHE IDEA: \n\n\nA tooth will hurt if it is broken, loose, or if it has a cavity. Cavities are the \nusual cause of toothaches. \n\n\nHealthy teeth are alive. \n\n\nTwo thin strings enter each tooth. One, the nerve, come from the brain and \ncarries the message of pain. The other is the blood vessel. It comes from \nthe heart and carries blood to the tooth. \n\n\nIf you could peel away \nthe gum and look inside \nthe bone, you would see \nthat a nerve and a blood \nvessel go into each one \nof a tooth’s roots. \n\n\naun NERVE \nm> BLOOD VESSEL \n\n\n=) \n\n\nvee: \n\n\na \n\n\nÙ \n\n\nThey give the tooth life \nand feeling. \n\n\nThe hard cover of the tooth protects the nerve and blood vessel inside it. But \nwhen tooth decay eats through that cover, the nerve and blood vessel are \nunprotected. A cavity lets food, water and air get closer to the nerve, and \nthat can make the tooth hurt. \n\n\nThe sugar in food makes tooth decay possible. Sweet food that is also sticky \nis the worst of all because it glues itself to the teeth. Germs inside your \nmouth use the sugar to grow and to work harder at making cavities. \n\n\nSee the next section for more discussion of how germs and sugar combine \nto cause cavities. \n\n\nWhere There Is No Dentist 2010 47 \n\n\nA cavity may look small on the outside, but it is much bigger inside. Decay \nspreads more easily in the soft part under the hard cover of the tooth. \n\n\nA tooth with a cavity may hurt, but it usually does not hurt all the time. This \nis because the bottom of the cavity is close, but not yet on the nerve inside \nthe tooth. \n\n\nFill a small cavity and save a tooth. \n\n\nA small cavity that is not treated grows bigger and gets deeper. When the \ncavity finally touches the nerve, it causes a tooth abscess. Infection from \nthe tooth decay going inside the tooth causes the tooth to ache all the time, \neven when you try to sleep. \n\n\nInfection can pass from the tooth to the bone. As it spreads under the skin, \nthere will be swelling of your face. \n\n\nA tooth with an abscess must either be taken out \nor have its nerve treated. \n\n\nAn abscessed tooth is dying. When it dies the tooth changes color from \nwhite to dark yellow, grey, or even black. Pus from the end of its root can \npass to the gum, making a sore called a gum bubble. \n\n\nvie \n\n\n7 = A tooth is like a light bulb. \nDES RA] When the bulb is alive from power inside, it is \nbright and useful. \nThe little wires inside the bulb are like the nerves \nCA) inside the tooth. When the bulb burns out, it is dark \n\n\nand not useful any more. \n\n\n48 Where There Is No Dentist 2010 \n\n\nACTIVITIES: \n\n\n1. Have each student look inside a partner’s mouth. Look for black \nspots that may be cavities, for dark teeth that are dead, and for sores \non the gums, especially near a bad tooth. \n\n\n2. Discover how sweet food sticks to teeth. \n\n\ne Cut several different kinds of food with a knife. \n\n\ne Vegetables and meat do not stick to \nthe knife. \n\n\ne Sweet foods, like chocolate and \njam buns, do stick to the knife. \nThey stick to your teeth the \nsame way. \n\n\nAs water is lost, the juice left in the dish \nbecomes sticky. It attracts flies. \n\n\nThe air you breathe dries the cola and \ncauses a Sticky, very sweet coating to \nform on your teeth. It attracts germs. \n\n\nTry to find some old teeth. Ask the \nstudents to keep their own baby teeth \nwhen they fall out. (Note: in some \ncountries this is not acceptable.) Your \ndental worker can save you some \nteeth that were taken out at the clinic. \n\n\nScrape the outer cover of the root with a knife. Feel how hard and \nsmooth it Is. \n\n\nThen find out what happens \nwhen the students leave a tooth \nin cola, milk, or plain water. \n\n\nAfter 3 days scrape each tooth \n\nagain with a knife. Students will \ndiscover that sweet cola drinks \nmake teeth softer and darker \n\nin color. \n\n\nWhere There Is No Dentist 2010 \n\n\n3. Look inside a tooth for the space where the nerve and blood vessel \n\n\nused to be. See how close they were to the tooth’s hard outer cover. \nLook for a small hole at the end of the root. That is the place where \nthe nerve and blood vessel enter the tooth. \n\n\nAsk your dental worker to find an old tooth \nwith a cavity and cut it for you. \nOR \n\n\ne Take a hammer. \ne Gently break open a tooth. \ne Look inside. \n\n\nSee how much bigger the cavity is on the \ninside. It soreads under the hard cover. \n\n\nCut through a rotten yam. See how the \nrotten part spreads under its skin in the \nsame way. \n\n\n. Do a project in class. \ne Count the number of students with cavities. \n\n\ne Count the number of teeth having cavities. Show the students how \nto look for them on the tops, sides and between the teeth. \n\n\ne Find out the person's age. \n\n\nHave the students write on the blackboard what they counted. Then \nmake a chart or graph. \n\n\n= \nTooTH DESAY IN OVA SCHOOL | \nTOTAL \n\n\nNUMBER OF STUDENTS AT SCHOOL \nê \n\ni t \na wet \n\n\nCY \n\n\ne Decide if tooth decay is a serious problem in your school. Ask your \ndental worker to look at your results and to come and treat the \nstudents, and help you prevent the problem from returning. \n\n\ne Do the same with brothers and sisters at home. Find out if tooth \ndecay is a problem with these young children. Tell your dental \nworker what you find. \n\n\n49 \n\n\n50 Where There Is No Dentist 2010 \n\n\nHow Do Germs Make Holes in the Teeth? \n\n\nTHE IDEA: \n\n\nAcid makes holes in the teeth. The acid is made when sweet foods mix with \ngerms in your mouth. \n\n\nIt is not possible to prevent cavities or gum problems by trying to kill all of \nthe germs in your mouth. There are too many—and some germs are good \nfor you. The important thing is to keep the germs from getting together \nand making a film or coating on your teeth. \n\n\nThis film on the teeth is called plaque, but you do not need to use this word. \nEvery morning we can all feel a ‘furry film’ on our teeth. This film must not \nbe allowed to stay on the teeth! It will mix with sugar and make acid. Worse, \nif it stays in a group (or ‘colony’) for more than 24 hours, it will mix with \nsaliva, harden, and make tartar (see page 52). \n\n\nThe main reason for cleaning teeth is to break up these colonies so they \ncannot make acid. Also, if you forget to clean your teeth, tartar will form, and \nyou will need a dental worker to scrape it off. This is why it is important to \nclean your teeth at least every 24 hours, so the tartar can never form on your \nteeth. \n\n\nTHE ACTIVITY: \nHere is a game called “Scatter!” that students can play outside. You need: \n\n\ne Five ‘bases’ (a tree, rock, or \nthe corner of a house can \nbe a base) in a half circle, \n12 meters apart. Each base \nmust have a ‘monitor’ who \nstays at the base. \n\nNote: children who cannot \nrun can be good monitors. \n\n\ne One person with a broom. \nThis person is the \n\n\ndecolonizer’. Children in Jocuixtita, Mexico, beginning a \ngame of “Scatter!” The ‘decolonizer’ is the \ngirl in the center with the broom. \n\nThe Game: \n\n\n20 students called ‘colonizers’ stand facing the decolonizer. When the \ndecolonizer says “go!” they try to ‘form colonies’ around the bases \nbefore the decolonizer can touch them with the broom. \n\n\nWhere There Is No Dentist 2010 51 \n\n\nThe colonizers win if they make \na colony. There are two kinds of \ncolony: (1) 15 people touching \none monitor at a base, or (2) a \nchain of 12 people holding \nhands, touching two monitors. \n\n\nPlay two games: one with \n\nchildren trying to form the first \n‘ kind of colony, one with the \n\nThe ‘decolonizer’ (with broom) has lost second kind. These photos are \n\nthe game. The children behind him have from the second game. \n\nformed a ‘colony’. \n\n\nThe decolonizer tries to stop the \nothers by touching them with the \nbroom. When the decolonizer \ntouches a colonizer with the \nbroom, the colonizer must leave \nthe area for one minute. (Give \nthat child a task to do—run \naround the school-house or lie \ndown and sit up 30 times.) \n\n\nThe decolonizer wins if no \n\n\nHere the decolonizer stops a boy from colonies form in 5 minutes. \ncompleting a chain. \n\n\nHOW MANY GERMS \nDO You SEE IN \nTHIS CIRCLE ? \n\n\nAfter The Game: \n\nTalk to the students about germs \nin their mouths and how small \nthey are. Can anyone see germs? \nNo, but they can feel them and \ntaste them. Ask the group what \ntheir mouths feel like in the \nmorning when they wake up. You \nmay get these answers: \n\n\ne My teeth feel mossy. \ne My breath is bad. \n\n\ne | feel a coating on my teeth, To teach about things too small to see, look \nbut it goes away when | at the suggestion on page 11-29 of Helping \nbrush them. Health Workers Learn. \n\n\nTell the students that this coating on the teeth is a ‘colony’ of germs. They \nare always trying to group together on the teeth or in spaces between the \nteeth—just as the ‘colonizers’ did in the game! \n\n\n52 Where There Is No Dentist 2010 \n\n\nWhat Makes the Gums Feel Sore? \n\n\nTHE IDEA: \n\n\nHealthy gums fit tightly around the teeth and help to hold them strongly. \nHealthy gums also cover and protect the bone under them. \n\n\nHealthy gums are pink in color, or \neven blue or dark yellow in some people. \nBut healthy gums are never red. \n\n\nHealthy gums are pointed between \nthe teeth. This lets food slide away and \nbe swallowed. \n\n\nHealthy gums fold under, making a \nlittle pocket around the tooth. \n\n\nAs we saw with the last activity (p. 50), when you have ‘colonies’ of germs \non your teeth, they can make acid that makes holes on your teeth. The same \ncoating of germs can make a different acid that makes the gums sore. This \nalso happens when food mixes with the coating on your teeth. Soft food \n\nis the worst kind, because when it mixes with spit it sticks more and stays \nlonger on your teeth. Juice from tea, betel nut, and meat color this food, \nmaking the tooth look dark. \n\n\nT a lA à \n\n\nWA \n\n\nHealthy gums become sore because of acid. When the coating on the \nteeth (p. 50) becomes hard, it is called tartar. Tartar can hurt the gums. \nAlso, the ‘colonies’ of germs can make a coating on top of tartar more \neasily than on a clean tooth. When the colonies are new, they make more \nacid which causes tooth and gum problems. After 24 hours, it hardens \nand makes a new layer of tartar. The tartar gets bigger and bigger. \n\n\nHere is a larger picture of the \n\n\nSore gums are infected. teeth in the box above: \n\n\nInfected gums are red \nand bleed easily. \n\n\nInfected gums are round and \nswollen between the teeth. \n\n\nThey are also loose instead of \ntight against the teeth. \n\n\nInfected gums have a deep gum pocket which catches even more food. \n\n\nWhere There Is No Dentist 2010 53 \n\n\nInfection in the gums is called gum disease. |t is important to treat gum \ndisease early, before it can spread to the root fibers and the bone. \n\n\nIf you have sore, bleeding \ngums, you can do much to \ntreat the infection yourself. \n\n\n1. Clean your teeth with a soft \nbrush gently and more often \n(see page 71). \n\n\n2. Eat more fresh fruits and \nvegetables. \n\n\n3. Rinse your mouth with warm \nsalt water. \n\n4. Clean between your teeth \nwith dental floss or string. At \nfirst your gums may bleed \nwhen you do this. But when \nthe gums are stronger the \nbleeding will stop. \n\n\nACTIVITIES: \n\n\n1. Have the students look in each other’s mouths. \nCan they see the coating on the teeth? Usually \nthey cannot. They may see food or ‘white stuff’, \nbut this is not the coating that makes acid. \nHowever, if someone has been chewing betel nut \nor eating berries, you will see stains on her teeth \nand the stains will be darkest where she has \nthese colonies of germs on her teeth. \n\n\n2. Put something on the teeth to stain the colonies of germs. Try using \nfood dye, betel nut or berry juices. Remember: first wash your hands! \nOlder students can rub berries on the teeth of the younger ones. Have \nthem rinse with a little water and spit it out. After this, the colored areas \non the teeth will show where the colonies of germs are forming. Where \nare they? Usually you will see the dark colors: \n\n\ne between the teeth \ne inthe pits or holes in the teeth \ne onthe tops (biting surfaces) of the teeth. \n\n\nThe older students can show the younger ones the best way to clean \nteeth (see pages 69-72). Have them use a mirror to see if they are getting \nthe colored juice from their teeth. They will learn that it is most difficult \n\nto get rid of the color between their teeth. Give them some string, dental \nfloss, or the soft stem from a young palm leaf and show them how to use \nit between their teeth (p. 72). Remind them to be gentle, or they will hurt \ntheir gums. Clean between your teeth every day. \n\n\n54 Where There Is No Dentist 2010 \n\n\nWhat Does It Mean if a Tooth is Loose? \n\n\nTHE IDEA: \n\n\nBaby teeth become loose when children are between 6 and 12 years old. \nThis is normal. If a loose baby tooth does not have a cavity, and if the gums \naround it are healthy, there is probably a permanent tooth growing under it. \n\n\nBut a tooth might be loose because it is broken or because it is sick from an \nabscess or gum disease. Either can destroy the bone around the tooth’s roots. \n\n\nWhen bone is lost, the tooth \nbecomes loose. A loose tooth hurts \nand usually must be taken out. \n\n\nThere is no medicine to make bone \ngrow back around the roots of \n\nABSCESS z \n\nWITH BOIL loose teeth. All you can do is stop \n\nthe infection from getting worse. \n\n\n~<——. GUM DISEASE \n\n\nACTIVITIES: \n\n\n1. Let the students look into each other's mouth for loose baby teeth. \nLook carefully to see why a tooth is loose. \n\n\nTouch the gum and bone beside the \nloose tooth. You can feel a bump—it is \nthe new permanent tooth growing. \n\n\nSave the baby tooth after it has fallen \nout. Look to see how the permanent \ntooth has eaten away its root by \npushing against it. \n\n\n2. Look for teeth that have cavities or gum \ndisease around them. The students can do \nthis with each other, and then later at home. \n(Remember they must wash their hands!) \n\n\nA tooth that has some of its root showing \nis probably loose. \n\n\nUsing your fingers or the handles of two \nspoons, rock the tooth back and forth \ngently. See how much it moves, and ask \nhow much it hurts. \n\n\nTell the person what he can do to \nprevent other teeth from becoming \nloose. (See the next section.) \n\n\nWhere There Is No Dentist 2010 55 \n\n\nHow Can We Prevent Cavities and Sore Gums? \n\n\nEating good food and carefully cleaning the teeth prevents both tooth decay \nand gum disease. \n\n\nFood from your own garden and local food from the market is best. \nThese foods are good for your body, your teeth, and your gums. \n\n\nhip A \nDIE Ñ \nSo \nVegetables, especially Peas and beans, like green Oil, from palm nut \nthose with dark green beans, soybeans, winged kernels, ground nuts, \nleaves. beans, and mung beans. and coconut. \nA) © of) Nom (|, OOD \nFruits, like banana, Fish, meat and eggs. Clean water, coconut \nguava, oranges, water, and milk are best \n\n\nand papaya. to drink. \n\n\nSoft foods and sweet foods from the store \nare not good for you. Soft foods stick to your \nteeth easily. They can work longer to cause \ncavities and infected gums. Sweet foods have \nmostly sugar in them, and it is ‘factory sugar’, \nnot the ‘natural sugar’ that is in the foods in \nthe pictures above. \n\n\nThis kind of sugar is quick to mix with germs \nand make acid. Remember: natural sugar \nmakes acid slowly; factory sugar makes acid \nquickly. \n\n\nChildren who eat a lot of sugar lose their \nappetite for other foods—the foods that help \nthem grow strong, stay healthy, and learn well \nin school. \n\n\nStore foods are also expensive. You can \nusually get better food, and more of it for \nthe same money, from your garden or in the \nmarket. \n\n\n56 Where There Is No Dentist 2010 \n\n\nCleaning your teeth carefully every day is another important way to take care \nof both teeth and gums. However, cleaning teeth is like building a house. \nTo do a good job, you need to work slowly and carefully. Once a day is \nenough, if you clean your teeth well every day. \n\n\n— ~~ _ es \n\n\nBuy a brush from the store, or make one yourself (see p. 4). But be sure the \ncleaning end of the brush is soft so that it won't hurt the gums. \n\n\nLEY \n\n\nnr pe ee ees \n\n\nUse your brush to clean all the teeth, especially the back ones with the \ngrooves. Back teeth are harder to reach and so It is easy not to clean them \nwell enough. Cavities start from sweet food and germs left together inside \nthe grooves. \n\n\n1. Scrub the inside, \noutside, and top of \neach tooth. \n\n\n2. Push the hairs of \nyour brush between \ntwo teeth. Sweep \nthe food away. \n\n\n3. Wash your mouth \nwith water, to \nremove any loose \nbits of food. \n\n\n—si_ \n\n\nSmall children are not able to clean their teeth carefully enough by \nthemselves. They need help. Look at the pictures on the cover and p.18 to \nsee how you can do this. Older children can care for younger brothers \nand sisters at home. \n\n\nWhere There Is No Dentist 2010 \n\n\nACTIVITIES: \nOne of the best ways to teach is by example. \n\n\nAND SO AT HOME WE \nPUT BOTH DRIED FISH \nAND GREEN LEAVES \nINTO THE SOUP. MY \nCHILDREN LIKE IT VERY \nMUCH. YOU WILL Too! \n\n\nStudents will believe what their teacher says if they know he eats good food \nand cleans his teeth. \n\n\nThe reverse is also true. Learning is harder when students know that their \nteacher does not do those things himself. \n\n\nStudents can be a good example for their community, too. They can: \n\n\ne draw pictures of foods that are both good and bad for teeth. Use them \nto make posters and flannel-board stories. \n\n\ne make puppets and plays to discuss ways people can become healthier. \nThere are some other ways to make learning meaningful and fun. \n\n\n1. Make a garden at school. Divide the ground so that each class has Its \nown space to plant a garden. \n\n\nUse some of the garden’s food to prepare a meal for the students, \nperhaps once a week. Students can bring food from home if there is \nnot enough ready in the garden. \n\n\n2. Organize a school lunch program. Each day the students can bring \nsome good food from home. Cooked yams, or maize, nuts, fruit and \nfresh vegetables are all good. Often the students will exchange food \nand talk about the many different foods that can be grown locally. \n\n\n57 \n\n\n58 Where There Is No Dentist 2010 \n\n\n3. Find the best way to clean teeth. Divide the class into groups. They will \nlearn more easily in a small group of 4 to 8 students. \n\n\nGive all the students something to eat that is sweet, sticky and dark in \ncolor, such as sweet chocolate biscuits. Ask the students to look in each \nother's mouth, to see how easily the biscuit sticks to the teeth. One or \ntwo of the students in a group can then try to clean away the pieces of \nbiscuit, using a different method. \n\n\neach person \n\n\neat a sweet \nMARIE sticky food SARA \nand... \n...do «brush \nnothing and rinse \nLAURA \n\n\nVINCENT \n\n\n...rinse ..eata \nonly fibrous \nfood \n\n\nWhen they are finished, the students can look at the teeth to decide if \n\n\nthey are clean or not. Put your findings on a chart and talk about what you \nhave learned. \n\n\nBETTER 1 \n\n\nstitL Dirty O \n\n\no) MARIE DID LAURA RINSED VINCENT ATE SARA BRUSHED \nNOT CLEAN ONLY WITH WATER A CARROT AND RINSED \n\n\nWhere There Is No Dentist 2010 59 \n\n\n4. Make cleaning part of a daily health activity. Older students can \nlook after younger students. They can first check their hair for lice, then \nsores for infection, and teeth for old food or germs. (To see the coating \nof germs on the teeth, try the activity on page 53.) One partner can \npoint out to the other where washing and brushing can be done better. \n\n\nCLEANLINESS CAN BEGIN AT SCHOOL \n\n\nAt school, students can wash their hands before lunch and brush their \nteeth afterward. Encourage them to keep a piece of soap and a toothbrush \nor brushstick (p. 4). One day a week, the whole class can treat their teeth \nwith fluoride (p. 205) to prevent cavities. \n\n\nThe student \ncan keep the \nbrush at her \nown desk... \n\n\nA piece of bamboo can hold a brush \nnicely. Make two holes near the top \nfor some grass string, to hang the \n\n\nbamboo brush ea | \n\n\n.. Orona \n\nrack at the \niro back of the \n\nroom. \n\n\nLet each student look after \nher own soap and brush. \n\n\n60 Where There Is No Dentist 2010 \n\n\nHave the students score each other's progress. Do not make it hard to \njudge, or they will not do it. In the example below, the tooth is either clean \nor net clean. \n\n1 SCORING TEETH \n\n\nPick 4 teeth, a back tooth and \na front tooth—two on top and \ntwo on the bottom. \n\n\nUse the same 4 teeth for each \nperson. Look for food on each \n2 tooth near the gums. \n\n\nr \n\n\ny A clean tooth = 2 points. \nA dirty tooth = 0 points. \nTotal possible points each day \nis 4 teeth x 2 = 8 points. \n\n\nIn this example the score is: \nTooth 1 = 2 points \nTooth 2 = 0 points \nTooth 3 = 0 points \nTooth 4 = 2 points \nTotal = 4 points \n\n\nHave each student put his daily score on a chart. At the end of the month he \ncan see how much he has improved. \n\n\n\"Err I ETO e Cele ee eee ese saa \n\n\nMonth of? March \n\n\nCHAPTER 5 \n\n\nTaking Care of \nTeeth and Gums \n\n\nWe can prevent most tooth and gum problems. This chapter gives more \ninformation about how teeth grow in and how to keep teeth and gums \nhealthy. Share this information and you will prevent problems from starting. \n\n\nBut remember that people are most interested in the problems they have \nnow. Before listening to what you know about prevention, people will \nwant treatment for the problems that are already causing them pain and \ndiscomfort. \n\n\nEarly treatment is a form of prevention. \n\n\nIt can prevent a tooth or gum problem \nfrom becoming more serious. \n\n\nWhen you treat a person's problem, it shows that you care about him. It \nalso shows that you know what treatment he needs. As his confidence in \nyou grows, he will want to learn from you about preventing tooth or gum \nproblems. \n\n\nT HAVE NEVER SEEN THIS PROBLEM, \nBUT I HAVE A FRIEND IN THE CITY \nWHO CAN HELP. E WANT TO GO WITH \nYou TO LEARN WHAT T CAN. \n\n\nIn order to help a person it is \nimportant to know what the \nproblem is and what is the \nbest treatment. But just as \nimportant is knowing what \nyou are not able to do, and \nwhen to seek help. \n\n\nIn this chapter, you will learn \nmore about teeth, gums, and \nproblems affecting them, \n\nbut you must never be too \nproud to get help from more \nexperienced dental workers. \n\n\nKnow your limits. \n\n\n61 \n\n\n62 Where There Is No Dentist 2010 \nTAKING CARE OF BABY TEETH \n\n\nA child's baby teeth are being made before birth while the baby is still inside \nthe mother’s womb. During the last months of pregnancy and the first few \nmonths after the child is born, the baby teeth take their final form. Pregnant \nmothers and young children need good food and good health in order \nto have strong baby teeth. \n\n\nStrong teeth Weak teeth \nare white and their have yellow marks that \nfront surface is smooth. are pitted and rough. \n\n\nBaby teeth get marks on them when: 1) the pregnant mother is sick or does \nnot eat good food; 2) the young baby is sick or does not eat good food; or, \nsometimes, 3) the baby’s birth was early or the delivery was difficult. \n\n\nThe marks are rougher than the rest of the tooth. Food \nsticks easily to them and turns the tooth yellow. \n\n\nThe marks are also soft. They need to be cleaned well \nevery day (p. 63) to prevent them from becoming \ncavities. A tooth with a cavity hurts. When children’s \nteeth hurt, they do not want to eat as much. \n\n\nCavities in baby teeth can make a child’s malnutrition worse. \nRemember this whenever you see a weak, poorly nourished child. When \nyou examine a child at the health clinic, lift his lip and look at his teeth. Do \nthis as part of your routine examination. \n\n\nYou can fill cavities with cement (Chapter 10). \nCement prevents food and air from going inside \nthe cavity and hurting the child. \n\n\nA sore on the gums may be a gum bubble. If so, \nit means the tooth has an abscess (page 81). \nThat cavity should not be filled with cement. \nInstead, the tooth needs to be taken out \n(Chapter 11) before the infection can get worse. \n\n\nWhere There Is No Dentist 2010 \n\n\nFor baby teeth to grow strong, mother and baby must stay healthy.* Help \nher to understand how important this is. A pregnant mother should: \n\n\ne Eat enough good kinds of foods, both for herself and her baby growing \ninside (page 68; also see Where There Is No Doctor, Chapter 11, and \nHelping Health Workers Learn, pages 25-39 to 25-44.) \n\n\ne Attend health clinic each month, so the health workers can examine her \nregularly and she can receive important medicines (see Where There \nIs No Doctor, page 250). \n\n\ne Not use the medicine tetracycline, because it can cause the teeth \nto turn dark. You, the health worker, must remember—do not give \ntetracycline to a pregnant woman or to a young child. If she needs \nan antibiotic, use a different one. \n\n\nFor baby teeth to stay strong, and to prevent marks from turning into \ncavities, mother should: \n\n\ne Continue to breast feed and never feed her \nchild juice or sweet tea from a bottle. Start \nadding soft foods, such as mashed banana or \npapaya, when the child is 6 months old. \n\n\ne Wipe her baby’s teeth with a clean cloth after \nthe baby eats. This cleans the baby’s teeth, \nand helps the baby get used to teeth cleaning. \nLater he will be happy with a brush. \n\n\nAround 1 year of age, there will be several baby teeth. At that time, mother \nshould start using water—not toothpaste—on a soft brush or brushstick. \n(With toothpaste, you cannot see the child’s teeth clearly because of the \nbubbles it makes.) She should scrub the sides and tops of each baby tooth \nas well as she can (page 69). \n\n\nThe child can also try to clean his own teeth. That should be encouraged. \nHowever, since he is too young to clean properly, mother (or father, or older \nbrother, sister) must clean his teeth once a day for him. Continue helping in \nthis way until the child is old enough to go to school. \n\n\n1 You can make a large brush smaller, \n` to fit more easily into a young \n_—T child’s mouth. \n\n\n“ite — Pull out some of the back hairs, or \nA cut them out with scissors. Do not \ncut the hairs in half, because the \n\n\ntops are often rounded or softer, and \nthat is better for the gums. \n\n\n*See the story about pregnancy and dental care on pages 15-16. \n\n\n63 \n\n\n64 Where There Is No Dentist 2010 \n\n\nWhy Baby Teeth Are Important \n\n\nBaby teeth are just as important to children as permanent teeth are to adults. \nThey help a child to eat, talk, and look good. \n\n\nHowever, many people feel that it is not worth the effort to look after baby \nteeth. Nor is it worth fixing them. After all, parents think, the permanent teeth \nwill take their place. \n\n\nThis kind of thinking is understandable. The problem is that we are forgetting \none other useful purpose of baby teeth. Baby teeth keep space in the mouth \nfor the permanent teeth to grow in. If there is not enough space, the new \nteeth will grow in crooked, and cavities grow faster around crooked teeth. \n\n\nPermanent Under each baby tooth a new \nmolars permanent tooth is growing. \n(PM) come \n\nin behind At the same time, extra \n\nthe baby permanent molars are forming \nmolars at the back of the mouth, \n(BM). inside the bone (page 43). \n\n\nFront baby teeth become \nloose and fall out (usually \n\n6-7 years, but sometimes as \nyoung as 5 years) ahead of \nback baby teeth (10-12 years). \nThis is because the front \npermanent teeth are formed \nand ready to grow in first. \n\n\nThe permanent molar (1 PM) is often the first of the permanent teeth to grow \ninto the mouth. That happens at 6 years of age. \n\n\nt dem \n\n\n26” \niPm \nLPM \nThe first permanent molar grows into Slowly but steadily the upper and \nthe mouth by sliding against the back lower permanent molars grow until \n\n\nof the second baby molar (2BM). they meet and fit tightly together. \n\n\nWhere There Is No Dentist 2010 \n\n\nBetween the ages of 6 and 11, a child needs healthy baby molars to guide \nthe first permanent molars into position and then to hold them there. When \nthe first permanent molars grow into the right place, this is a good sign. It \nmeans the other permanent teeth will also grow in properly, because they \nwill have enough space. \n\n\nNote: Some people are born without enough space. But most people are \nnot born with this problem—they lose the spaces when they remove \nbaby teeth instead of fixing them. \n\n\nHEALTHY BABY TEETH —— help > STRAIGHT PERMANENT TEETH \n\n\na \n\n\nto ma \n\n\n10 years \n\n\nSICK BABY TEETH ———— ee —> CROOKED PERMANENT TEETH \n\n\n4pm 2am { \n\n\nTAKEN OUT \nBEFORE \n\n\n26\" \napm \nMOVING INTO NOT ENOUGH \nTHE CAVITY SPACE \n\n\n10 years adult \n\n\nTell mothers why baby teeth are important. Good food and regular cleaning \nkeep them healthy. They should know that new teeth coming in do not \ncause diarrhea and fever, but that a child may have diarrhea or fever at the \nsame time. \n\n\nIf there is a cavity, fix it so the tooth can be kept in the mouth to do its \nimportant work (see Chapter 10). \n\n\n65 \n\n\n66 Where There Is No Dentist 2010 \nTAKING CARE OF MOLAR TEETH \n\n\nWe often notice front teeth growing in, but not the back ones. Back teeth \nmolars are not so obvious. Swelling on the face can be either a new molar \ngrowing in or an abscess. So, to help you to decide, look at the tooth for a \ncavity and at the gums beside it for a gum bubble. \n\n\nCAVITY Can \n\n\nGUM BUBBLE \n\n\nWhen you see a swollen face, look for the two signs of an abscess. \n\n\nBut if the person is young (16-22 years), it often is not an abscess. The third \npermanent molar tooth may be growing in at the back of her mouth. As the \ntooth grows, it cuts through the skin. Just as a dirty cut on a person’s hand \ncan get infected, the cut gum around her new tooth also can get infected, \ncausing a swollen face. \n\n\nSee the red swollen skin on \nLook behind her back teeth. top of the new tooth. \n\n\nIf there is enough space for the tooth, it will grow in by itself. It only needs \ntime. Before acting, decide how serious the problem is. \n\n\nIf there is no swelling and she can open her mouth, explain to her what is \nhappening and what she can do herself to reduce infection and toughen the \ngums. The best medicine is to rinse warm salt water over the sore area. \n\nA good home remedy is to rinse until the tooth grows all the way into the \nmouth. \n\n\nIf it does appear serious (severe pain, swelling, not able to open the mouth), \nsee page 94 for further treatment. \n\n\nWhere There Is No Dentist 2010 \n\n\nTAKING CARE OF ALL YOUR TEETH \n\n\nThis book often repeats an important message: eat good food and clean \nyour teeth. It is repeated because this is the most important thing you \ncan learn from this book. Later chapters will discuss what to do when \nproblems occur, but if you follow these two suggestions, you will almost \nnever have problems with your teeth and gums. This is true because good \nfood keeps your whole body healthy, including your teeth. Also, with no \n‘colonies’ of germs (page 50) or harmful factory sugar (page 55) on your \nteeth, your mouth cannot make the acids that cause both tooth and gum \nproblems. So, remember: \n\n\n1. Eat Good Food \n\n\nAn easy-to-remember rule is the same foods that are good for the \nbody are good for the teeth. A healthy body is the best protection \nagainst infection. \n\n\nGood nutrition (eating well) means 2 things: \n\n\n1) Eat a mixture of different kinds of foods \nevery time you eat. Look at the pictures \non page 55. There are several groups of \nfoods. Every time you eat, try to eat one or \ntwo foods from each of the groups. This \nway, you will get 3 important kinds of food: \ngrow food (body-building food) to give you \nthe protein you need; glow food (protective \nfood) to give you vitamins and minerals; and \n\nThe MAIN FOOD is at go food (concentrated energy food) to give \n\nthe center of every meal. you calories to be active all day. \n\n\n2) Be sure you eat enough \n\n\nfood to give your body the a= \nenergy it needs. This is even cat 3 \nmore important than the first = ney \n\n\nsuggestion. We get half or \nmore of our energy from our \nmain food. In most parts of the ee \nworld, people eat one low-cost oe oe \nenergy food with almost every a a ea \n\n; means he only has to eat \nmeal. Depending on the area, \nhi inf about 3⁄4 as much of the \nt IS mam ood may be rice, local main food in order to \nmaize, millet, wheat, cassava, meet his energy needs. The \npotato, breadfruit, or banana. added oil helps make sure \nThe main food is the central or he gets enough calories by \n‘super’ food in the local diet. the time his belly is full. \n\n\n68 Where There Is No Dentist 2010 \n\n\nBe sure always \nto eat grow \nfoods and \nglow foods \n\nto get the \nvitamins and \nprotein you \nneed. \n\n\nYour energy \nfoods give \n\nyou the most \nimportant \n\npart of your \ndiet—calories. \nHalf or more \nof our \n\ncalories come \nfrom the main \nfood, and most \nof the other \ncalories come \nfrom go foods. \n\n\nWARNING ABOUT GO FOODS: Although go foods give us the energy \n\nwe need, some go foods are worse than others. Honey, molasses, and \nespecially white sugar can be very bad for the teeth, even though they \nhave the calories we need. Fruits, nuts, and oils all give us energy (calories) \nwithout attacking the teeth. \n\n\nWhere There Is No Dentist 2010 \n\n\n2. Clean Your Teeth \n\n\nCleaning teeth requires time and care. If you hurry, you will leave food \nand germs behind, and they continue to make cavities and sore gums. \n\n\nYou may find that different dental workers recommend different ways \nof brushing teeth. Some ways are definitely better, but often they are \nharder to learn. \n\n\nTeach a method of cleaning that a person can learn and will do at home. \nLet him start by scrubbing his teeth (and his children’s teeth) back and \nforth, or round and round. Encourage him to improve his method only \nwhen you think he is ready. \n\n\nToothpaste is not necessary. Some people use charcoal or salt \ninstead. But it is the brush hairs that do the cleaning, so water on the \nbrush is enough. \n\n\nScrub the outside, inside, and top of each tooth carefully. \n\n\nWhen you finish, feel the tooth with your tongue to make sure it is \nsmooth and clean. \n\n\nFinally, push the hairs of the brush \nbetween the teeth and sweep away \nany bits of food caught there. Do \nthis for both upper and lower teeth. \n\n\nSweep away in the direction the \ntooth grows: sweep upper teeth \ndown and lower teeth up. \n\n\n69 \n\n\n70 Where There Is No Dentist 2010 \n\n\nExplain how important it is to use a brush with soft hairs. A brush that is stiff \nand hard will hurt the gums, not help them. \n\n\nYES \n\n\nYou can make a hard brush softer \nby putting the hairs into hot water \nfor a few minutes. \n\n\nDo not put the plastic handle into \nthe hot water, or it will melt. \n\n\nIf your store has only hard brushes, tell the store keeper that hard \ntoothbrushes do not help the people in the community. Ask him to order and \nsell only soft toothbrushes. \n\n\nNote: Another important way to reduce cavities is by adding \nfluoride to teeth. Fluoride is a substance which, like \ncalcium, makes teeth harder and stronger. \n\n\nFluoride in drinking water, toothpaste, salt, vitamins, and mouth \nrinses helps to prevent cavities. These methods are sometimes \nexpensive. But treating teeth once a week with fluoride toothpaste \nis effective and inexpensive. See page 205. \n\n\nFluoride can also be found naturally in food and water. For \nexample, tea leaves and most foods from the sea contain a large \namount of fluoride. \n\n\nSo, your source of fluoride can be either: \n\n\nWhere There Is No Dentist 2010 71 \nCLEANING BETWEEN THE TEETH IS VERY IMPORTANT \n\n\nHere are three ways to clean between the teeth: \n1. Push the hairs of a toothbrush between the teeth, and sweep the bits \nof food away. \n\n\n2. Remove the stem from a palm leaf. Use the thinner end and move it \ngently in and out between the teeth. \n\n\nRub the stem against \n4 $2 y one tooth and then \n= the other. This way, \nyou clean the sides \nof both teeth. \n\n\n3. Use some thin but strong thread or string. String can be the best \nmethod of all—but you must be careful with it. \n\n\nGet some thin cotton rope Buy and use dental floss.This \nused for fishing nets. Unwind OR is a special kind of string for \nand use one strand of it. cleaning between the teeth. \n\n\nBe careful! The string can hurt your gums if you do not use it correctly. \nThe next page shows how to use the string, but the best way to learn \nhow to ‘floss’ your teeth is to have someone show you. Ask a \ndental worker who has experience. \n\n\n72 Where There Is No Dentist 2010 \n\n\nWrap the ends of the \nstring around the middle \nfinger of each hand. \n\n\nUse the thumb and finger to guide the string. Go back and forth to slide the \nstring between two teeth. Be careful not to let it snap down and hurt the gums. \n\n\nUpper teeth \n— \n\n\nLower teeth \n\n\nWith your fingers pull the \nstring against the side of one \ntooth. Now move the string \nup and down. Do not pull \nthe string back and forth or \nit will cut the gum. \n\n\nLift the string over the pointed \ngum and clean the other tooth. \n\n\nWhen you have cleaned both teeth, release the string from one finger and \npull it out from between the teeth. Then wrap it around your two middle \nfingers once again, and clean between the next two teeth. \n\n\nRemember: clean teeth and good food \nwill prevent almost all dental problems. \n\n\nCHAPTER ( \n\n\nExamination \nand Diagnosis \n\n\nWhenever you do an CARE THE TEETH HEALTHY 2) Oo \n\ni i o e \nexamination, remember 5 . \nto examine the mouth. olen Gu \n\n\nYou can prevent much suffering Dg 5 \nand serious sickness when \nyou notice and treat problems early. \nWhenever you hold a health clinic, try \nto find out how healthy each person's \nmouth is. \n\n\nAsk if she is having a problem now, or \nhas had a problem recently. \n\n\nAlways write down what you find out, \nso you remember what treatment that When you look inside someone's \nperson needs. mouth, ask yourself these questions. \n\n\n1. Are the teeth healthy? Look for: \nTell the person what is \n1. A New S happening and how to \nkeep the skin around it \nhealthy (page 66). \n\n\nThey may be cavities \nwhich should be \n\nfilled when they are \nstill small (page 47). \n\n\nTell the person what is \nhappening and how to prevent \nit from getting worse or \naffecting other teeth (page 54). \n\n\nA tooth that is dark is dead and infection \nfrom its root can go into the bone (page 47). \nThis can make a sore on the gums (page 74). \n\n\n73 \n\n\n74 Where There Is No Dentist 2010 \n\n\n2. Are the gums healthy? \n\n\nLook at page 52 and compare the pictures of healthy and unhealthy gums. \nUnhealthy gums often are red and they bleed when you touch them. \n\n\nA bubble on the gums below the \n\ntooth is a clear sign that the person \n\nhas an abscess. The abscess may be \n\nfrom the tooth, or it may be from the \n\ngums. To decide, look carefully at Z T -Z \nboth the tooth and the gum around it. 1 a \n\n\nA bubble beside a healthy tooth is a sign \n\n\nof infected gums. Scale the tooth carefully. x jz \nSee Chapter 8. So ae \nA bubble beside a decayed tooth is a sign E + z \n\n\nof a tooth abscess. (See page 93.) \n\n\nA sore on the gums from a badly decayed GUM BUBBLE \n\n\ntooth appears when a gum bubble breaks \nopen and lets out the pus from inside. \n\n\n3. Are there any sores? \n\n\nLook for sores under the smooth skin on the inside of the lips and \ncheeks. Look also under the tongue and along its sides. \n\n\nA \nLASET \n\n\n1. A sore on the 2. Sores on the inside . Sores on the \ngums may be of the lip or cheek lips or tongue \nfrom an infected may be from a may may be \ntooth (p. 93). virus (p. 104). cancer (p. 125). \n\n\nAfter your examination, tell the person what you have found. If you notice \na problem starting, explain what to do to prevent it from getting worse. If \nthere are no problems and the mouth is healthy, congratulate the person. \n\n\nShare your knowledge—explain things to people. \n\n\nHelp them learn how they can prevent and even \nmanage their own problems with their teeth. \n\n\nWhere There Is No Dentist 2010 75 \n\n\nWHERE TO EXAMINE \n\n\nExamine people in a light and bright place. It is dark inside a person's mouth, \nso you need light to see the teeth and gums. \n\n\nUse the sun. Examine outside, or inside a room facing the window. With \nsunlight alone, you will be able to see most places in the mouth well \nenough. If you cannot, set up a lamp or have someone hold a lamp for you. \nReflect the light off a small mouth mirror onto the tooth or gum. \n\n\nIf you have a low chair, lift up the \nperson's chin so that you do not have to \nbend over as far when you look into the \nmouth. An even better way Is to have the \nperson sit on some books. The person's \nhead can lean back on a piece of cloth. \n\n\nUse an old chair with a strong back. \n\n\nAttach two flat sticks to the chair. Then \ntie a strip of clean cloth to the sticks. Tie \nit strong enough to support the head, but \nloose enough to let the head lean back. \n\n\nTHE INSTRUMENTS YOU NEED \n\n\nThree instruments are really enough: \n\n\n2» 1. A wooden tongue blade to hold back \nthe cheek, lips, and tongue. \n\n\nK 2 2. Asmall mirror to let you look more \nclosely at a tooth and the gums \n\n\naround it. \n\n\n3. A sharp probe to feel for cavities \nand to check for tartar under the \ngum. \n\n\nAEE PE CNRS RS 5 A, \n\n\nIf you have many people to examine, it is helpful to have more than one of \neach instrument. But be sure they are clean. \n\n\nDirty instruments easily can pass infection \nfrom one person to another. After you finish \nan examination, clean your instruments in soap \nand water and then leave them in a germ-killing \nsolution like the ones described on page 89. \n\n\n76 Where There Is No Dentist 2010 \n\n\nA GOOD DIAGNOSIS \n\n\nYou are making a diagnosis when you decide what a person's problem is \nand what is causing it. To do this, you need information. You need to make \na careful examination to make a good diagnosis. \n\n\nLearn all you can about the person’s problem: \n1. Ask questions about the problem. \n\n\n2. Look at the person's face. Think about the person's age. \n3. Examine the mouth more carefully than before. \n4. Touch the place that is sore. \n\n\n1. Ask the person about the problem. \n\n\nGive a sick person a chance to \ndescribe how he is feeling. \n\n\nListen. Think about what possibly is \nhappening in his mouth. \n\n\nYou may have an idea about what \nthe person has. Now try to find out \nmore by asking questions: \n\n\ne What is the problem? Ask him \nto talk about the pain, swelling, \nbleeding, or whatever he is feeling. \n\ne Where does it feel that way? See if he can put his finger on the tooth \nor place that is bothering him. \n\ne When do you have the most pain? Find out if it happens all the time \nor only some of the time (for example, when he drinks something very \ncold). \n\ne When did it start? Find out if he has already had this problem before. \nAsk how he took care of it. \n\ne Have you had an accident or injury lately? Infection still inside the \nbone from an old injury in the mouth can make a sore on his face, or \nstart swelling. \n\ne Are you having other problems? A head cold or fever can make the \nteeth hurt. \n\ne« How old are you? Think about a new tooth coming into the mouth. \n\n\nAfter you hear the answers to your questions, decide if your original idea \nis the correct diagnosis. If not, try to think of another possibility and ask \nmore questions. This is the scientific method of making a diagnosis. \nFor a good explanation of scientific method, see Chapter 17 of Helping \nHealth Workers Learn. \n\n\nWhere There Is No Dentist 2010 \n\n\nWhen you talk to a woman, find \nout if she is pregnant. A pregnant \nwoman's gums can easily become \ninfected. The gums may bleed and \nshe may have more tooth decay. \nBut this does not have to happen. \n\nIf a pregnant woman takes extra \ncare of her teeth and gums, she can \nprevent most dental problems. But \nif she already has a problem, do not \nwait for the baby’s birth before you \nhelp her. You can treat a pregnant \nwoman's mouth problems now. In \nfact, this may be an important way of dental care, they can give \nprotecting her baby as well (see pages you helpful information \n\n\n15 to 16). about the women’s health. \n\n\n| TRANSFER To \nDENTAL CLINIC \nMaria Antonio \n\n\nTrain midwives to examine \nwomen’s mouths. When \nthey send women to you for \n\n\nCaring for a pregnant woman—a guide for dental workers \n\n\n. Ask her how many months she has been \npregnant and find out if she has high blood \npressure. Any person with blood pressure over \n150/100 may bleed excessively after extraction. \nTo get this information, encourage all women \nto have regular check-ups with a midwife or a \ntrained health worker who has equipment for \nmeasuring blood pressure. \n\n\n. Do not take X-rays of teeth unless absolutely \nnecessary. X-rays are dangerous to the unborn \nbaby inside. Before an X-ray, always cover the \nmother's chest, belly, and thighs with an apron \nlined with lead. \n\n\n. Do not give her tetracycline or doxycycline while she is pregnant \nor breastfeeding. \n\n\n. Always give a careful and complete mouth examination. Tell her \nwhat treatment she needs and how to prevent tooth problems. \n\n\n. Be gentle. Show the woman that you care, that you want her to \nbe comfortable, and that you can treat her without hurting her. \n\n\n78 Where There Is No Dentist 2010 \n\n\n2. Look at the person. \n\n\nPeople have some problems more often at certain ages. When a person \nfirst comes in to see you, notice his age. Then, before you ask him to \nopen his mouth, look at his face for a sore or swollen area. \n\n\nCHILD \n\n\nSwelling can come from: \n\n\n* mumps \n\ne an infection in the spit \ngland (p. 119) \n\ne a tooth abscess (p. 93) \n\n\nCHILD \n\n\nA sore can come from: \n\n\n* impetigo \ne Vincent's infection \n(p. 102) \n\n\nSWELLING \n\n\nYOUNG PERSON \n\n\nSwelling can come from: \n\n\ne anew tooth growing \nin (p. 100) \ne a tooth abscess (p. 93) \n\n\nYOUNG PERSON \n\n\nA sore can come from: \n\n\ne fever blisters (p. 104) \ne a tooth abscess (p. 93) \n\n\nSwelling can come from: \n\n\ne a tooth abscess (p. 93) \ne a broken jaw (p. 113) \ne a tumor (p. 125) \n\n\nA sore can come from: \n\n\ne a tooth abscess (p. 93) \ne a bone infection \n(osteomyelitis) \n\n\nWhere There Is No Dentist 2010 \n\n\n3. Examine inside the mouth. \n\n\nRemember what the person said, the person’s age, and what you saw. \nNow look more closely at the problem area. \n\n\nLook at the teeth: \n\n\ne Is a new one growing in? \ne Isa tooth loose? \ne Is there a dark (dead) tooth? \n\n\nLET ME THINK \nL PAIN ALL THE \nTIME \n2. SWOLLEN FACE \n\n\n3 LARGE CAVITY \nIN MOLAR \n\n\nABSCESS ? \n\n\nLook at the gums: \n\nAre they red? \n\nIs there any swelling? \n\nDo they bleed? \n\nAre the gums eaten away \nbetween the teeth? \n\n\nLook also for sores on the inside of the cheek or lips, and on the tongue. \n\n\n4. Touch the sore place. \n\n\nTouching is a good way to find out how serious the problem is. This will \nhelp you decide which treatment to give. \n\n\nPush gently against each tooth in the area of pain to see if a tooth is \nloose. Rock the loose tooth backward and forward between your fingers, \nto see if it hurts when you move it. \n\n\n1 MUST TAKE OUT \nYOUR TOOTH. 1T \nHAS AN ABSCESS. \nUsing the end of your mirror, tap against \n\n\nseveral teeth, including the one you suspect. \n\n\nThere is probably \nan abscess on a \ntooth that hurts \nwhen you tap it. \n\n\nPress against the gums with cotton gauze. Wait a moment, and then look \nclosely to see if they start bleeding. Then use your probe gently to feel \nunder the gum for tartar. Carefully scrape some away. Wait and look again \nto see if the gums bleed. When gums bleed, it is a sign of gum disease. \n\n\n80 Where There Is No Dentist 2010 \n\n\nLEARN TO TELL SIMILAR PROBLEMS APART \n\n\nIf a person comes to you with a toothache or a sore \nor a loose tooth, there are many possible causes for \neach problem. The first thing you notice—the \ntoothache, sore or loose tooth—is your first step \n\nto a diagnosis. To this you must add more information \nbefore you can point to the most probable cause. \n\n\nPut together what you have found with what \nyou already know about teeth and gums. You \ncan make a good diagnosis of a problem without \nknowing a special name for it. \n\n\nUsually it is easy to make a diagnosis. However, \nsometimes you will not be sure, and these are the \ntimes to seek the advice of a more experienced dental \nworker. Never pretend to know something you do not. Only treat \nproblems that you are sure about and have supplies to treat properly. \nSee Where There Is No Doctor, p. w4. \n\n\nUse the charts beginning here to help you make the diagnosis. For more \npractice using charts to tell problems apart, see Chapter 21 of Helping \nHealth Workers Learn. \n\n\nIF THE PERSON AND YOU FIND OUT HE/SHE \nHAS THAT MAY HAVE \n\n\ny It hurts only after eating or \n\n\ndrinking. There is a cavity, but the a cavity \ntooth does not hurt when you tap it. \n\n\nPart of the filling has fallen out, or is a cavity \ncracked and ready to fall out. Eating 8 under an \nand drinking make the tooth hurt. old filling \n\n\nA TOOTHACHE The tooth hurts when chewing food. tartar \nt may hurt when tapped, but there is between \nno cavity and the tooth looks healthy. : the teeth \n\n\nt hurts all the time—even when ae | \nperson tries to sleep. The tooth i \n: S ` an abscess \nhurts when you tap it and it feels a \nbit loose. \n\n\nt hurts when person breathes in cold a cracked \n\n\nair. The tooth was hit recently. or broken \ntooth \n\n\nHe cannot open his mouth properly. \nSteady pain and a bad taste are a new tooth \ncoming, from the back of the mouth. growing in \n\n\nSeveral top teeth hurt, even when \n\nyou tap them. She had a head cold “ an infected \nand can only breathe through her i sinus \nmouth. \n\n\nIF THE PERSON \n\n\nHAS \nY \n\n\nA \nSWOLLEN FACE \n\n\nWe \n\n\n-om \n\n\nA \nLOOSE TOOTH \n\n\nWhere There Is No Dentist 2010 81 \n\n\nAND YOU FIND OUT \n\n\nTHAT \nvy \n\n\nHe had a toothache recently. \nThe bad tooth hurts when \nyou tap it. \n\n\nShe is young, about 18 years \nold, and has trouble opening \nher mouth. \n\n\nHe was hit on the face or jaw. \nThe bone hurts when you \nouch it. The teeth do not fit \nogether properly. \n\n\nThe swelling is under or \nbehind the jaw. It gets worse \nwhen he is hungry and smells \nood. \n\n\nThe swelling has been there for \na long time. It does not seem to \nget better. \n\n\nFood and tartar are attached \nto the tooth. The gums \naround it are loose and \nswollen. \n\n\nThere was pain in the tooth \nbefore, but it does not hurt \nso much anymore. It has a \ncavity and there may be a \nsore on the gums near it. \n\n\nThe tooth was hit \nsome time ago. \n\n\nWhen the loose tooth \nmoves, the bone around it \nand the tooth beside it also \nmove. \n\n\nf \n\n\nBONE BROKEN ‘ \nUNDER THE GUM Ta \n\n\nWhen you ask the person to \nslowly close his teeth, one \ntooth hits another, before the \nother teeth come together. \n\n\nHE/SHE MAY| SEE \nHAVE PAGE \n—y \na tooth \nabscess \n\n\n3 \n00 \n08 \n19 \n\n5 \n01 \n\n\na new tooth \ngrowing in \n\n\nan infection \ninside the spit \ngland \n\n\naad a \n\n\n99 \nand \n93 \n\n\n9 \n1 \n\n1 \n\n1 \n12 \ninfection \ninside the root \n\n\nfibers—from \ngum disease \n\n\ninfection in the \nbone—from \nan old tooth \nabscess \n\n\na root broken \nunder the gum \n\n\na broken bone \naround the \ntooth’s roots \n\n\nOR \n\n\ninfection inside \nthe bone from \nVincent's \nInfection \n\n\na tooth is out \n\nof position and \nbiting too hard \naganist another \n\n\n82 Where There Is No Dentist 2010 \n\n\nIF THE PERSON \nHAS \n\n\ny \n\n\nA SORE MOUTH \nfrom \nINFECTED GUMS \n\n\nor \nA SORE MOUTH \nfroma \nSMALL SORE \nin another \nplace \n\n\nAND YOU FIND OUT \nTHAT \n\n\nThe gums are red and \nswollen. They bleed when the \nteeth are cleaned. \n\n\nBetween two teeth the gums \nare sore and swollen, like a \nsmall tumor. \n\n\nThe gums between the teeth \nhave died and are no longer \npointed. Pus and blood around \nthe teeth make the mouth \nsmell bad. \n\n\nThe gums are bright red and \nsore, but between the teeth \nthey are still pointed. \n\n\nA sore on the inside of the \ncheek, lips, or under the \ntongue, is yellow with the \nskin around it bright red. \nFood touching it makes the \nsore hurt more. \n\n\nA sore spot around or under \na denture hurts when you \ntouch it. \n\n\nA kind of white cloth seems \nto be stuck to the top of the \nmouth or tongue. It may \nstop a baby from sucking. \n\n\nThe sore is near the root of \na bad tooth. \n\n\nThe corners of the mouth \nare dry. The lips crack and \nare sore. \n\n\nSmall painful blisters on the \nlips soon break and form dry \nscabs. \n\n\nHE/SHE \nMAY HAVE \n= \n\n\ngum disease \nstarting \n\n\nsomething \ncaught under \nthe gum \n\n\nVincent's \nInfection (a \nmore serous \ngum infection) \n\n\nfever blisters \non the gums— \nfrom Herpes \nVirus \n\n\na canker sore \n\n\na sharp place \non a denture, \nor an old \ndenture that \nneeds to be \nrefitted \n\n\ngum bubble \n\n\nfever blisters— \nfrom Herpes \nVirus \n\n\nA SORE THAT DOES NOT HEAL PROPERLY MAY BE CANCER (See page 125). \n\n\nWhere There Is No Dentist 2010 83 \n\n\nIF THE PERSON AND YOU FIND OUT HE/SHE MAY \nHAS THAT HAVE \n\n\ny \n\n\nnside his mouth, he has a } abscessed tooth \nooth abscess or a broken draining pus to \nooth near the sore. the outside of \n\n\nthe face \nA SORE \n\n\nON THE FACE ; . \nA dark sore is eating through a condition \n\n\nhe cheek. Her gums are Lal ® called Noma— \nbadly infected. A bad smell is | starting from \ncoming from the dying skin on Vincent's \n\nhe face, and from inside the Infection of the \nmouth. gums \n\n\nA 1-month-old sore on the lips \n\n\n; : $ SS cancer \nis not healing with medicine. \n\n\nHe is young, between \n16-24 years, with some \nswelling behind his jaw. \n\n\na new tooth \ngrowing in \n\n\nTROUBLE a broken jaw— \nOPENING THE He recently had an accident. probably in \n\n\nfront of the ear \n\n\nHe had a toothache before \nin a back tooth with some \nswelling. \n\n\nan abscess ina \nback tooth \n\n\n1 CAN NOT When she tries to open- : o \n\nOPEN ANY her mouth, there is clicking pain in the \n\nMORE THAN sound from in front of her Mt joint—where \near. It also hurts in that place AM the jawbone \nwhenever she tries to open joins the head \nher mouth or chew food. \n\n\nSwallowing is difficult and %2.prx 8.0 \n\nthe jaw grows stiff. Germs \n\nhave gone into the body A tetanus \nfrom dirty instruments or an / \n\ninfected wound. \n\n\nTROUBLE After opening wide to eat \nCLOSING THE or yawn, his mouth became j: a dislocated \nstuck there. He was many j jaw \nmissing back teeth. \n\n\nHe had an accident and now \nsomething is stopping the € 2 a broken jaw \nteeth from coming together. \n\n\nWhere There Is No Dentist 2010 \n\n\nCHAPTER 7 \n\n\nTreating Some \nCommon Problems \n\n\nYou must make a good diagnosis to treat a problem so it goes away and \ndoes not return. Why treat a sore on the face by cleaning it when the sore \nis from pus draining from a tooth with an abscess? You need to know the \ncause of the sore to give the best kind of treatment. \n\n\nAfter you make the diagnosis, you must decide whether you or a more \nexperienced dental worker should provide the treatment. \n\n\nKnow your limits. Do only \n\nwhat you know how to do. \nIn the following pages, we describe the kinds of problems you as a health \nworker may see, and we also give the treatment for each problem. \n\n\nBefore you touch the inside of anyone’s mouth, learn how to keep \nclean. The next 6 pages explain how you can prevent infections by washing \nyour hands, wearing gloves, and sterilizing your instruments. \n\n\nGerms in the mouth \n\n\nThe mouth is a natural home for germs. They usually do not cause problems \nbecause the body is used to them. In fact, many germs are helpful. For \nexample, when we eat, some germs break down chewed food into parts \nsmall enough for the body to use. \n\n\nThere are problems when the number of these ordinary germs increases \ngreatly, or when strange, harmful germs come into a healthy body from \noutside. Fever and swelling follow. It is an infection. \n\n\nWhen we regularly clean the mouth, the number of germs stays normal. \nYou can teach others to clean teeth and gums, but cleaning is each person's \nresponsibility. \n\n\nHowever, dental workers have one serious responsibility. You must not \nspread germs from a sick person to a healthy person. You must do \neverything you can to make sure your instruments are clean. An instrument \nwith blood on it can spread hepatitis (a serious liver disease) or HIV, which \ncauses AIDS. \n\n\n85 \n\n\n86 Where There Is No Dentist 2010 \nTHE FIRST RULE FOR TREATMENT: STAY CLEAN! \n\n\nNo matter what problem you are treating, be sure that your workplace, your \ninstruments, and you are always clean. For example, prevent infection by \nalways washing your hands before you examine or treat Someone. \n\n\nWash your hands in front of the person, in the same room. You will show \nthat you are a careful and caring health worker. Also, you will demonstrate \njust how important cleanliness really is. \n\n\nWear gloves \n\n\nLatex or plastic gloves protect the people you \ntouch from germs that may be stuck under your \nfingernails or on your skin, even after you wash \nyour hands. They also protect you from getting \ninfections. Wear clean gloves whenever you \ntouch someone's mouth or any blood. \n\n\nIf you are filling or removing a tooth, or if you are touching any \ninstruments that have been sterilized, you must wear sterile gloves. \n\n\nees hee, If you do not have gloves, use plastic bags that \nhave been washed in disinfectant soap instead. \nBags are harder to use than gloves, but they are \nbetter than nothing. \n\n\nWhere There Is No Dentist 2010 87 \n\n\nGerms hide inside bits of old food, cement, or \nblood on an instrument. There they can continue \nto live, even in boiling water. \n\n\nThis is why you must be sure to scrub the working \nend of each instrument carefully with soap and \nwater. Rinse, and then look carefully to see that it \nis clean and shiny. \n\n\nRemember that ‘clean looking’ is not necessarily ‘clean’. Truly ‘clean’ means \nfree of germs. Unless you sterilize, that instrument may still have germs, \nthe kind that cause infection in the next person that it touches. \n\n\nSterilizing means killing germs. The best way to sterilize is with heat. High \nheat kills almost all harmful germs—especially those that cause hepatitis, \ntetanus, and mouth infections. Wet heat (steam) is always more effective \nthan dry heat from an oven. \n\n\nHere is a simple rule to use in \ndeciding when to sterilize: \n\n\nBoil or sterilize with steam \nany instrument that has \ntouched blood. \n\n\nThat means always sterilize \nall syringes, needles, and \ninstruments you use when \nscaling teeth (Chapter 8) \n\nor when taking out a tooth \n(Chapter 11). \n\n\nBe safe: When in doubt, sterilize. \n\n\nInstruments left in boiling water need 30 minutes to become sterile. A pot \nwith a cover to trap the steam can act faster. The inside becomes hotter and \n20 minutes is enough. But remember that water can rust metal instruments. \nTo prevent rust: \n\n\ne Add 5 spoonfuls (20 ml) of oil to every liter of water you boil. \n\n\ne Then lay the hot instruments on a dry, clean (sterile, if possible) cloth, \nso the water can evaporate. \n\n\nNever put an instrument away while it is wet. \n\n\n88 Where There Is No Dentist 2010 \n\n\nSterilizing with steam under pressure is the fastest and surest method. It \nkills harmful germs in 15 minutes. You need a strong pot with a tight fitting \nlid. But be sure to make a small hole in the lid so steam can escape \n\n\nwhen the pressure becomes too great. \n\n\nA special pot called a pressure cooker is perfect for this. It even has a safety \n\n\nhole on it to release extra steam. \n\n\n1. Put 2 cups of water and \n2 spoonfuls of cooking \noil into the pot. \n\n\n2. Place the handles together. \nPut on high heat until a loud \nhissing noise begins. \n\n\n3. Put on lower heat. Begin \ntiming now. Leave the hissing \npot on the low flame for \n15 minutes. \n\n\n4. Cool the pot under water, open, \n\n\nand lay the instruments on a \nclean towel to dry. \n\n\nDO NOT LET \nTHE COOKER \nBOIL DRY! \n\n\nThe next time you use the pot, \nyou can use the same water that \nwas left inside it. \n\n\nWhere There Is No Dentist 2010 89 \n\n\nSterilizing with heat is not necessary for instruments that do not touch \nblood. For example, after you examine a person or place a temporary filling, \nyou can clean your instruments and then soak them in a solution of alcohol \nor bleach. \n\n\nAlcohol solution tight fitting \n1. Mix in a large container each week: cH lid \n\n\n7 parts alcohol (95%) with 3 parts LLL \nclean water. Keep the container Een, water \ntightly covered to prevent 1 AHH \nevaporation. \n2. Keep a covered pan half filled with alcohol \n\n\nthis mixture. You will have to add \nsome more of the mixture from the \nlarge container to the pan each day. \n\n\n3. Leave your clean instruments in the 2 \npan, completely covered with the Se \n\n\nliquid, for 30 minutes. \n\n\nBleach solution (sodium hypocholorite) \n\nFind the cheapest brand name in your area for bleach. \nExamples are Javex, Clorox, Purex, and Cidex. Make \n1 liter of solution with a mixture of % cup \n(125 ml) of bleach and 3% cups (875 ml) \nof clean water. \n\n\nUnfortunately, bleach rusts metal \ninstruments. To reduce rust, \n\nadd 1 large spoonful of baking \nsoda (sodium bicarbonate) to \n\nthe solution, and leave your \ninstruments in the solution for only \n30 minutes. \n\n\nWipe each instrument with alcohol \nto remove the film of bleach. Then \nstore it dry inside a clean cloth or in \nanother covered pan. Change the solution each week. \n\n\n90 Where There Is No Dentist 2010 \n\n\nKeep your sterile instruments together in a clean place. \n\n\nWrap them in a clean cloth OR Leave them in disinfectant \n(p. 89) \n\n\nBefore you use any instrument \nagain, wash it with clean water—to \nremove the taste of the disinfectant. \n\n\nMark with tape the names \nof the instruments inside. \n\n\nGerms living in dirty cotton can easily go inside the socket and start an \ninfection. It is important, therefore, to keep the cut pieces in a container that \nis clean and has a cover. Use clean tweezers to remove the cotton gauze \nwhen you need some. \n\n\nAlso, keep your room and work area clean. Sweep or mop the floor one or \ntwo times a day, and wipe down the chair and tables after every patient. \n\n\nStaying clean is a part of staying healthy. \n\n\nWhere There Is No Dentist 2010 91 \nNEEDLES \n\n\nMany people get sick with serious illnesses like hepatitis or HIV from using \nunsterilized needles. \n\n\nReusable syringes and disposable syringes \n\n\nReusable syringes can be used again and again. Reusable syringes make \nless waste and can save money, but they must be washed very carefully and \nsterilized after every use. \n\n\nUse each disposable needle only one time and then throw it away in a box \nlike the one on pages 199-200. If you must reuse a needle, replace the cap \nvery carefully and put the needle in a safe place (such as a pan full of bleach \nsolution) until you are ready to clean and sterilize it (p. 138). \n\n\nHOW TO WASH AND STERILIZE A SYRINGE AND \nNEEDLE FOR REUSE: \n\n\n1. Put on a pair of heavy gloves \nto protect your hands from \ngerms and from sticking \nyourself with the needle. \n\n\n2. Draw 5% bleach solution (see page 89) up i \nthrough the needle into the syringe barrel. : \n\n\n3. Squirt out the bleach solution. \n\n\n4. Repeat several times. Rinse everything \nseveral times with clean water. \n\n\n5. Take the syringe and needle apart and boil or \nsteam them. (See page 138.) \n\n\nNever reuse a needle or syringe without \n\n\ncleaning and sterilizing it first. \n\n\n92 Where There Is No Dentist 2010 \n\n\nPART 1 \nPROBLEMS YOU WILL SEE MOST OFTEN \n\n\nCAVITIES AND LOST OR BROKEN FILLINGS \n\n\nA cavity can occur in any tooth. A cavity can also start around an old filling, \nespecially if it is dirty. The deeper a cavity gets inside the tooth where the \nnerve lives, the more the tooth hurts. \n\n\nSIGNS: \n\n\ne Pain when drinking water or eating \nsomething sweet. \n\ne A hole (or black spot) on the tooth, or \nbetween two teeth. \n\ne Pain if food gets caught inside the hole. \n\ne No pain when you tap the tooth. \n\n\nTREATMENT (when there is no abscess): \n\n\nTry to remove any loose piece of filling with a probe. Then, following the \nsteps in Chapter 10, put in a temporary filling. \n\n\nNow: \n\n\n1. Fill the hole with cement. If you have no cement, put some cotton into \nthe hole to keep food out. \n\n2. Look for cavities or broken fillings in the other teeth. Fill each one with \ncement before it gets worse and starts to hurt. \n\n\nSoon (within a few months): \n\n\n3. Arrange for someone to replace the temporary filling with a permanent \none. You will need a person who has experience using a dental drill \n(see page 151), or doing Atraumatic Restorative Treatment (ART), a \nway to remove cavities without drilling.. \n\n\nA groove on the neck of a tooth is a more difficult \ncavity to fill. For the temporary cement to hold hye \nproperly, you need to shape the groove with = J \n\na drill. To help temporarily, you can put a little BES A \nfluoride toothpaste on the groove (page 205). Do \n\nthis once each week until the inside part of the groove is stronger and the \ntooth hurts less. Or, you can paint the inside of the groove with oil of cloves \n(eugenol) to reduce the pain. \n\n\nTo avoid making the problem worse, (1) do not use a hard toothbrush; \n(2) do not brush back and forth along the gums; and (3) do not chew tobacco \nor betel nut and do not hold them against the teeth. \n\n\nWhere There Is No Dentist 2010 93 \nTOOTH ABSCESS \n\n\nA cavity that is not filled grows bigger and deeper until it touches the nerve. \nGerms travel inside the tooth’s root and start an infection called an abscess. \n\n\nPus forms at the end of the root, inside the bone. As the pus increases, it \ncauses great pressure. This is why an abscess causes severe pain. \n\n\nSIGNS: \ne Pain all the time, even when trying \nto sleep. \ne Tooth often feels longer, and even \na bit loose. \n\n\ne Tooth hurts when it is tapped. \n\ne A sore on the gums near where \nthe root ends (gum bubble). \n\ne Swelling of the gums around the \ntooth, or swelling of the face on \nthe same side as the bad tooth. \n\n\nTREATMENT: \n\n\nIf there is no swelling, take out the tooth immediately (unless you are able \nto give root canal treatment). This allows the pus to escape and relieves the \npain. See Chapter 11. \n\n\nIf there is swelling, treat the swelling first. Take out the tooth only after the \nswelling goes down. This is necessary because an anesthetic (see Chapter \n9) will not work if there is swelling. \n\n\nTo treat the swelling, give an antibiotic. Penicillin by mouth is best. Use an \ninjection only when the person is in immediate danger. For example, inject \npenicillin when the person has a fever or if the swelling is pressing against \nthe throat. But remember you can treat most serious infections with simple \npenicillin by mouth. For the doses for serious infections, look below the box \non the next page. If you still think an injection is necessary, look at the \nsection on ‘aqueous procaine penicillin’ on page 204. \n\n\nAdults and children over 25 kg (60 pounds) of weight should take the same \namount of oral penicillin. Children under 25 kg should take % as much. For \nmost infections, penicillin by mouth is taken 4 times a day for 5 to 7 days. \nThe first dose is double and then the regular dose is taken every 6 hours. The \nperson should take all of the penicillin, even if the pain or swelling goes \ndown. For the correct doses, see the next page. \n\n\n94 Where There Is No Dentist 2010 \n\n\nTHE BEST CHOICE SECOND CHOICE PSY \n(for those allergic to penicillin) \n\n\nPenicillin: 1 tablet = 250 mg \nGive enough tablets for 5 to 7 days \n\n\nErythromycin: 1 tablet (or capsule) = 250 mg \n\n\nGive enough tablets for 5 days \n\n\nFirst Dose (take all at once) \n\n\nAdults 4 tablets \nand children over 25 kg (1000 mg) \nChildren under 25 kg 2 tablets \n(500 mg) \n\n\nThen every 6 hours for 5 to 7 days \nAdults 2 tablets \nand children over 25 kg (500 mg) \nChildren under 25 kg 1 tablet \n(250 mg) \n\n\nFirst Dose (take all at once) \n\n\nAdults 4 tablets \nand children over 25 kg (1000 mg) \nChildren under 25 kg 2 tablets \n(500 mg) \n\n\nThen every 6 hours for 5 days \nAdults 2 tablets \nand children over 25 kg (500 mg) \nChildren under 25 kg 1 tablet \n(250 mg) \n\n\nIMPORTANT: to allow it to best fight infection, \ntake penicillin before eating. \n\n\nIMPORTANT: to avoid upset stomach, take \nerythromycin with meals. \n\n\nNote: If you do not have penicillin, use amoxicillin, 3 times a day for 7 days. \nAdults and children over 25 kg take 500 mg each dose, and children under \n25 kg take 250 mg each dose. To use ampicillin, see Where There Is No \nDoctor. People allergic to penicillin will also be allergic to amoxicillin and \nampicillin. \n\n\nFor many infections, taking penicillin for 5 days should be enough. For \nserious infections, it may be necessary to take the antibiotics for 7 days. \nFor however long you take them, always take the double dose the first time, \nand then the regular dose 4 times a day (every 6 hours). If the infection does \nnot heal, you may need a different medicine. Usually you can take out the \ntooth 1 or 2 days before the end of the antibiotic treatment, but the person \nmust continue to take all of the tablets, even after you have taken out \nthe tooth. If not, the infection might come back even stronger than before. \n\n\nIf the swelling is ‘pointing’, open it with a sharp sterile knife to release the \npus. Cover the wound with a sterile dressing to keep it clean. If you are not \nable to do that, explain how to reduce the swelling with heat. As often as \npossible until the swelling goes away: \n\n\ne soak a cloth in warm water and hold it against the face. \ne hold warm water inside the mouth near the swelling. It is not \nnecessary to add salt to the water. \n\n\nFinally, give the person medicine for pain. A 2-day supply will be enough, \nbecause the penicillin and the heat will reduce the pressure and that will \nreduce the pain. The best medicines for pain are aspirin, which comes in \n\n300 mg tablets, and acetaminophen (paracetamol), which comes in \n\n500 mg tablets. Aspirin is usually cheaper, but acetaminophen does not cause \nstomach pain and it is safer than aspirin for children. (To avoid stomach pain, \ntake aspirin with food, milk, or water.) See doses at the top of the next page. \n\n\nWhere There Is No Dentist 2010 95 \n\n\nEVERY 6 HOURS (4 times a day): aspirin or acetominophen \nadults 600 mg | 1000 mg \nchildren 8 to 12 years 300 mg 500 mg \n\n3 to 7 years 150 mg 250 mg \n1 to 2 years do not use 125 mg \n\n\nINFECTED SINUS \n\n\nA sinus is a hollow place inside the bone. There is a sinus under the eyes, on \neach side of the nose. Because the sinus is very close to the roots of the top \nteeth, these teeth may hurt if the sinus becomes infected. \n\n\nSIGNS: \n\n\ne Toothache in several top teeth. The \nteeth look healthy, but hurt when you tap \nthem. \n\n\ne Ahead cold, and plugged nose. She can \nonly breathe through her mouth. \n\n\ne Hurts when you press against the bone \nunder her eyes. \n\n\ne Tooth feels different when patient bends over forward. \n\n\nTREATMENT: \n\n\nDo not take out any teeth. They will feel better after you treat the sinus \ninfection. \n\n\n1. Give penicillin for 5 days (page 94). \n\n\n2. Explain to the person that she should: \n\n\ne drink lots of water. \n\n\ne breathe steam from boiling water to clear \nher nose. \n\n\ne hold a warm wet cloth against her face, as \noften as possible. \n\n\ne not try to blow her nose, or else her ears will \nhurt. Wiping the nose is better. \n\n\n3. See the person again after 3 days, and \n\n\ne examine her teeth closely, tapping them to be sure they are strong \nand healthy. \n\n\ne if she is not better, get help from a more experienced health worker. \n\n\n96 Where There Is No Dentist 2010 \nTOOTH INJURIES \n\n\n1. Broken tooth \n\n\nIt is possible to save a broken tooth. It depends on where the tooth is \nbroken and whether its nerve is still covered. \n\n\nSIGNS: \n\n\ne Pain when breathing air or drinking \nwater. \n\n\ne Blood from the gums around the tooth. \ne Tooth moves when you touch it. \n\n\nTREATMENT: \nTake out the broken tooth if: \n\n\ne its nerve is not covered. If no one can give special root canal \ntreatment, the tooth must come out. Germs from the saliva have \nalready gone inside the tooth and started a small infection. \n\n\ne its root is broken. To see if it is broken, push gently against the \ntooth as you feel the bone around its roots. The tooth’s root \nprobably is broken if the tooth moves but the bone does not. The \nroot probably is not broken if both the tooth and bone move. \nHowever, the bone around the roots may be broken (page 109). \n\n\nYou can save a broken tooth if the nerve is still covered and the \nroot is not broken. To do this, use a file on the sharp edges around the \nbreak. This makes them smooth so they do not cut the tongue. Later, an \nexperienced dental worker who has the equipment can cover the broken \npart with a cap or a filling. Until this is possible, tell the person how to \nprotect the tooth: \n\n\ne Give the tooth a rest. Use other teeth to eat. \n\n\ne Do not drink things that are very hot or cold, and do not eat spicy \nfood. \n\n\ne Watch the tooth. See if it changes color (gets darker). Also watch \nthe gums near the root. See if a sore (gum bubble) develops. \n\n\nA dark tooth and gum bubble are signs that the tooth is dying. Take it out, \nunless you can give special nerve treatment. \n\n\nWhere There Is No Dentist 2010 \n\n\n2. Tooth knocked out \n\n\nWhen a tooth is knocked out of the mouth, you should ask two questions: \n(1) Was it a baby tooth? (2) How long ago did it happen? \n\n\nBaby tooth. There is no reason to try to put a baby tooth back into the socket. \nTell the child to bite on some cotton to stop the bleeding. Then wait for the \npermanent tooth to replace it. Warn the mother that the permanent tooth \nmay take more time than usual to grow into the mouth. \n\n\nSimilarly, there is no need for \ntreatment if the baby tooth is \npushed up under the gum. \n\n\nThe tooth may grow back into the \nright place later, or it may turn dark \nand die. if you see a darkened tooth \nor a gum bubble (page 74), take out \nthe baby tooth before it hurts the \npermanent tooth that is growing \nunder it. \n\n\nPermanent tooth. A permanent tooth is worth saving. How long ago was \nit knocked out? If it was less than 12 hours ago, you can put a permanent \ntooth back into the socket. The sooner you do this the better, so do not \nwait. If you replace the tooth in the first hour, it has a much better \nchance of joining with the gum and bone. In order to heal and to join the \nbone, the tooth must be held firmly. \n\n\na) Wash the tooth \ngently with saline, \nmilk, or clean water. \nThere should not be Y \nany bits of dirt on the \n\n\nroot of the tooth. Kor’) \n\n\nKeep the tooth \ndamp with wet \ncotton gauze. \n\n\nDo not scrape away any skin from the \nroot or from the inside of the socket. \n\n\n97 \n\n\n98 Where There Is No Dentist 2010 \n\n\nb) If you can not use anesthetic, tell the patient that it will hurt \nsomewhat. Gently push the tooth up into the socket. As you push it \nup, use a slight turning movement \nback and forth. \n\n\nlt sm, \nsgt ule, Pay \nsats ity time \nPT SON R \n\n\nThe biting edge of the loose \ntooth should be at the same \nlevel as the teeth beside it. \n\n\nHold it in place with your \nfingers for about 5 minutes. \n\n\nc) Soften some beeswax and \nform it into 2 thin rolls. Place 1 \nroll near the gums on the front \nside of 5 teeth: the loose tooth \nand the 2 teeth on each side \nof it. Press the wax firmly, but \ncarefully, against these teeth. \n\n\nDo the same with the second \n\nroll of wax on the back side of \nthe same teeth, again near the \ngums. \n\n\nIt is good if the wax on the \nback side is touching the wax \non the front side. This helps \nthe wax hold the teeth more \nfirmly. To do this, you can \npush the wax between the \nteeth with the end of your \ncotton tweezers. \n\n\nKeep the wax in its position \nfor at least 3 weeks. \n\n\nTell the person with the injured tooth to return to see you several \ntimes. The tooth may die several months or even several years later (see \npage 47). If that happens, you must take out the tooth, unless you can do \nroot canal treatment. \n\n\nIf it is possible, take an X-ray of the tooth 6 months later and then again each \nyear. Look at the X-ray picture of the root to be sure an infection is not eating \nit away. To do this, compare the root with the roots of the teeth beside it. \n\n\nWhere There Is No Dentist 2010 \n\n\nLOOSE TOOTH \n\n\nA tooth may be loose for one of several reasons. Decide the reason before \ngiving the treatment. \n\n\nIF THE TOOTH IS LOOSE \nBECAUSE THE BEST TREATMENT \n\n\n3 \n\n\na new permanent tooth is . tell the mother and child what is happening. \ngrowing under it. . pull out the loose baby tooth, if it is hurting the \nchild. \n\n\ngum disease or an old abscess has . take out the tooth, especially if it also hurts. \neaten the bone around its roots. . explain to the person what to do to prevent this \n\n\nproblem in other teeth. (See Chapter 5.) \n\n\nits root has been broken. take out both parts of the tooth. If you have trouble \ntaking out the broken root, leave it and try again a \nweek later. \n\n\nthe bone around its root is cracked. Do not take out the tooth. If you do, the bone will \n(The bone moves when you push come out with it. Instead, hold the tooth with wires \nagainst the tooth.) (page 110). \n\n\nA tooth may also be loose because another \ntooth Is biting too hard against it. \n\n\nSIGNS: \n\n\ne You can feel the tooth move when \nthe upper and lower teeth meet. \n\n\ne That tooth hurts. \n\n\nTREATMENT: \n\n\nYou need to remove a bit of each of the teeth that are biting too hard. Use \neither a dental worker's drill, a small file, or a hard stone. \n\n\n1. Smooth the inside edge \nof the upper tooth. \n\n\n2. Smooth the outside edge \nof the lower tooth. \n\n\n99 \n\n\n100 Where There Is No Dentist 2010 \nNEW TOOTH GROWING IN \n\n\nA new tooth cuts through the gums when it grows into the mouth. Germs \ncan easily go under the gums in that place and cause an infection. When the \nopposite tooth bites against the sore gum it can make an infection worse. \n\n\nSIGNS: \ne Toothache at the back of the jaw. \ne Mouth cannot open properly. \n\n\ne Abad taste coming from the back \nof the mouth. \n\n\ne Sore throat. \n\n\ne Skin over the new tooth is sore \nand hurts when you touch it. \n\n\ne The age of the person is the right \nage for growing a new molar \n\n\ntooth (page 66). Infection in the gums and pressure from \n\n\nthe new tooth are painful. Notice the \n‘flap’ of skin over the new tooth. \n\n\nTREATMENT: \n\n\nDo not take out a new tooth while there is still infection and pain. Wait \nfor the infection to finish. Then decide if there is room for the tooth to grow \nin. A dental X-ray can help you make that decision. New molar teeth are \noften difficult to take out. Ask an experienced dental worker to take out the \ntooth, if it must be done. \n\n\nWhat you can do \n\nFirst, treat the infection. Then wait for the new tooth to grow more into the \nmouth. Tell the person what is happening. Tell him what he can do to keep \nthe gums healthy while the tooth grows in: \n\n\ne Rinse the area with warm salt water (page 7). Make 4 cups each day \nuntil the mouth opens normally again. Then make 1 cup each day to \nprevent the problem from returning. Keep rinsing this way until the \ntooth grows all the way in. \n\ne Hold a warm wet cloth against the jaw as often as possible each day. \n\n\ne Take aspirin for pain (page 94). \n\n\nGive penicillin (pages 93-94) if there is fever, a swelling, or if he is only able \nto open his mouth a little. \n\n\nWhere There Is No Dentist 2010 101 \nTEETHING \n\n\nWhen babies and small children first get their teeth, it is called teething. \nThis can make the child unhappy, because his gums are sore. \n\n\nTeething does not cause fever, \nhead colds, or cough. \n\n\nBut a child can have any of \nthese problems at the same \ntime as he gets a new tooth. \n\n\nTREATMENT: \n\n\nIf the child has another sickness, do not blame it on teething. Look for \nanother cause and treat it separately. Also, do not cut the gum over the \nnew tooth. Let the tooth grow through the gum by itself. \n\n\n1. Give acetaminophen for pain and fever (page 94). \n\n\n2. Give the child something hard to bite against. This will help the tooth to \ngrow through the gums faster. For example, let him chew on a dry hard \nbiscuit. \n\n\nGUM DISEASE STARTING \n\n\nInfection can start in the gums whenever the teeth near them are not clean. \nFor example, there may be swelling between only 2 teeth or between many \nteeth. In addition, gums that are weak from poor nutrition are not able to \nresist the infection. This is why pregnant women and people living with HIV \nmust take special care to eat well and clean their teeth carefully. When a \nperson has HIV, his body cannot fight infections well, so a gum infection can \nquickly get worse (page 183). \n\n\nSIGNS: \ne Gums are red instead of pink. \n\n\ne Gums are loose instead of \ntight against the tooth. \n\n\ne Between the teeth, gums are \nround instead of pointed. \n\n\ne Gums bleed when the person \nbrushes or flosses. \n\n\nFeel for tartar under the gum—or \neven a piece of fishbone. \n\n\ne Gums bleed when you press \nagainst them, or when you scrape away food from under them. \n\n\ne The person has bad breath and a bad taste inside the mouth. \n\n\n102 Where There Is No Dentist 2010 \n\n\nTREATMENT: \nExplain to the person the cause of her gum problem and what she can do \n\n\nto help herself. The only way to stop gum disease is to remove plaque and \ntartar from the teeth and then to keep them clean. \n\n\n1. Show her how to clean her teeth better near the gums (page 69). \n\n\n2. Tell her to rinse her mouth with warm salt water (page 7). Make 4 cups \neach day until the bleeding stops. Then make 1 cup each day to keep \nthe gums strong and tough. \n\n\n3. Tell her to eat fresh fruits and vegetables. Guavas, oranges, pineapples, \npapayas, tomatoes, peas, and green leaves give strength to gums. \n\n\n4. Gently reach under the gums and remove tartar (or loose piece of \nfishbone) that is caught there (see Chapter 8). \nSometimes a pregnant woman's gums become swollen, and the swelling \ndoes not go down even after cleaning with a soft brush and rinsing with salt \nwater. These swellings must be cut away. But she should wait to have this \nsmall operation until after the baby is born. \n\n\nMORE SERIOUS GUM DISEASE \n\n\nVincent’s infection of the gums, also called trench mouth, affects both \nadults and children. In its worst form, it can eat a hole through the cheek of a \nweak child (page 121). \n\n\nA person with Vincent's Infection may not want to eat because his teeth \nhurt when he chews food. That can make a child’s malnutrition worse. \n\n\nYou must prevent this problem from starting, especially in a child who is \nweak from sickness. Teach mothers to clean their children’s teeth and to get \ntheir children to rinse their mouths with warm salt water. \n\nSIGNS: \n\n\ne Gums between the teeth are dying \nand turning gray. \n\n\ne Pus and old blood collect around \nthe teeth. \n\n\ne Burning pain from the gums. \ne Bleeding from the gums. \n\n\ne The mouth smells bad. \n\n\nTREATMENT: \n\n\nYou will need to see the person over a 2-week period. Start some \ntreatment now: \n\n\n1. If the person is already sick, give penicillin for 7 days (page 94). \n\n\nWhere There Is No Dentist 2010 103 \n\n\n2. Clean away the pus, old food, and big pieces of tartar. Then: \ne Tell the person to rinse his mouth with warm water. \n\n\ne Wipe his gums with cotton soaked in a 3% solution of hydrogen \nperoxide, iodine, disinfectant mouth wash, or warm salt water. Rinse \nwith warm water. For a child, use a weaker solution, such as 1 part \nhydrogen peroxide mixed with 5 parts water. \n\n\ne Scrape away the bigger pieces of tartar. Do not try to remove all of it. \nYou can do that later. Put topical anesthetic on the gums if you have \nsome (first dry the area with cotton so the topical anesthetic will stay \nlonger). Rinse away any loose bits of tartar with warm water. \n\n\n3. Teach the person how to care for the gums at home: \n\n\ne Rinse at home for 3 days with a weak solution of hydrogen peroxide, \n(page 8), iodine, disinfectant mouth wash, or warm salt water. Try \nto hold the solution in the mouth for several minutes. The longer the \nsolution touches the gums, the better it is for the gums. Rinse once \nevery hour. After 3 days, change to salt water, 4 cups a day. \n\n\ne Clean the teeth with a soft brush. Parents can clean children’s teeth. \nShow them how (page 18), and ask them to do it even if the gums \nbleed. \n\n\nFor a young child who is not able to \nrinse, Mother or Father can wipe his \ngums with the weak solution 4 times \na day. \n\n\nShow parents how to do this. Give \nthem some cotton gauze and hydrogen \nperoxide, iodine, or disinfectant mouth \nwash to take home. \n\n\n4. Cook food that is soft (like pounded yam) and not spicy (no pepper). Eat \nfresh fruits and vegetables that give strength to the gums (page 102). \nIf you cannot eat well because of pain, take a multi-vitamin, or at least \nVitamin C and Zinc. \n\n\ne Stop smoking and stop chewing betel nut. \n\n\nOne week later, scrape away the rest of the tartar from the teeth. Then \nuse the person's own brush and show him how to do a better job of \ncleaning his teeth. \n\n\n104 Where There Is No Dentist 2010 \n\n\nFEVER BLISTERS \n\n\nHerpes virus is a kind of germ that causes fever blisters. Fever blisters are \nsores that can form inside the mouth on the gums or outside on the lips. Blisters \non the inside cheeks only are not from herpes (see canker sores, page 106). \n\n\nSores inside the mouth are a serious problem that usually affect children \nbetween 1 and 5 years old. A child with fever blisters in his mouth can become \nvery sick. He will not be able to eat properly. If he does not drink enough fluids, \nhe can become dehydrated (lose his body water). This is dangerous! Fever \nblisters are also a problem for people living with HIV. See pages 186 to 187. \n\n\nSIGNS: \ne Sore throat. \n\n\nInside the mouth \n\n\ne Fever. \n\n\ne Crying, stops sucking 2-3 days before sores appear. \ne Spit spills from the mouth because it hurts to swallow. \ne Painful swelling under the jaw. \n\n\ne Bright red blisters on the gums, but not between the teeth. Blisters also \nmay be on the roof of the mouth. \n\n\nTREATMENT: \n\n\nMedicine cannot kill the herpes virus. The sores will go away by themselves in \nabout 10 days. The treatment is to help the person feel more comfortable and \nto be sure he gets enough to eat and drink. \n\n\n1. Give aspirin or acetaminophen for fever (page 94). \n\n\n2. Wipe milk or yogurt over the sores to protect them before eating. Wash \nyour hands before touching the inside of someone’s mouth! (See \npage 86.) Then give food that is soft and not spicy. If the person cannot \neat, prepare a special milk-oil drink, as on page 111. \n\n\n3. Give lots of fluids to drink. \n\n\nSores on the lips usually occur after the age of 5. (æ a) \nThey often appear when the person is weak and { \n\nsick (for example, with diarrhea or pneumonia.) . \nUsually there is no fever. The blisters soon break \nopen and release water. When they dry, a crust \nforms. The blisters often return. When sores leak \nwater they can pass infection. If you or anyone else \ntouches them, wash your hands immediately. \n\n\nOn the lips \n\n\nTo prevent the blisters from becoming infected, put an antibacterial cream \n\nor petroleum jelly (Vaseline) on them. If you hold ice against the sores for \nseveral minutes each day, it may help them heal faster. See page 187 for more \noptions. \n\n\nWhere There Is No Dentist 2010 105 \n\n\nTHRUSH \n\n\nThrush is an infection caused by a yeast fungus called Candida. It often \nappears when a person is weak and poorly nourished, or sick and taking \nmedicine like tetracycline or ampicillin. In a baby, thrush usually appears \non the tongue or top of the mouth. It can stop the baby from sucking. In \nan adult, thrush often occurs under a denture. Thrush is a very common \nproblem for people living with HIV (see pages 180 to 181). \n\n\nSIGNS: \n\n\ne White patches on the tongue, cheek, or \ntop of the mouth. Wipe the white area: If \nthere is no bleeding it is old milk. If there \nis bleeding, it is thrush. \n\n\ne The child may not want to suck or eat. \n\n\nTREATMENT: \n\n\nThere is usually something else present which is helping thrush to grow. \nTry to find what it is and deal with it. For example, treat the malnutrition, \ndiabetes, or anemia, change or stop the antibiotic medicine, or clean the \ndenture and leave it out of the mouth for a while. Then: \n\n\n1. Cover the white patches with nystatin drops. Use a full dropper 4 or 5 \ntimes a day until the patches are gone. If you do not have nystatin you \ncan soak a piece of cotton in gentian violet and use it to paint the white \npatches 2 times a day. \n\n\nIf the baby’s mother has sore, painful nipples, she may also have thrush \nin her breasts. She should treat her nipples the same way she treats \nthe baby’s mouth. \n\n\nDo not use penicillin or any other antibiotic unless you need to \ntreat something different. Thrush can get worse when a person uses \nan antibiotic for a long time. \n\n\n2. Continue breastfeeding. For older persons, make their food soft and \neasy to chew. \n\n\nIMPORTANT: Sometimes white lines appear on the inside of an adult's \ncheek or on the roof of the mouth. If these lines become sore and do not \nget better with treatment, they can change into a cancer (page 125). To \nprevent this cancer, ask the person to stop smoking (especially pipes), stop \nchewing betel nut, and get dentures adjusted if they do not fit properly. \n\n\n106 Where There Is No Dentist 2010 \n\n\nCANKER SORES \n\n\nThe exact cause of canker sores is not known. Canker sores affect both \nadults and children, and are very common among youth. \n\n\nOne or more sores can appear at any time. These sores hurt, especially \nwhen pieces of food touch them. \n\n\nSIGNS: \n\n\ne A sore can appear on the cheeks, \ninside the lips, on the tongue, or below \nthe gums on the smooth skin. \n\n\ne The sore is white or yellow with the \nskin around it bright red. \n\ne The person may have had a similar kind \nof sore before. It tends to come back. \n\n\nNote: a sharp edge of a denture rubbing against the gums can \nmake a similar kind of sore. \n\n\nTREATMENT: \n\n\nA canker sore goes away by itself in about 10 days. Medicine does not make \nthat happen any faster. (However, smoothing a denture or fixing a broken \ntooth does help.) The treatment is simple. Tell the person how to feel more \ncomfortable while waiting for the 10 days to pass: \n\n\ne Eat foods that are soft and not likely to hurt the sore. \n\ne Do not eat spicy food. \n\ne Drink lots of water. \n\ne Chew food on the other side of the mouth, away from the sore. \n\n\nA denture which does not fit \nshould be remade. \n\n\nIn the meantime, leave the \ndenture out of the mouth for \n2 or 3 days. \n\n\nAsk the person to rinse with \nwarm sait water, 4 cups each \nday until the sore is better. \n\n\nIf the sore continues after 10 days, it may be infected. Give penicillin (page 93). \n\n\nA sore that does not heal after antibiotic treatment may be cancer (see \npage 125). See a doctor immediately. \n\n\nWhere There Is No Dentist 2010 107 \nSORES AT THE CORNERS OF THE MOUTH \n\n\nTeeth support the lips. When they come together for chewing, the teeth \nstop the person's chin from moving any closer to the nose. \n\n\nA person without many teeth looks old. A person with a poor fitting denture \nalso looks old. \n\n\nThe distance from his chin to his \nnose is shorter than normal. v a _ ) p \n\n\nHe must close his jaw further to \\ J \neat. That causes lines to form at \nthe corners of his mouth. a \n\n\nPoor health can make lines at \n\nthe corners of the mouth crack \nand become sore. These cracks are \noften infected with thrush and can be treated with nystatin (see page 105). \nIf sores are not at the corners but around the mouth, they could be due to a \nbacterial infection (see page 94). \n\n\nA person with missing teeth needs dentures. Dentures will help him \nchew more food and make him look younger. They support his lips and \nopen his mouth more. (See page 164). \n\n\nA child who has had a fever or measles often has dry lips. The corners of her \nmouth can crack and become sore. \n\n\nCracks and sores appearing at the \ncorners of a child’s mouth are signs of \ndehydration and malnutrition. \n\n\nThe child needs to eat the kind of foods that give strength, energy, and \nprotection. Feed her beans, milk, eggs, fish, oils, fruits, and green leafy \nvegetables (see page 67). \n\n\nTREATMENT (when sores occur): \n1. Wash the sores with soap and hot water. \n2. Mix 1 part sulfur with 10 parts of petroleum jelly (Vaseline). \n3. Smear some on the sores 3-4 times a day. \n\n\n108 Where There Is No Dentist 2010 \n\n\nPART 2 \nSOME SPECIAL PROBLEMS \n\n\nYou will find some problems that are too serious for you to treat. If you can, \nsend the sick person to a more experienced dental worker as soon as possible. \n\n\nSometimes, however, it is better to start some of the treatment yourself. \nEarly treatment can prevent some problems from becoming more serious. \nAlso, if you know what to do when someone returns from the hospital, you \ncan help that person to get well faster. \n\n\nSometimes, you will find it impossible to get help. Therefore, we will discuss \neach of these more serious problems in detail, so you can give as much help \nas necessary. \n\n\nBROKEN BONE \n\n\nThree main bones form the face and lower jaw. \n\n\n1. cheek bone Și \n\n\n2. upper jaw bone \n\n\n5 \n\n\n(lower jaw joins \nthe head here) \n\n\n3. lower jaw bone moe \n\n\nA bone can break completely, or part of it can crack. In either case, the teeth \nare usually pushed out of position. Look for this as a sign of a broken bone. \n\n\nSIGNS of a broken bone: \ne The person has had an injury. \ne When teeth are closed, some upper s \nteeth do not meet lower teeth. 4} ) \ne The person cannot open or \n\n\nclose the mouth properly. \ne There is bleeding from between 2 teeth. \ne There is swelling or a bruise on the face or jaw. \ne There is bleeding into the eye. \n\n\nWhere There Is No Dentist 2010 109 \n\n\nSIGNS of a cracked bone \naround the tooth’s roots: ® AND THE OTHER \n\n\ne When you move one tooth, y TOOTH ALSO MOVES \nthe tooth beside it also moves. \n\n\ne When you move the loose \n\n\ntooth, the bone moves with it. Siw @ BECAUSE THE \n\n\ne Blood is coming from f BONE AROUND \nunder the gums. © PUSH GENTLY THEIR ROOTS \nAGAINST ONE {S CRACKED. \nTREATMENT: TOOTH \n\n\nWhen a bone is broken or cracked, the treatment is to hold the broken \nparts together so that the parts can rejoin. The usual way to do this is to put \nwires around the teeth. An experienced dental worker should do this. There \nare two things you can do. First, provide emergency care. Later, show the \nperson how to eat and how to keep his mouth clean. \n\n\nEmergency care (pages 109-110): \n\n\n1. Be sure the person can breathe. \n2. Stop the bleeding. \n\n\n3. Put a bandage on the person's head. \n4. Give penicillin to stop infection. \n5. Give aspirin or acetominophen for pain. \n\n\n1. Be sure the person can breathe. \n\n\nLie him on his side so \nthat his tongue and \njaw fall forward. \n\n\nLater, carry him to the hospital in that position. If he goes in a car, be sure \nhe sits with his head forward. His jaw and tongue will be forward and he \nwill breathe more easily. \n\n\nLook inside the mouth to see if any tooth is broken and very loose. A \nbroken piece of tooth can fall out and block the person's airway, so take \nout the broken part now. You can leave in the root, but if you do, tell the \ndental workers at the hospital (p. 213). They will remove the root when \nthey put on the final wires. \n\n\n2. Stop the bleeding. \n\n\nWipe away the dried blood from his face and from inside his mouth. Look \nfor the place that is bleeding. Sew any deep cuts on his face (see Where \nThere Is No Doctor, p. 86). If you gently press cotton gauze against the \nbleeding gums, it will usually control the bleeding. \n\n\n110 Where There Is No Dentist 2010 \n\n\nBleeding inside the mouth, from between the broken parts of the \nbone, is more difficult to stop. You must pull the two sides together \nand hold them in that position. To do this, you need wire that is thin, \n\nstrong, and bends easily. ‘Ligature wire’ (0.20 gauge) is be \n\n\nPlace a piece of wire around 2 teeth, \none on each side of the break. Choose \nthe strongest tooth on each side—the \nones with the longest or the most roots. \n\n\nTighten the wire around the two strong \nteeth with pliers or a hemostat. \n\n\nBLEEDING FROM THE BONE \n\n\nAsk the person to close his teeth. Lift up the broken part of the jaw and \nhold it so the lower teeth meet the upper teeth properly. This is the \nnormal way the jawbone holds the teeth. \n\n\nNow join the wires. Twist and tighten \nthem together. This may be painful. \n\nYou can inject local anesthetic—see \nChapter 8. You must twist the wire tight \nenough to hold the broken parts together. \n\n\nBend the end of the twisted wire toward the teeth. Now it cannot poke \nthe person's lips or cheek. \n\n\n3. Put on a head bandage. \n\n\nGently close the person's jaw so that his teeth come together. Support it \nin this position with a head-and-chin bandage. \n\n\nTie the bandage to support the jaw, not to pull it. \nDo not make it too tight. It is all right if his mouth \nstays partly open with the teeth slightly apart. \n\n\nBe sure not to let the bandage choke the person. \n\n\n4. Give penicillin by injection (page 204) for 5 days to stop infection inside \nthe bone. \n\n\n5. Give something for pain. Aspirin (page 94) may be enough. Give \n600 mg by mouth, 4 to 6 times a day, as needed. For children, see doses \non page 165. If there is a lot of pain and the person cannot sleep, give \ncodeine. The dose for an adult is 30 mg, 4 to 6 times a day as needed. \n\n\nWhere There Is No Dentist 2010 111 \n\n\nSend the person to the hospital as soon as possible. The person must have \nwires placed on his teeth within a week of the accident. The wires must \nremain there for 4 to 6 weeks. Every week, the person must return to the \nhospital to have the wires tightened. During this time he cannot open his \nmouth to chew food or brush his teeth. \n\n\nCARING FOR A PERSON WHO CANNOT EAT PROPERLY \n1. Give liquid foods for strength and energy. \n\n\nPrepare food in two ways: (a) First, a milk-oil drink to build strength and \nthen (b) a special soup to keep him strong and give him energy. \n\n\nTo build strength: Milk-oil drink \n\nMix for him each day at your clinic: \n\ne 9 cups of water e 150 ml of peanut oil or coconut milk \ne 3 cups of milk powder e %2 cup of honey or 1 cup of sugar \n\n\nLeave some near his bed, and keep the rest in a cool place. \n\n\nTo keep strength and give energy: Special vegetable soup \nCut into small pieces and cook together in a pot of water: \n\n\ne tin of fish or a handful of dried fish \n\ne 4 small spoonfuls of peanut oil or palm oil \ne 6 sweet potatoes or small yams \n\ne 1 large handful of green leaves \ne 1 small spoonful of salt \n\n\nPour the soup into an empty tin with small holes made in the bottom. \nUse the back of a spoon to press as much of the cooked food as you can \nthrough the holes. The person can suck the soup between the teeth to \nthe throat and then swallow it. Clean the tin and set it in boiling water, so \nyou can use it again the next day. \n\n\n2. Keep the teeth clean and the gums tough. \n\n\nThe person must learn to clean teeth and gums or the gums can quickly \nbecome infected and the mouth will feel sore. So: \n\n\ne Scrub both the wires and the teeth with a soft brush after drinking \nsoup. \n\n\ne Rinse with warm salt water (page 7), 2 cups every day. \n\n\n112 Where There Is No Dentist 2010 \n\n\nLOOSE TEETH \n\n\nIf the bone around the roots of the teeth is cracked, those teeth will be \nloose. Do not take the teeth out until the bone is healed. Otherwise, \nbone will come out with the teeth and there will be a big hole in the jaw. \nInstead, support the teeth, in order to hold both sides of the bone steady. \n\n\n1. With your thumb and finger, gently \nmove the loose teeth and bone back \ninto normal position. \n\n\n2. Cut a hypodermic needle and use it \nas a splint. Make it long enough to fit \n\n\naround two strong teeth on each side of BEND THE NEEDLE \n\n\nAROUND THE TOOTH \n\n\nthe loose teeth. Curve the needle so it SO IT DOES NOT \nfits the curve of the teeth. To make the STICK OUT \nsharp ends smooth, use a file or rub the A \n\n\nends against a stone. TT \n3. Tie each tooth to the needle. Use short \npieces of 0.20 gauge ligature wire (page 110). \n\n\nPut one end of the wire under the needle. \nBring it around the back of one tooth and \nout to the front again over the needle. \n\n\nUse the end of a small instrument to aN \nhold down the wire at the back of the USE A STRONG \nteeth. Then twist the ends together. HEMOSTAT OR \nTighten the wire around each one of NEEDLE HOLDER \nthe 6 teeth. \n\n\n4. Cut the ends of the ligature wire. Turn \nthem toward the teeth, so they will not \ncut the lip. \n\n\n5. Tighten the wires the next day, and then once each week. But be \ncareful. Only % a turn usually is needed. More, and the wire will break. \nAlways twist in the direction a clock moves. With this habit, you will \nremember which way tightens the wire and which way loosens it. \n\n\n6. Explain to the person that it takes 4 weeks for the bone to heal. The \nwires must remain on the teeth for this time. To help the teeth to heal, \nask the person to: \n\ne give these teeth a rest. Use other teeth for chewing. \ne clean both the teeth and the wires with a soft brush. \ne rinse with warm salt water, 2 cups every day (page 8). \ne return to have the wires tightened every week. \n7. After 4 weeks, cut and remove the wires. Ask the person to watch \n\n\nthose teeth. A dark tooth and gum bubble are signs that the tooth is \ndying. Take it out, unless you can give special nerve treatment. \n\n\nWhere There Is No Dentist 2010 113 \n\n\nDISLOCATED JAW \n\n\nIf a person opens her mouth wide and then is unable to close it, we say her \njaw is dislocated. It is stuck in the open position. This problem often happens \nto a person who does not have several of her back teeth. When she opens \nwide to yawn or shout, the part of her jaw that joins her head moves too far \nforward inside the joint. It is then unable to return to its normal position. You \ncan also dislocate the lower jaw by accident while extracting a tooth. \n\n\nSIGNS: \n\n\ne She is unable to close her \nteeth together. \n\ne She cannot close her lips \neasily. \n\ne Her lower jaw looks long \nand pointed. \n\n\ne It hurts when you press on \nthe joint in front of her ear. \n\n\ne She cannot speak clearly. \n\n\nNORMAL DISLOCATED \n\n\nTREATMENT: \n\n\nThe treatment is to try to move the lower jaw back where it belongs. Then \nhold it in that position until the muscles can relax. \n\n\n1. Find a way to support the person's head. For example, have the person \nsit on the floor with her head against a wall. \n\n\n2. Kneel in front of her. Put your fingers under her jaw, outside the \nmouth. Put your thumbs beside her last molar tooth on each side. Do \nnot put your thumbs on the molars. The person may bite them! \n\n\nPress down hard with the ends of your \nthumbs. Force the jaw to move quickly \ndown and back into position. Be sure \nto press down before you press back. \n\n\nIf the jaw will not move, perhaps the \nmuscles are too tight. A doctor or \ndentist can put the person to sleep, \nwhich will relax the muscles. \n\n\n3. Support the jaw with a head—and-chin \nbandage for 3 to 4 days (page 110). \n\n\n4. Give aspirin or acetominophen for pain (page 94). \n\n\n5. Explain the problem to the person and tell her how to care for her \njaw: (a) eat mostly soft foods for 2 weeks; (b) hold a warm wet cloth \nagainst the jaw; (c) remember not to open the mouth wide anymore. If \npossible, replace the missing back teeth with dentures (page 107). \n\n\n114 Where There Is No Dentist 2010 \nPAIN IN THE JOINT \n\n\nA joint is the place where one bone joins another. The Jawbone has two \njoints, for it joins the head in front of each ear. \n\n\nThe mouth opens and closes because: \ne muscles pull the jawbone; and \n\n\ne the jawbone slides against the head \nbone, inside the joints. \n\n\nPain in these joints may be because: \n\n\n(1) The muscles are tight because the \nthe person is tense or nervous. \n\n\n(2) The jawbone is fractured in the area \nof the joint. (Also check the lower \njaw on the other side since a fracture \nnear the joint is often caused by a \nblow to the other side of the face.) \n\n\n(3) The teeth do not fit together properly. \n\n\nTREATMENT: \n\n\nBefore you treat, decide what is causing the pain. We will discuss the three \ncauses mentioned above. \n\n\n1. Tension. \n\n\nTalk with the person and help, if you can, to find a solution to her \npersonal problems. This can do much to help her and her muscles relax. \nIn addition, explain how to care for the sore joint: \n(a) Eat only soft foods until it no longer hurts to chew. \n(b) Hold a hot, wet cloth against the jaw, to help relax the muscle. \n\nDo this as often as possible, but be careful not to burn the skin. \n(c) Take aspirin or acetominophen (page 94) to reduce the pain. \n\n\n2. Fracture. \n\n\nIf an X-ray shows a fracture, the person needs expert help. A dentist \ncan wire the teeth in a way that will allow the bone to heal. \n\n\n3. Teeth do not fit together properly. \n\n\nImagine a line that passes between the 2 middle upper teeth and the \n\n2 middle lower teeth in the person's closed mouth (see the next page). \nWhen the person opens the mouth, this line becomes longer, but it is \nstill a straight line. If it is not, this condition can, after a long time, cause \npain in the joint. \n\n\nWhere There Is No Dentist 2010 115 \n\n\nThese teeth are normal. The line formed between the \ntwo middle teeth does not shift when the mouth opens. \n\n\nWhen you see teeth that do not fit \nproperly: \n\n\ne Warn the person not to open his \nmouth wide. Suggest, for example, \nthat he take his food in small bites. \n\n\ne Tell the person what can be done \nto help. Often a dentist can grind \nthe teeth in a special way and this \ncan end the pain. \n\n\nThese teeth do not fit properly. Because the \nline shifts, this means the jaw is also shifting. \nThis shift can cause pain in the joint. \n\n\nSWOLLEN GUMS AND EPILEPSY \n\n\nMany persons who suffer from epilepsy \n(see Where There Is No Doctor, page \n178) have a problem with swollen \n\ngums. In severe cases, the gums are so \nswollen that they cover the teeth. This \nproblem is caused not by epilepsy but \nby diphenylhydantoin (Dilantin), a drug \nused to control epilepsy. \n\n\nWhen you see swollen gums, find out what medicines the person is taking. \nIf possible, change to a different drug. If the person must continue using \ndiphenylhydantoin, explain how to prevent this swelling of the gums. Show \nthe person this book, especially pages 69 to 72. Persons who take this drug \nmay be able to prevent the swelling by brushing the teeth carefully after \neach meal, and taking special care to clean between the teeth (page 71). \n\n\n116 Where There Is No Dentist 2010 \n\n\nBLOOD IN THE MOUTH \n\n\nUse wet cotton gauze to wipe away the old blood from inside the mouth. \nThen you can see where it is coming from. Treat the cause of the bleeding. \n\n\nIF YOU SEE: TO STOP THE BLEEDING: SEE = \na large red clot growing 1. Remove the clot with \nout of a socket where you cotton tweezers. \nhave taken out a tooth 2. Ask the person to bite \n\n\non a piece of cotton. \n\n\nsore and bleeding gums 1. Rinse with a mixture of \nand the mouth smells hydrogen peroxide and water. \nbad (Vincent's infection) 2. Remove as much tartar as you can. \n\n\na red, bleeding growth Take out the tooth; \ninside the cavity in a tooth it has an abscess. \n\n\na loose tooth with Hold the tooth with wires, or if the \nbleeding gums around it root is broken, take out the tooth. \n\n\ntorn gums with broken 1. With wire, hold the broken \n\nbone and bleeding parts of the bone together. \n2. Send the person to an \n\nexperienced dental worker. \n\n\nPROBLEMS AFTER YOU TAKE OUT A TOOTH \n\n\nProblems such as swelling, severe pain, and bleeding can occur after you \ntake out a tooth. Tetanus (page 118), a more serious problem, can also \noccur, especially if your instruments were not clean. \n\n\nSwelling of the Face \n\n\nYou can expect some swelling after \nyou take out a tooth. But if the \nswelling continues to grow, and it is \npainful, this is not normal. Probably an \ninfection has started. The treatment \nis the same as for a tooth abscess: \npenicillin for 5 days to fight infection, \nheat to reduce the swelling, and \naspirin or acetominophen for pain. \nSee page 94 for the proper doses. \n\n\nWhere There Is No Dentist 2010 117 \n\n\nPain from the Socket \n\n\nThere is always some pain after a tooth is taken out. Aspirin is usually \nenough to help. \n\n\nHowever, sometimes a severe kind of pain starts inside the tooth’s ‘socket’ \n(the wound) 2 to 3 days after you take out the tooth. This problem is called \ndry socket and it needs special care. \n\n\nTREATMENT: \n1. Place a dressing inside the socket. Change it each day until the pain stops. \n\n\nFirst, clean out the socket. \n\n\nSquirt warm water inside the socket with \na clean syringe. After the person spits out \nthe water, squirt water inside once more. \nUse a blunt needle so that it does not \n\nhurt the gums or bone if it touches them. \n\n\nThird, place the dressing \ngently inside the socket. \n\n\nPlace one piece of dressing \ninto each root space. Push \n\nSoak 1 to 2 small pieces it down into the root space \nof cotton in eugenol (oil of gently. \n\ncloves.) \n\nSqueeze each piece so that it \nis damp but not wet. \n\n\nSecond, prepare the dressing. \n\n\nCover the socket with plain \ncotton gauze, and send \nthe person home bitting \n\n\nNote: There may be local \nmedicine in your area that \nrelieves pain. Use it instead of \neugenol. \n\n\nagainst it. He can remove \nthe plain cotton in an hour. \nThe dressing should remain \ninside the socket. \n\n\n2. Give aspirin or acetominophen for pain (page 94). \n\n\n118 Where There Is No Dentist 2010 \n\n\nBleeding from the Socket \n\n\nWhen you take out a tooth it leaves a wound, so you can expect some \nblood. However, if the person bites firmly against a piece of cotton, it usually \ncontrols the bleeding. To help the wound heal (from a clot), tell the person \nnot to smoke, rinse with salt water, or spit for 1 or 2 days after you take out \nthe tooth. \n\n\nWhen the first bleeding occurs, put a new piece of cotton on top of the \nwound and ask the person to close her teeth against it for an hour. Keep \nher there with you, to be sure she continues to bite on the cotton. (If it is \ntoo painful, you may want to inject anesthetic. See Chapter 9.) Change the \ncotton if it becomes soaked with blood. \n\n\nTREATMENT (if the bleeding continues): \n\n\n1. Take her blood pressure (see Where \nThere Is No Doctor, pages 410-411). If it \nis high, you may need medicine to bring \nit down. That can help slow the bleeding. \n\n\n2. Look carefully at the wound. \nIf the gum is torn or loose, \nput in a suture (pages 161-163). \n\n\n3. Wrap tea leaves in cotton gauze. Soak the bundle in water and then \nput it on the socket. Have the person bite against it. Or, have her bite \nagainst cotton gauze soaked with cactus juice. \n\n\nLet the person go home only when the bleeding stops. Give her \nsome clean cotton to use in case the bleeding starts again later \n(see page 161). \n\n\nTETANUS \n\n\nThis is a very serious infection. Tetanus germs enter the body when a \nwound, like a wound on the bottom of the foot, gets dirty. Germs can also \nbe carried to the socket when you use a dirty instrument to take out a tooth. \nTo avoid this, carefully read pages 86 to 89. \n\n\nSIGNS: OLD, DRY BLOOD \n\n\ne the jaw becomes stiff and tight \nnot \ncleaning \n\n\ne the whole body becomes tight, properly \nwith sudden spasms \n\n\ne itis hard to swallow \n\n\n(e) \n\n\nTREATMENT: \n\n\nA person with signs of tetanus requires immediate medical help. See \nWhere There is No Doctor, pages 182 to 184, if you cannot get help \nimmediately. \n\n\nWhere There Is No Dentist 2010 119 \n\n\nINFECTION INSIDE THE SPIT (SALIVA) GLAND \n\n\nSpit glands are places where the spit or saliva is made. They are located in front \nof the ear and under the jaw, on each side of the head. If there is an infection \ninside a spit gland, the face will become swollen and the area will hurt. \n\n\nSpit is sent from the gland to the mouth through a thin pipe called a duct. \nDucts open into the mouth in two places: on the inside of each cheek and \nunder the tongue. \n\n\nA small stone can often block a duct and cause an infection in the spit gland \nand swelling of the face. You may be able to feel the stone near where the \nduct enters the mouth. \n\n\nSIGNS: \n\n\nTONGUE \n\n\nswelling in the area of the spit gland. \n\n\npain which gets worse when the person is hungry, and when he sees \nor smells food. \n\n\nthe opening of the duct is red, swollen, and hurts when you touch it. \n\n\nspit from \nthis gland \nenters on \nthe inside of \nthe cheek \n\n\nspit from \nthis gland \nenters under \nthe tongue \n\n\nTREATMENT: \nReduce the infection and swelling first. Later try to remove the stone. \n\n\n1. \n\n\nGive penicillin for 5 days (page 94). If the swelling is large and the \ninfection serious, start with short-acting crystalline penicillin (see \npage 204). \n\n\n2. Give aspirin or acetominophen for pain (see page 94). \n\n\n3. Apply a wet hot cloth to the swelling as often as possible. \n\n\n4. Give enough soft food to prevent the person from feeling hungry. \n\n\nThe pain will be less then. \n\n\n. When the person feels better, a dentist or doctor can remove the \n\n\nstone that is blocking the duct. \n\n\n120 Where There Is No Dentist 2010 \n\n\nSORES ON THE FACE \n\n\nWhenever you see a sore on a person's cheek or under his chin, remember \nthere may be a tooth or gum problem. If it is a gum problem, it may be \nNoma. See the following pages. \n\n\nA bad tooth: \n\n\nAsk him to open his mouth. \nLook for an infected tooth in \nthe area of the sore. There \nmay be a large cavity and the \ntooth may be loose. \n\n\nOr the tooth may be darker \nin color than the others. \nThis is because it is dead. \n\n\nThe pus is draining onto \nthe skin, so the pressure \nis reduced and the person \ndoes not complain of pain. \n\n\nTREATMENT: \n\n\n1. Take out the tooth (see Chapter 11). \n2. Give penicillin for 7 days (see page 94). \n\n\n3. After the penicillin treatment, check the sore. If it has healed, there is \nno longer infection inside. The treatment is finished. \n\n\nBut if the sore is still open and you can squeeze out pus, you will need the \nhelp of experienced health workers who can: \n\n\ne test the pus to see if it is resistant to penicillin. The person may \nneed to take a different antibiotic. \n\n\ne take an X-ray to see if there are dead pieces of bone which are \nkeeping the infection alive. If there are, they must be removed. \n\n\nIf infected gums (and not a bad tooth) are the cause of a sore on the cheek \nor chin, the problem is more serious. See the next 4 pages. \n\n\nWhere There Is No Dentist 2010 121 \n\n\nNOMA \n\n\nWhen a child is sick, a simple gum infection can get out of control and \nspread through the cheek to the face. When that happens the condition \nis called Noma or Cancrum Oris. Noma is a complication of Vincent's \nInfection of the gums (page 102). \n\n\nYou will usully see Noma in children. It will only \ndevelop if these 3 things are true: \n\n\n(1) The child's general resistance is low. \nUsually, he is undernourished and anemic \n(lacks iron). He may have tuberculosis. \n\n\n(2) The child has Vincent's Infection. \n\n\n(3) The child has recently had a serious \nillness such as measles or malaria. \n\n\nNoma can also be a problem for adults living with HIV. See page 185. \n\n\nSIGNS: Pa \nThe infection starts in the mouth. \n\n\nThen it passes to the gums. \n1. Sore mouth with itching gums. E \n2. Swollen, sore gums. Y us \n3. Gums bleed when eating or ax D B \nwhen teeth are cleaned. S ) \n\n\n4. Bad breath, spits a lot. \n\n\nThen it reaches the jaw. \n5. Loose teeth. \n6. Loose pieces of bone \naround the teeth. ien \n\n\nFinally, it affects the cheek. \n7. Skin is tight with dark red \nswelling. \n8. Black spot on the cheek \n\n\n= oon \nbreaks open, leaving a hole A wD B \n\n\ninto the mouth. \n9. A line separates dead \ntissue from healthy tissue. \n\n\n122 Where There Is No Dentist 2010 \n\n\nTREATMENT: \n\n\nYou must start treatment for Noma immediately in order to prevent the hole \nfrom getting bigger. The bigger the hole, the tighter the scar that forms after \nyou close the hole. A tight scar will prevent the child from opening his mouth \nand chewing the food he needs to grow stronger. \n\n\n1. Give fluids. \n\n\nThe child needs to overcome both \nthe lack of body water (dehydration) \nand his lack of resistance to disease. \n\n\nStart giving the milk-oil drink \ndescribed on p. 111. \n\n\nIf he cannot drink by himself, help \nhim. Use a spoon or syringe. \n\n\nPlace the fluid on the inside of the \nhealthy cheek and ask the child to \nswallow. \n\n\n2. Treat the anemia. \n\n\nStart giving iron (ferrous sulfate) now. The child should continue taking \nthe tablets or mixture for 3 months, with food. \n\n\nFerrous Sulfate Tablets \n\n\nover 6 years 200 mg (1 tab) 3 times a day \n\n\n3-6 years 100 mg (% tab) 3 times a day \n\n\nunder 3 years 50 mg (4 tab) 3 times a day \n\n\nYou can also use ferrous fumarate. Advise the mother that the iron \nwill make the child’s stool black. \n\n\nAlso give food rich in iron: meat, fish, eggs, dark green leafy \nvegetables, peas and beans. \n\n\nNote: A child may have anemia because he has worms. It is a good \nidea to do a stool analysis to find out. If he has worms, give him \nmedicine right away. Mebendazole, albendazole, and thiabendazole \ntreat many different worm infections. Piperazine treats roundworm and \npinworm infections, and there are other medicines for tapeworm and \nblood flukes. Also give folic acid. For doses, see Where There Is No \nDoctor, pages 373 to 376, and page 392. \n\n\nWhere There Is No Dentist 2010 123 \n\n\n3. Start antibiotics. \n\n\nMetronidazole is the best medicine to use. Give 200 mg by mouth 3 times \na day for 10 days. You can also use clindamycin. To decide how much to \ngive, weigh the child. For adults, see the medicines and doses on page \n185. \n\n\nWeight Dose for clindamycin (give 3 times a day for 5 days) \n\n\n5 to 10 kg 50 mg by mouth or 60 mg by injection \n\n10 to 17 kg 100 mg by mouth or 130 mg by injection \n17 to 25 kg 150 mg by mouth or 225 mg by injection \nover 25 kg 250 mg by mouth or 333 mg by injection \n\n\n4. Treat the other illness that helped Noma to develop. \nIt is wise to assume that the child has malaria and to begin treating \n\n\nwith antimalarial drugs (see Where There Is No Doctor, pages 364 \nto 367). \n\n\nLook for any other illnesses and treat them, too, especially measles and \ntuberculosis. \n\n\n5. Clean the sore. \n\n\nGently pull away any dead skin with tweezers. Wash the inside of the \nsore with hydrogen peroxide. (Be sure you measure the hydrogen \nperoxide carefully. See page 8.) Then put in a wet dressing. (You can also \nclean the sore with an iodine solution.) \n\n\nThe dressing: \n\n\ne Soak cotton gauze in salt water. Squeeze out the extra water so that \nit is damp but not wet. \n\ne Put it in the hole and cover it with a dry bandage. \n\ne Every day, remove the bandage, wash the hole with hydrogen \n\n\nperoxide, and put in a new dressing. Do this until the hole does not \nsmell anymore and there is no more dark dead skin. \n\n\n6. Remove the loose teeth and dead bone. \n\n\nYou can use a local anesthetic (Chapter 9). Usually there is not much \nbleeding. If gums are loose, join them with a suture (see pages 161 to \n163). \n\n\n124 Where There Is No Dentist 2010 \n\n\n7. Keep the mouth clean. \n\n\ne Use a soft brush\n…[truncated]", "summary": "Where There Is No Dentist by Murray Dickson updated and expanded with information about HIV and AIDS by Richard Bebermeyer, Martin Hobdell and Gene Stevenson Introduction by David Werner, author of Where There lIs No Doctor EULIEN GA hesperian Berkeley, California, USA www.hesperian.org Hesperian encourages others to copy, reproduce, or adapt to meet local needs any or all parts of this book, including the illustrations, provided that the parts reproduced are…", "source_url": "https://archive.org/details/where-there-is-no-dentist-hesperian-2010", "pdf_url": "https://archive.org/details/where-there-is-no-dentist-hesperian-2010", "case": "hesperian", "tags": ["hesperian", "Medical"], "page_count": 0}