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OlFI
■llouhnnicn ' Inntitutn Libl-.*^ C;, :

fxZ'^r'

•'V. "Nr '-. ?A«

Tact is a gift; it is likewise a grace. As a gift it may or may not

have fallen to our share; as a grace we are bound either to possess

or to acquire it.

Christina Rossetti.

A motive that gives a sublime rhythm to a woman's life, and
exalts habit mto partnership with the world's highest needs, is not
to be had where and how she wills ; to know that high initiation,
she must often tread where it is hard to tread, and feel the chill
air, and watch through darkne<(S. It is not true that love makes all
things easy; it makes us choose what is difficult.

George Eliot.

NURSING:

ITS PRINCIPLES AND PRACTICE.

FOR HOSPITAL AND PRIVATE USE.

•A'* ISABEL ADAMS HAMPTONJ ^^\,.

Qr»4uk(eoItli*NevrTorkTralnlDKSanooltarNnraMattMb«dtoB«llaviM '

Ho*plM] : Inle SuMTlnUudeDt ot Nnne* and Prlncliiftl of Uhi TralnlnK

Sctionl for Nune*. Johni Hopkliu UosplMI. B&lUniDre. Hd.. laie

8uperiiitaiid«it ol Nuraei. IJJlnola Trnlnlni School loi

Mimet, OhicKio, [Illnol*; Member ol (tie Bouilot

LMf HuiBKera Lakeside Hoapllnl. Olera-

. Ohio; Honor

LoiidoD, England.

BKVI8BD AND BNI.ABOBD.

ILLUaTRATaD.

E. C. KOECKERT,

702 Rose Building,

Clbvbland, Ohio.

19D2.

CopTrtSbt. 13M. br I. A. HAUPTON.

pSDICATKD

TO MY PUPILS

ILLINOIS TRAINING SCHOOL FOR NURSES,

CHICAGO,

THE JOHNS HOPKINS HOSPITAL TRAINING SCHOOL. ]

BALTIMORE.

Prefatory Note to Second Edition.

IN preparing the second edition very little has been changed,
but new matter has been added to bring the book up to
(he latest methods. A suggestive chapter has been added
on the division of work over ihrce years of instruction, and
courses of lectures have been mapped out to cover (his time.
Some new figures have been added, of which the majority
illustrate the appliances employed in surgical work, which
have been tested and found of practical use.

My thanks are due to Dr. ]. Whitridge Williams for his
criticisms and suggestions on the obstetrical chapter; and to
Dr. Booker, of Baltimore, and Dr. Edward Gushing, of Cleve-
land, for reviewing the chapter on children; also to many of
my friends among superintendents of training schools for sug-
gestions and material. The form of marking the pupil nurses'
standing was kindly supplied me by the Superintendent of the
Lakeside Hospital Training SchooL

CONTENTS.

CHAI'TER I.

Training School Organization and Management. — Refer-
ence Library. — Method and Outline of Course of
Theoretical Teaching for the Two Years. — Classes
and Lectures for (a) First-Year Students ; (li) Second-
Year Students. — Examinations. — Suggestive Outline
for the Three Years' Course IT'S

CHAPTER n.
X Hospital Ward ; Free and Private. — Its Staff and Divis-
ion of Work. — Hospital Etiquette. — Ward Discipline.
— Hours of Duty, Study, Recreation. — The Night
Nurse 54 J

CHAPTER in.
Ward Supplies. — Nurses' Toilet-Baskets. — Ward Work. —
Daily Care of the Ward.—Specia! Care of the Ward.
— Cleanliness of the Beds and Blankets. — Care of
Ward Utensils 77 1

CHAPTER IV.
Beds. — Bed-making for Bed Patients ; for Convalescents.
— To Prepare a Bed for an Operation PaticnL —
Fracture Beds. — Mechanical Appliances for the Relief
of Bed Patients. — Head-rests.— Pads.— Lifting and
Moving

COJ^TENTS

CHAPTER V.
Hygiene of the Sick-room and Ward. — Air. — Ventilalion.
— Methods of Ventilating. — Sick-room Tempera
— Disposal of Excreta. — Soiled Dressings and Soiled
linen lo;

CHAPTER VI.
Care of New Patients. — Treatment. — What to Observe. —
Reporting to the Physician. — Care of the Bed Patients.
— Frequency of Bathing. — Care of the Teeth and
Mouth.— The Prevention and Treatment of Bed-
sores.— Care of Convalescents. — Care of the Dead. . 1)8

CHAPTER Vir.
Uaths—Classificalion.— Temperature.— Baths for Clean-
hness. — Tub-baths. — Bcii-baths. — Foot-baths. —
Baths as Therapeutic Agents. — Mustard-bath. — Sim-
ple Hot Bath.— Hot-air, Steam or Vapor Baths. —
Salt-water Baths. — Sponge-baths and Tub-baths in
Typhoid Fever. — The Cold Pack. — The Continuous
Bath 133

CHAPTER VIII.
bisinfectant Solutions. — The Metric System. — The Prep-
aration of Solutions 149

CHAPTER IX.
Bacteriological Notes. — Disinfection of Clothing, Rooms,

Furniture, Wards, Excreta, Sputa, and Vessels, . . I S9

CHAPTER X.

Enemata. — Kinds. — Methods of Preparation. — Frequency
and Mode of Administration, — Care of Appliances. —
Douche^i. — Catheterization. 169

^^^^^ CONTENTS 7 ^^k
V CHAPTER XI. ^1

^1 mometer. — Charting and Recording Notes. . . .181 ^^|

B CHAPTER XII. ^H

External Applications (general and local). — Dry Heat. — ^^|

Hot-water Bags and Cans.— Hot UoCties.— Flannels- ^H

—Salt-bags. — Moist Heat. — Fomentations. — Poul- ^^|

H tices.— Cold Applications.— Ice.— Cold Water.— ^"

H CHAPTER XIH.

H Counter-irritants. — Mustard Poultices (Plasters and

CHAPTER XIV.
^ Medicines. — Method of Adminislration. — Dosage. —
^L Medicine-closets. — Medicine Lisls. — Weights and

CHAPTER XV.
Surgical Nursing. — Aseptic and Antiseptic Surgery. —
Preparation of Patients for Operations (capital an-i

mation. — Wounds. — Method of Healing. — Surgical

K CHAPTER XVI.

^1 GyniEcology. — General and Special Preparation of Patients
^1 for Examinations and Operations. — Positions.— In-
^1 struments and Dressings. — Care after Abdominal
^^k Section and Minor Operations. — Gynscologicai

CHAPTER XVir.
Surgical Operating-rooms. — Nurses' Technique. — Hoiv to

Prepare for Operations in Private Houses 369

CHAPTER XVin.
1 ia^inorrhages 383

CHAPTER XIX.

Bandages. — Surgi cal Emergencies. — Sh ock. — Fractures.
— Dislocations. — Sprains. — Contusions, — Burns and
Scalds. — Frosi-bitc. — Foreign Bodies in the Eye,
Nose. Ear. and Larynx 39/

CHAPTER XX.

Medical Emergencies. — Artificial Respiration. — Drown-
ing. — Poisons. — Medical Appliances. — Medical
Rounds 320

CHAPTER XXI.

CHAPTER XXir.
of Anicsthetics 3

CHAPTER XXIir.
How to Observe, Report, and Record Symptoms. ... 3

CHAPTER XXIV.
Obsletrics. — Pregnancy — Symptoms and Physical Signs.
Development of the Fcetiis. — Abortion. — Miscar-

Lriage. — Premature Labor, — Care of the Patient
before, during and after Labor, — Care of the Breasts.
-Care of ihe Child, — The Puerperal Slate, ... 3

TOIl-ET-BASKET FOR PATIENTS . . FlVnltSpUei

U OfEHATioN Bed Faee page g^

HiA Chart " '■ 19S

Fever Chart " '■

B Record Chart

I, Carkiace Face pagt aso

} BRnsR

X Assisting the Patient to Move Himself

toTBCTivE Pad ....
Listing tub Clothes o

rs Bath . . .
Sterilizer

CULTKTTS BANIMCB ......

Tontaininc Salt Soll'tion
>ininc Licaturbs on Glass Rei

1 8 NUaSlNG.

be first considered, but not to the exclusion of what is
just and right toward the pupil nursts. All connected
with the hospital should resolve that they will work
harmoniously together and with the exercise of judg-
ment and due consideration on the part of the heads
of the different departments justice may be done to all.
Division of Time. — As two years is still the pre-
scribed length of time for study in many schools, we
win first consider the division of the twenty-four work-
ing months, the probation month not being counted.
These months should be divided according to the
number of departments in the hospital, the longest
time being given to the most important branches,
such as the work in the medical and surgical wards.
Each nurse in turn should be afforded the advantages
of each department for about the same length. of time ;
I for instance, in a hospital with medical, surgical, gy-
I ntecological, and private wards, operating-room and
\ dispensary services, the two years may be divided by
L allowing five months for each of the first four divisions.
I two for experience in operating-room work, one for the
, dispensary, and one for special work. It is advisable
to keep a record sheet to be made up from the day
book at the end of each month, on which can be seen
at a glance how much time any one nurse has spent in
any one department. The specimen extracts from such
records herewith appended will explain themselves.
Besides the general reception-room and library in a
training-school for nurses, there should be a room to be
used exclusively as a study, lecture-room, and class-
room. Among the necessary fittings should be in-
cluded a disarticulated skeleton upon which to begin

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OUTLINE OF IVORA: 21

the study and classification of the bones, also an artic-
ulated one to teach the relation of the bones to one
another and to the skeleton as a whole. For the pur-
pose of teaching visceral anatomy, the position of the
organs, and their relation to each other, a mannikin
that can be taken apart will be found useful. The
shelves should contain a full set of various kinds of
pads, which may be used as models for making similar
ones and for demonstrating their uses and the meth-
ods of applying them. The room should also contain
various charts, specimens, pictures, etc. — in fact, all the
things necessary for class or individual teaching ; and
last, but not least, as complete a set of books of refer-
ence as circumstances will allow. All these are things
which will gradually find their way to such a room.
Object-teaching should be the method of instruction in
every subject, wherever this is possible, and in this di-
rection valuable aid may often be rendered by the phy-
sicians, who are always willing to aid in procuring any-
thing needed for demonstrations,

A good reference library may be made up from the
following works: Gray's Anatomy; Hiitnan Physi-
ology, Foster or Stewart ; PnndpUs and Practice of
Medicine, Osier ; Materia Medica and Therapeultcs,
Wood or Hare; Text-book of General Therapeutics^
Hale White; Diseases of Children, Rotch or Holt;
Taylor on Poisons; Practical Examination of Urine,
Tyson ; Nursing and the Care of the Nervous and
Insane, Mills; Bandaging, Wharton; An American
Text-book of Surgery, Keen and White, or Den-
nis' System ; Antiseptic Surgery, Robb ; Gyna;-
cplogy^ Kelly or Penrose; Obstetrical Nursing, ^^xnzW

I
I

22 NURSING.

or Parvin ; Puerptrat Convalescence and Diseases o^
the Puerperal Period, Kucher ; Massage ami the Swed-
ish Movements, Ostrom ; Drait,age and Sewerage of
Dwellings, Gerhard ; Parkes, Pruetical Hygiene ; Hus-
pital Construction, hiWxugs; Diclioimry, Gould; Notes
on Nursing, Florence Nightingale; Guide to District
Nursing, Mrs, Dacre Craven {Florence Lees); Text-
Baok of Nursing, Clara Weeks; Duties of Hospital
Sisters, Eva Luckes.

A list of text-books for class-teaching may be
made up of the following : A Text-Boo^ on Nursing ;
Anatomy and Physiology. Kimber; The Human Body.
Martin; Materia Medicafor Nurses, Dock; A Hand-
book of Invalid Cooking. Boland.

These text-books most be supplemented and their
study facilitated by oral instruction. Thus, for in-
stance, before beginning the study of the nervous sys-
tem the students should be given a general talk upon
the subject, and should be prepared in some measure
for what they will find in their books. Many valuable
notes may be selected for them from Prof. Martin's
work, and a careful study of the plates in Gray will be
found of great assistance, though nothing at all in the
text need be attempted,

In order that class-work and lectures may be of any
practical value to the student nurse, it is imperative
that they should be systematic and regularly attended.
To accomplish this, in a school for nurses attached to
a general hospital the pupils should be admitted at
stated intervals, and the term of theoretical instruction
regulated as it is for the ordinary school or college
year. It will be found practicable in schools with from
sixty to eighty pupils, for entrance purposea to divide

OVTLI.VE OF WORK.

the year into two terms, a spring and an autumn ses-
sion, and to accept pupils only during one of these.
The spring term should extend from the beginning of
March to the end of May, and the autumn term from
the latter part of August to October. In making up a
class of thirty, half may be accepted for the spring
term and half for the autumn, the number being di-
vided up through the months of March, April, and
May, so that when the two year.s are completed all
the members of the class will not finish at once, and
new pupils may be worked in again gradually, with-
out the nursing staff feeling the change too markedly.
Classes and lecture courses can then be arranged, be-
ginning the first week in October, and continue without
interruption until the first week in June, when formal
graduating exercises may take place and vacations be-
gin. This plan allows eight consecutive months of
theoretical study during the cooler part of the year,
and four months of purely practical nursing in the
summer, when nurses may be sent off in relays for va-
cations, and thus lose nothing in the way of valuable
instruction while absent. Classes of twenty 01 more
can be subdivided into two sections, and held on dif-
ferent days from 3 to 4 p. M., when the students are
usually off duty in the wards.

As it is impossible to have all the students together
at one time, the formation of senior and junior, or first-
and second-year, classes is necessary. In this way sub-
jects can be taken up in order, the more difficult ones
being reserved for the senior year.

Notes should be taken during lectures, and afterward
written out neatly in ink and handed in for correction.

24 NUKSINC.

Nurses will find such notes of much value for future
reference, since they can thus readily review the essen-
tial points of a subject when text-books are not always
at hand.

FIRST-YEAR OR JUNIOR CLASS WORK.

As nearly as possible the same subjects should be
taught in class by the principal of the school as those
taken up at the same time by the physician in his lec-
tures. In this way the mind is kept in the same train
of thought until the subject is finished, and confusion
is avoided.

From October ist until June ist there will be about
thirty-two teaching weeks. Class subjects may be di-
vided for that time in the following manner:

The first three months should be devoted entirely
to human anatomy and physiology, together with
practical talks on nursing. We have given here an
outline of the different lessons, each of which will oc-
cupy one or more hours according to circumstances;

Subjects for October.

First IVetk.

Anatomy. Praeticat Nuning.

Outlioe of Human Anatomy. The Hospital Ward.

Tilk on Cell-life ; properties, Tunc- lU Stalf and Division of Labor.

tions, kinds. Hospital Etiquette, Waid Disci-
Talks on Ibe Skeleton as a. Whole. pline.
The Bones and Iheir Funclions ; ?Ioiirs of Duty.

Slmctare. Study, Recreation.

Compoiition, Nighl Nursing.

Nutrition ,

I'eridBteal Covering.

Diviiion and Number*.

^V-^d ^^^^^B

3i V

^^^^H OUTLINE

OF WORK. ^^^H

^^^^H Second Week. ^|

Anatomy.

Praclieal Nuriing.

Bones of Ihe Cianium ;

Ward Supplies ; Nurses' Toilet-Bw-

Principnl Suiures.

ket.

[tones of Ihe Face,

Ward Work : DaUy Care of Ihe

The Skull as a Whole.

Ward; Special Care of Ihe

The Hyoid Done.

Ward: Daily Dusting; Week-

ly Qeaning.

Cleanliness of Ihe Bed and Blank-

Care of Ward Utensils.

Tk.

mek.

The \ertebral Column :

Bed-making:

General Choiacteristics.

For Bed Patienis; for Convalet-

lis DivLsions, and their Names.

cenlF.

lis RelalioD lo the Skull.

Preparation of Bed for an Ope-

The Ribs and Slemum.

ration Patient. Fracture Bed*.

The Pelvb.

Mechanical Appliances for Ihe Re-

Uef of Paticnis :

Pads, Head.res(s. Lifiing. Mov-

ing.

Fmrth

■ Week.

Bones of the Upper Eilremily :

Hygiene of the »ck-room and

Their Divisions.

Ward :

Bones of the Shouldcr-Girille.

Ventilation.

The Arm. Ihe Forearm, the Hand.

Method of Ventilating.

Dhri-iion of Bones of the Lowei

Eitremity :

Bed-room Air.

The Thigh, the Leg. the Foot, with

Dbiposal of Ekcrela.

Names of Bones in each.

Soiled Dressings and Soiled Lia-

Fifth

Week.

Review of the Skeleton and of the i

Chaplets on Nursing.

,^H

.VURSING.

November.
First IVeck.

Praefkal Nursing.
Artieula- Catc of New I'lUienls.
Care of Bed Pnlienls.
Caitilage. Ligatnent^, Synovial Caxe of Convalescents.

Membranes, Bu[S.-e.
Joints, Voriely, Divisions, and
Movements of Principal Artic-

Analomy.

Introductory Notes

Introductory Notes on the Muscles ;

Geneial Anatomy, Vanelies,

Functions, Modes of Attach-

Origin and Insertion.
Tendons. Fascia:.
Foims of Musdes.

i Week.

Baths;

Classificatinn and Temperature.

Baths for Cleanliness ; Tub-balhs,
lied -baths. Foot- tubs.

Baths as Therapeutic Agents;
Mustard Baths. Salt Baths,
Hot-air, Steam, or Vapor
Bathl ; the Conlinnous Bath.

Sponge- and Tub-balh! in Ty-
phoid Fever; the Cold Pack.

Third Week.
IVindpat Muscles of the Head, Disinfectant Solutions, Dcodoriieis.
Neck, Back. Abdomen, and The Metric System.
Thorax, with Origin, Insertion.
and Action.

Fourth IVeek.
ftindpol Muscles of the Upper Bacteriological Notes.

and Lcmei Limbs. Disinfection of Rooms, Ward, Fur-

niture, Gothing, Excreta, Spu
turn, and Vessels.

December.
First ISWi,

Visceral Anatomy.
General Talk on Lungs, Heart,
Stomach, and Organs of the

Kinds, Preparation, Method, and
Frequency of Administration

^^^^^^^^^Sd^^^^l

^^^^^^^^^^^^^^^^^^^^^^^^l^^^^^^^^^l

m ^m

^^ OUTLINE OF WORK. ^T^^k

Analomy. PraitUal NurHng. ^^|

Abdormnal Cavily, with a Cite of AppliaDCes. ^^H

Kelalion of One O^n [o Another. ^^H

Their Function!!. ^^^|

Second Wifk. ^H

lies. Veins, and Capillaiiesi Charting. ^^^|

theit Functions. Recording Nules. ^^H

Third Week. ^^1

Review of Quarter's Lessons. ExaminBtion. ^^H

In Jiknuary, in ikddition to (lie Anatomy and Fiactical Talks on Nnll-^^H

ing, Materia Medica will be taken up. ^H

January. ^^^|

First Week. ^^|

The Principal Arteries of Ihe Head External and Local Applications:

and Trunk, [heir Course and Dry Heal, Hot-Water Bags and

Sall-bags. Moist Heat. Fo-

Application of Cold (Ice, Cold Wa-

ter).

Second Week. ^|

Pkincipal Arteries oflhe Upper and Counter-inilaWs : Cups. Mustard ^H

Lower Limbs. Plasters and Leavo. Caiilhar- ^^|

Thi^d ^^k

Classificalion of Veins. Medicines : Methods of Adniinis- ^^

Course of Principal Veins in each (ration, Dosage. Weights aof"

System. Mea.suics. Symbols and Ab-

Medicine-Closet and Medicine-

Lists.

^^^^^^M

^^^3h^^H

^^^^^^^^^^^H

^^^^^^^^^^^^^^^H

jVCJfS/.VC.
Fourth Wtek.

AHotomy,

Praclical Nwni^g.

Review of Vascular Syslci

n. Review of Chapters on Nursing.

Februar\'.
First mei.

Su^cal Kuisii^, Antiaeptic and

Organa of Vt^ce and Kesj»raliuii, Aseplic Surgery ; Preiuuation

with desciipdon uf ihe 1 Jiryiix, of Palicnt for OperaJion.

Trachea, and Bronchi

Materia Medica : Terms. Prepom^
tionR of Drags. {See Materm
Aftdiat.)

Second Week.

Function of the Lun^ and lleurie. Caie of Patient aflcr OpenUion.

Method of HeaUng. Surgical

Rounds.

Opium.

Third Week.

The Digestive Otgans.

General and Special Care of Cyn.

Description and Function

of each ecological Patients. Pitpani-

Portion.

Positions, In!itniment$, and Lircss-

ings.
Morphine and Chloral.

Fourth Week.

Glands and their Function:

;. Second half of chapter on GjnK-

Liver, Spleen, Pancreas.

cology.

The Lymphatics.

-i

Gyniccological Tenns and Defini-
tiona.

W^^^^B^^^M

■

OUTLAYS OF IfO/lfir. 3^

March.

The Urinary Organs !

Firs! mei.

Pra. Ileal Nursing.
Surpcal Oncraling-room5— Nurses'
Technique : How to Prepue foi
Operations in Private Houses.
Calhartics : Lniiitives, Simple Puiga-
lives, Drastics, Cholagoguea.

Or|;ans of General iun

The I'erilQneum.
The Mammaiy Glandi

Stcond Week.

lla^morrhBECs.

Mercury, Alcohol, Brandy, Whis-
key; Action and Dose.

A Talk on the Nen,oi;
Divisions, Slniclure

Tka-d n\ek

IS System I'rticljcal Demonstrations of Mcth-

thage
Tomes Iron, Arsenic, Cinchona

The iirain.

Fourth ile,-i.

Ibndages.

Nm Vomica, Gentian.

The Spinal Cord.

Fi//A Week.
Shock.

Fractures ; Kinds, Treatineat.
Nerrincs : Valerian, Asafo-lida,
Slramonium.

April. ^H

Firsf ^M

ler w fw as ihe Nerrous Sys-
tem.

■

NURSING. ^^^H

Second Weik. ^^k

■ Anatomy.

Practical Nursing. ^H

Review ot Uie Nervous Sys

lem. Uislocaliuns and Sprains. ^^H
Veratium Viride. ^H

Belladonna. ^H

Hyoscyamus.

Third liWi.

Anatomy of ihe Skin ;
Dcsciiptiun and Function

Surgical Emergencies concluded.
s. Minor Surgery.

Fcur/A HW6.

Otgan-^ .A Tasle and Smell
Aiiaiuiny.

: Medical Emc^eneies.
Poisons.

Artificial Respinuion.
Drowning.
Aconite, Iodine.

May.

First IVeii.

Descriptioti of the Eye : Second half of chaixet on Medical
Anatomy. Emerge ntirs.
^1 The Humots and Appendages of Bismuth, Eigoi, Aium. Zinc.

■ the Eye.

■ Srcond Wetk.

^H Anatomy ol ihc Ear :
H The Eitenml and Middli

Diet.
; Ear. Acids, Oils.

^1 The Internal Ear.

■

Third Week.

H Review of the Sjiccial Sens

■

Emetics,

■

Fourth Wfct.

^m Review of the First lialf

of the How (o Observe, Report, and Re-

■ Year's Work.

cord Symptotns.

■

Fi/ih met.

^H General Review of the Second Half of the Year's Work.

OUTLINE OF WQl?K-.

SCHEDULE FOR JUNIOR LECTURES.

I'KIDAYSi.

Hygiau:
Oct. 7, 14. 21, 28; Nov. 4. 1 1. Dr. .

1. Air: Chemistry of the atmosphere — The influ-
ence of its various constituents on the animal body. —
The alterations produced on the surrounding atmo-
sphere through respiration, — Pollution of air from
various sources. — Ready method of testing the quality
jf air. — Ventilation and heating.

2. Water; Injurious organic and inorganic constitu-
ents to be found in water. — Purification of water.

3. Prevention and limitation of certain diseases :
The role played by bacteria. — An outline of bacterio-
logical methods. — Wound -infection. — Sterilization and
disinfection of clothing, apartments, excreta, — Disposal
of excreta.

4. Food preservation.

Pathological Anatomy, with Demonstrations.
Nov. IS, 25 ; Dec. 2. Dr. .

1. The circulatory system and its structure. — Demon-
stration of the circulation.

2. The norma! anatomy of the lungs and kidneys. —
Certain pathological changes in these organs. — Demon-
stration.

3. The alimentary tract ; the pathological changes in
typhoid fever. — Demonstration.

Afedical Lectures.

Dec. 9. 16. 23; Jan. 6, 13, 20, 27. Dr. .

t. The general care and observation of patients.

32 ArUJfS/Ji^G.

2. The recording of observations of temperature,
pulse, and respiration.

3. Nursing in febrile diseases, including the use of
the cold-water bath.

4. The blood.

5. Nursing in contagious diseases.

6. Diet.

7. Medical appliances, emergencies, and common
poisons with their antidotes.

Surgical Lectures.
Feb. 3, 10, 17, 24; March 3. 10, 17. 24. Dr. .

1. Cell-life: Heating of wounds ; inflammation.

2. Principles of aseptic and antiseptic surgery:
Dressings and disinfectants ; their preparation and

3. Anaesthetics and their administration : Care of
patients before, during, and after operation. — Shock
and emergencies.

4. Some special operations. — Surgical diseases, tu-
mors, etc.

5. Haemorrhage and its treatment. — Wounds and
their treatment.

6. Fractures, dislocations, contusions, and sprains:
Diagnosis and treatment. — Prompt aid to the injured.

7. Wounds, accidents, suppuration, abscess, erysip-
elas, septicaemia, tetanus, etc.

8. Principles of bandaging.

March 31 ; April 7, 14, 21. Dr. .

I. Special anatomy of the pelvis. — Diseases of wo-
men.— Gynaecological instruments.

OUTLINE OF WORK.

2. Abdominal surgery: Technique to be observed
by the nurse.

3. Post-operative care of abdominal cases. Vom-
iting, pain, tympanites. cathi;tcrization, position of pa.
lient, dressings, enemata. hypodermic injections.

4. Peritonitis and wound-infection. — Modes of infec-
tion, and how to prevent it. General gynaecological
operations. — Preparation for operation, and the after-
care of the patient

Diseases of the Eye and Ear.
April 28 ; May 5. 12. Dr. .

1. The anatomy of the eye: Care in health anJ
disease.

2. Care of the eyes after operatioii.s.

3. Anatomy of the ear: Care in health and diseai'^.

Diseases of the Throat and Xose.
May 16, 26. Dr. — — .

1. Diseases of the throat and nose.

2. Treatment and nursing of diseases of throat apd
nose.

SENIOR OH SECOND YEAR'S WORK.

Before beginning the subjects of the second year,
the first week in October should be set apart for ex-
aminations on the first year's work. The examinations
in medical and surgical nursing should be conducted
by a physician and a surgeon respectively, and practi-
cal tests in nursing should be given to the student by
the superintendent of the school. An examination-
paper usually contains ten questions — five to be an-
swered orally, five in writing. The class-standing for

m As

^H [nedtc

(be second year is based upon the results of
examination, and any one failing to pass it should
be considered unqualified to become a head nurse at
the end of her second year.

Frequent opportunities of expressing herself in writ-
ing should be given to the nurse in the second year's
work. Of the class-hour, from ten to fifteen minutes
should be devoted to the answering of questions
in writing, and these may be corrected and criticised
at once. Words and definitions relating to the sub-
ject should be dictated and written as part of the
work. At the end of each subject a written examina-
tion should be given, consisting of five questions bear-
ing on the principal points, and the papers examined
by the teacher before the next meeting of the class.

In the first year's work the study was restricted to
the normal conditions of the various systems of the
body. The teaching of the second year will refer more
particularly to the changes which take place in the.se
systems when invaded by disease, to the signs by
which they may be recognized, and to the duties of
the nurse in regard to them. In addition to this
notes should be taken and quizzes held on some
.special subjects, as Obstetrics, Urine, Anaesthesia, etc.
When at all practicable the same idea of object-teach-
ing should be carried out as recommended in the first
year's work. In addition to this teaching, the previous
chapters on nursing, the application of medicines, and
the doses used in the various diseases should be re-
viewed.

As they will have already gone over their materia
[nedtca, it is a good plan to let the students write out

of this ^1

OUTLINE OF WORK. 35

I a list of the medicines given in certain diseases and
I their doses; as a part of their next week's lesson, and
I then quiz upon them in class. From time to time they
1 should also prepare papers on some of the more im-
portant drugs and groups of drugs, such as Opium,
Digitalis, Hydrargyrum, Cathartics. The principal
points in nursing {t'-g. a nurse's observation of symp-
toms and the treatment in emergencies) form suitable
subjects for other papers.

The plan of study can be arranged something after
the following schedule:

October.

First Week.
Examination and assignment of class-standing.

Second Week.
Obstetrics: Anatomy of the organs of generation,
with illustrations, — Description of their functions.

Third Week.
I Pregnancy : Symptoms and physical signs. — Ob-
I stetrical terms and definitions.

Fourth Week.
Development of the ftetus, — Abortion, — Miscar-
riage.— Premature labor. — Terms and definition.s.

Fifth Week.
Fcetai circulation, — Terms and definitions,

NURSING.

November.
^ First Week.

Care of patienl before, during, and after labor, —
Tenns and definitions.

Secojtd Week.
Care of the breasts. — Care of the child. — Care of the
eyes. — Infant-feeding. — Terms and definitions.

Third Week.
The puerperal state. — Terms and definitions.

Fonrlh Week.
Review and Examination in Obstetrics.

December.
First Week.
The care of infants. — Terms and definitions.

Second Week.

Conditions peculiar to children : Thrush, Cholera

infantum, Convulsions, Infantile paralysis, Chorea,

Rickets, Croup, Eczema. — The infectious diseases of

childhood.

Third Week.
Revii-'W and Examination.

January.

First Week.

The urinary organs: Their location and functions. —

Normal urine. — Composition. — Specific gravity. —

Physical prof)erties.

OUTLINE OF WORK.

SecQud W(€k.
Preparation of a specimen uf urine for examination.^
Reaction. — Color. — Sediment.- — Increase and decrease
in quantity. — Specimens.— Terms and definitions.

Thint Wet-k.
Tests for albumen, sugar, bile, carbolic acid, and
—Terms and definitions.

Fourth Wfik.
_■ of the kidney.-;. — Uraimia (acute
nic). — Hriglit's disease (nephritis), — Cystitis.

FiCBKUAKV.

First Wi-ck.
V and Examination on Urine.
Scioiid Week.
Notes on the principal contagious and infectious
I diseases ; Scarlet fever. — Typhoid and malarial fevers.
— Tcrmii and definition.'^.

TInrd Week.
-Asiatic cholera. -

■Small-pox. — Ery-

Foiirth Week.
Septicemia. — Pya;mia. — Tetanus. — Diphtheria. —
[ Phthisis. — Terms and definitions.

March.
First Week.
Review and Examination on Contagious and Infec-
\ tious Diseases.

^^^^■1

^P^

^^HH^^^I

" s«

AKfcS/AW.

Notes on disease

Second Wfd: ^H
;s of the digestive system. ^^

Third Wa-k.

Notes on disease
cal terms and dcfin

s of the respiratory system. — Medi-
itions.

Fourlh Week.

^L Review of notes

on the diseases of the
with examination.

Aprii.
First Week.

digestive and

Notes on diseases of the nervous system. — Terms
and definitions.

Sci-oml Wa-i'.

Notes on the di
tin ued . — M assage-
^m definitions.

iseases of the nervous
-The -Rest Cur^."-

Tkird Week.

; system, con-
—Terms and

^r Notes on diseases of the circulatory system. — Terms
and definitions.

Fourlh Week.

Terms and definitions. — Oral Review.

May.

Examinations.

■

First Week.

H Hygiene; General Medicine; Materia

Medica.

OUTLINE OF iVOXJC. 39

Second Week.
Surgery; Gynascology; Obstetrics.

Third Week.
Analysis of urine; Children in health and disease;

Fourth Week.

Dietetics ; Massage.

These test questions should be limited to five, and
should be prepared by the lecturer on the subject, and
the written papers afterward valued by him.

SCHEDULE FOR SENIOR LECTURES.

TUESD.-WS.

Obstetrical Lectures.
Oct 4, 11, iS, 25; Nov. I. 8. Dr. .

1. Pregnancy: Organs of the body concerned in
pregnancy and in parturition: (a) The bony canal, the
false and the true pelvis; (1^) The soft parts, uterus.
vagina, and pelvic floor,

2. Impregnation: The ovum and its development. —
The placenta. — The enlargement of the uterus. — The
hygiene of the pregnant state. — The diet. — Care of tlie
bowels. — Care of the breasts, etc. — The vomiting of
pregnancy. — The diagnosis of pregnancy. — Quicken-
in;.^, the fatal heart-sounds, etc. — Table for calculating
the probable duration of pregnancy. — Death of the
fwluH in utero.

3. Physiology of pregnancy : Condition of the pelvic
organs at term. — Changes in the entire organism. — The

iwxsarc.

mature fcetus. — Forces bnngic^ about aad resisdi^
the btnb of the child.

4. Natural labor : Preliminary preparadoos for st^es
of labor. — Position of fcelus, etc — What to do in an
emcrgcnc)'. — ^Thc birth of the placenta and its manage-
ment.— Post-partum hemorrhage. — Laceration of the
perineum.

J. The pucrpcntl state: Oeanliness. — Articles re-
quired.— Receiving, washing, and dressing the child.
— The immediate care of the child.

6. The management of the puerperal state. — Dan-
gers to be avoided.

Children.
Nov. 15. 22, 29; Dec. 6. Dr. .

1. Care of Infants: Condition of the child imme-
diately after birth — (1) general appearance; (3) bony
framework; (3) internal organs; (4) changes in the
blood-circulation ; (5) establishment of pulmonary
respiration.

2. Infancy: (1) Growth and development of infants;
{2) physiologLCiil pecuhdfities; {3) tendency to disease;
(4) Mortality among infants; causes and prophylaxis.

3. Care of Healthy Infants: (1) Handling; (2)
bathing; (3) clothing; (4) sleep; (5) exercise; (6) the
nursery,

4. Infant-feeding: (1) In health; (2) in sickness.

Elfctro- Thcrapfutics.

Dec. 1 3, 20. Dr. -,

Practical application of electricity.

OUTLCNE OF WORK.

The Urine.
Jan. 3, 10. Dr. .

1. Elementary analysis of the urine.

2. Tests with practical work in sections.

Jan. 17, 24, 31 ; Feb. 7, 1 4. 21, 28; March 7. Miss .

1. History. — In the hands of the masseuse. — In the
hands of the nurse. — Demonstrations on the hand and
arm.

2. Effects on digestion. — Demonstrations on the
chest and abdomen.

3. Demonstration on the foot and leg.

4. Thigh. — Passive movements.

5. Massage of head. — Soporific effect. — How ob-
tained.

6. Demonstrations on the back.

7. Demon.stration on the back and gluteal region. —
Resistive movements.

S. Sprains, dislocations, indurations, paralysis.
9. I'ercus.sion, position, use of oils.

Contagion.

March 14. Dr. .

Some common modes of contagion, an-i how to
guard against them.

Gaicral Medicine.
March 21. 28. Dr. .

1. Nervous system.

2. Heart and respiratory organs.

JfUSSING.

Insanity,

April 4. II, i8. Dr. .

1, The care of the nervous and insane,

a. What to do for special form;* of insanity.

3. Occupation for the invalid and convalescent

Diseases of the Skin.
April 25 ; May 2. Dr. .

1 , Anatomy and care of the skin.

2. Nursing in diseases of the skin.

Dietetics.
May 9, 16, 23. Miss ,

1. Nutrition. — Some proofs that different methods
of cooking produce different results in food as to its
di[iestibility.

2. Processes of cooking. — Fire. — Effect of heat on
food materials. — Relative merits of different ways of
njiplying heat.

3. Flavors. — ^Temperature of foods. — Selection of
dishes and colors.

Nursing.

May 30. Miss .

Ethics of nursing, — Private nursing.
May. — Final Examinations.
June 2, — Graduating Exercises.

H cxte

General Plan,

The course of instruction is to be graded and lo

extend over three years, including the time of proba-

OUTLINE OF WORK.

tion. The teaching should include a thorough course
of practical work in the various wards, demonstrations
at the bedside of the patient and in the class-room,
together with a regular course of lectures, classes
being held and recitations being given with special
regard to practical teaching. Not more than eight
hours in the 24 should be devoted to practical work
in the wards; two additional hours are to be spent
daily in attending either classes "and lectures or in
study. The course should be arranged so that the
work of one year will, so far as possible, be a neces-
sary preparation for that of the succeeding year.
Classes and lectures should begin with the first
week in October, and continue until the following
May, with the usual intermissions at Christmas and
Easter,

Division of Time.

For the first two years. — Four months each in the
medical and surgical wards ; 3 months in the gynjeco-
logical ward;, 2 months in the children's wards; 3
months in the private wards; 3 months in the operat-
ing rooms ; I y^ months in the diet school ; i month
in the dispensary; i month on special duty; \%
months on vacation.

For the third year. — Two months in obstetrical work ;
1 month on special duty ; 6 months as assistant in the
superintendent of nurses' office (for a limited number);
3 months as assistant in the linen room and nurses'
home ; and 6 months as head nurse (for a limited
number), with classes for head nurses.

^B and

First or Junior Yea

Practical work in the wards :

Class Work. — This should consist of systematic
instruction in practical nursing, including the general
care of tlie ward and the ward utensils, together with
the general care of the ordinary medical, surgical and
g}'Ti ecological patients. Practical illustrations in the
ethics of nursing, in the elements of hygiene and bac-
teriology, materia medica, anatomy and physiology
are also given.

Lectures. — A systematic course of didactic lectures,
in connection with the above subjects, should be given
by specialists in their various branches. Notes upon
each lecture to be taken and written up in full by the
student later.

Six weeks should be spent in the diet school, under
a competent teacher, from whom the student receives
practical and scientific lessons on the preparation of
foods. A course of lectures on "Diet in Dis-easc"
to be given by a physician,

hilermaiiatf Year.

Practical work in ihe wards:

The practical work of the second year to include a
service in the dispensary, the general surgical operat-
ing rooms, and the gynaecological operating room;
the care of patients before and after operation, special
nursing in the public and private wards ; a course as
assistants in the linen room and nurses' home.

Class Work. — The care of children; examination
and testing of urine; the care of the nervous and

OUTLINE OF WORK.

insane; nursing in medical and surgical diseases;
surgical technique; bandaging; ethics of nursing.

Lectures on the above subjects, in connection with
the class work, to be given by physicians.
Third Year.

Practical work in the wards:

The first two months to be devoted move particu-
larly to class work and lectures upon obstetrics and
practical work in the obstetrical wards. Lectures are
given on special subjects, such as diseases of the eye,
ear, throat, skin aiul electrii-.d therapeutics. Students
who wish to prepare for hospital positions will be
expected to act as assistants in the superintendent's
office, and to hold classes under her observation and
criticism, to act as head nurses in the wards, or as
night head nurses. Students who desire to qualify
more especially for private duly should be given spe*
rial advantages for this work during the third year.
Examinations.

At the end of the first year, examinations should be
held upon (i) practical nursing; (2) materia medica 1(3)
anatomy and physiology ; (4) diet. At ihe end of the
second year : (i) children ; (2) medical nursing, includ-
ing massage, examination of urine and hygiene; (3)
surgical nursing, including the duties of the operat-
ing room and the nurse's duty in emergencies; {4)
gynecology. The third-year examinations should
include (1) nursing in obstetrics ; (3) special branches;
(3) the practical care of wards and of the nurses'
home, linen room and laundry; (4) the buying of
ho.spital supplies; (5} private nursing; ^6) the ethics
of nursing.

TABLE-SHOWING IN DETAIL A SCHEM
INSTRUCTION EXTENDING OVER
THREE YEARS.

Junior Ciass Lectures.

Ethics of Nursisg.

1. Hospital Etiquette,

2. Duties of probationers and junior nurses to the
hospital ; to officials ; to patients ; to visitors ; to
each other.

HVGIENE,

1 . Bacteriology. — The role plaj'ed by bacteria. — An
outline of bacteriological methods.

2. Disinfection. — Sterilization and disinfection of
clothing, apartments, etc.; excreta and their disposal.

3. Air. — Chemistry of the atmosphere. — The influ-
ence of its various constituents on the animal body. —
The alterations produced on the surrounding atmos-
phere through respiration — Pollution of air from vari-
ous sources. — Ventilation and heating.

4. Water. — Injurious organic and inorganic con-
stituents to be found in water. — Sources of contami-
nation.— Purification of water.

5. Personal hygiene. — Food. — Clothing. — Bathing.
— Exercise.

Materia Medica.

1. Medicines and the methods of administering
them. — Dosage, weights and measures, terms and
preparations.

2. Classification of drugs. — Cathartics, emetics, stim-
ulants, hypnotics, sedatives, etc.

3. Drugs acting on the respiratory, circulatory and
cxcrctorj' systems ; the physiological action in each. —
Incidental effects.

ME FOR ^1

i^UTLINE OF WORK.

4. Poisons. — Symptoms and antidotes. — Hypoder-
mic injections.

Anatomy and Physiology,

1. Histology. — Cells and tissues. — General structure
and composition of the body. — Physiological prop-

2. The skeleton. — Gross, microscopic and chemical
structure; composition of bone, joints, cartilage and
muscle.

3. The glandular system. — The physiology of secre-
tions and excretions.

4. The circulatory system.

5. The respiratory system,

6. The excretory system.

Medical,

1. General care and observation of patients. —
Recording of symptoms.

2. Temperature, — Pulse. — Respiration,

3. Nur.sing in febrile diseases.

4- Diet. — Physiology and alimentary secretions.
5. Food-stuffs and their assimilation.
Surgical.

1. Principles of modern surgery.

2. Care of patients before, during and after opera-
tions.

3. Nursing in special operations.

4. Haemorrhage and its treatment. — Shock and
other emergencies.

5. Anaesthetics and their administration.

6. Principles of bandaging (demonstrations to be
given in sections). — Surgical dressings and appliances ;
use of disinfectants.

48 XU/IS/NG.

Gynecology.

1. Pelvic anatomy.

2. Preparation of patients for operation. — Instru-
mtiits. — Positions of patients during examination and
treatment,

3. Care of patients after operation. — Catheteriza-
tion,— Enemeta.

INTERMEDIATE CLASS LECTURES.
Ethics of Nursing,

1. Duties and responsibilities of intermediate nurses.

2. A talk on system, methods and order in work. —
Tact. — Professional manners, authority, etc.

SUKGICAL.

1. Technique to be observed by the nurse in the

operating room.

2. Principles of aseptic and antiseptic surgery. —
Wound healing.

3. Wound accidents, inflammation, suppuration,
abscess, erysipelas, septicsemia, etc.

4. Fractures, dislocations, contusions and sjirains.

5. Surgical diseases. — Tumors, etc.

GyN-ECO LOGICAL.

1. Inflammatory diseases of the pelvis; diseases of
the uterus and adnexa. — Their causes and treatment.

2. Menstruation and its disorders. — Causes and
treatment.

3. Diseases of the vagina and genitalia. — Prepara-
tion of patients for minor operation-;. — .'Vfter care.

oi'Ti.iNE OF wpka: 49

Nursing in Diseases of the Digestive Organs.

1. The blood and ductless glands, and their diseases.
— Anaemia, chlorosis, leukaemia, etc.

2. Diseases of the stomach. — Gastritis, acute and
thronic, Nturoses of stomach. Dilatation. Gastric
ulcer, cancer, etc.

3. Diseases of the intestines, liver and pancreas.

The Respiratokv System.

1. Diseases of the bronchi. — Diseases of the pleura.

2. Diseases of the lungs.

The Circulatory System.

1. Diseases of the heart and pericardium.

2. Diseases of the blood vessels.

Contagious and Infectious Diseases,

1. General considerations. — Isolation; disinfection;
general treatment; hydrotherapy.

2. Typhoid fever. — Malaria! fever,

3. Scarlet fever, measles, small pox and other exan-
themata.

4. Diphtheria and allied affections.

5. Tuberculosis.

6. Asiatic cholera, amcebic dyseniery. leprosy.
glanders and other less common infectious diseases.

Children.

1. Two lectures on the diseases peculiar to children.
— Infantile diseases, — Opthalmia neonatorum, thrush,
diarrhoea, convulsions, cholera infantum.

2. Meningitis, infantile paralysis, chorea, croup,

The Care of the Nervous and Insane.

1. What to do for special forms of insanity. Neur-
asthenia ; nervous prostration. The rest cure.

2. Occupation for the invalid and convalescent.
Nursing in Some Constitutional Diseases.

I. Two lectures on the following subjects: Rheu-
matic affections; arthritis deformans and gout; dia-
betes mellitus and insipidus, rickets, scurvy.
The Urine.

1, A consideration of the anatomy and physiolc^y
of the urinary organs.

2, Elementary analysis of urine (practical instruc-
tion to be given to the class in sections).

3, Nursing in ura;mia, Bright's disease, etc., and
other diseases of the urinary system,

SENIOR CLASS LECTURES.
Obstetrical.

1. Pregnancy; Organs of the body concerned in
pregnancy and in parturition : (a) The bony canal,
the false and true pelvis; (6) The soft parts, uterus,
vagina, and pelvic floor.

2. Impregnation : The ovum and its development,
— The placenta. — The enlargement of the uterus- —
The hygiene of the pregnant state. — Diet. — Care of
the bowels. — Care of the breasts, etc. — The vomiting
of pregnancy. — The diagnosis of pregnancy. — Quick-
ening, the fcetal heart-sounds, etc. — Table for calcu-
lating the probable duration of pregnancy. — Death of

he foetus in uUro.
\ Phys.iology ofjregnancy : Condition of the pelvic

OUTLINE OF WORK.

organs at term. — Changes in the entire organism. —
The mature fetus. — Forces bringing about and resist-
ing the birth of the child.

4. Natural labor : Preliminary preparations for
.stages of labor. — Position of fcetus, etc. — What to do
in an emergency. — The birth of the placenta and its
management. — Post-partum hemorrhage. — Lacera-
tion of the perineum.

5. The puerperal state : Cleanliness. — Articles re-
quired,— Receiving, washing and dressing the child. —
The immediate care of the child.

6- The management of the puerperal state. — Dan-
gers to be avoided.

Children.

1. Care of Infants: Condition of the child imme-
diately after birth, — (1) General appearance; (2) bony
framework ; (3) internal organs ; (4) changes in the
circulation; (5) establishment of pulmonary respira-
tion.

2, Infancy : ( 1 ) Growth and development of infants ;
(2) physiological peculiarities; (3) tendency to dis-
ease; (4) mortality ;iniong infants; causes and pre-
vention.

3, Care of healthy Infants: (i) Handling; (2)
bathing; {3) clothing; (4) sleep; {;) exercise; (6)
the nursery.

4. Infant Feeding: (i) In health; (2) in sickness.

Massage.

1. History. — In the hands of the masseuse- — In the
hands of the nurse. — Demonstrations on hand and arm.

2. Effects on digestion. — Demonstrations on chest
and abdomen.

NURS/A'G.

3. Demonstration on the foot, leg and thigh.^Pas-
sive movements.

4. Massage of head. — Soporific effect. — How ob-
tained.

5. Demonstration on the back and gluteal region. —
Resistive movements,

6. Sprains, dislocations, indurations, paralysis, per-
cussion, position, use of oils.

Diseases op tub Skin.

1. Anatomy and care of the skin.

2. Nursing in diseases of the skin.

Diseases of the Eve and Ear.

1. The anatomy of the eye. — Care in health and
disease.

2. Care of the eyes after operations.

3. Anatomy of the ear. — Care in health and disease.

Diseases of the Thkoat and Nose.

I. Diseases of the throat and nose. — Treatment and
nursing.

Ethics of Nursing.

Private nursing. — Etiquette; remuneration; profes-
sioniii engagements; uniform.

The other half of the year to be devoted to head-
nurse classes, discussions upon the work, duties and
responsibilities of head nurses, and upon the methods
to be employed in ward instruction.

In order to follow the progress of the pupil nurse
throughout her entire course, a weekly report upon
her genenil standing may be made up by the head
nurse, somewhat in accordance with the following
form-

OUTLINE OF WORK. 53

Form of Weekly Report of the Pupil Nurse.

Thoroughness in work,_

Inleresl displayed, ^

Powers of observation, _

Punctualit]'', _^

Neatness,

General attention and kindness lo pacients.

General deportment and behavior,

Disposition,^ ,

Any marlced peculiarity,

Strong points! j character and work.
Weak points )

Improvement — if any, _
General Remarks :

CHAPTER II.

A Hospital Ward; Frek and Private.— Its Staff and Division
OF Work.— HospiTAi, Etiquette, — Ward Discipline. — Houks
OF DuTV. Study, Recreation. — The Nirht Nurse.

With the increasing development in the science of
medicine, and particularly in the field of bacteriology.
and with the conviction, which is becoming recognized
more and more, that thoroughly clean surroundings
and pure air are conditions absolutely necessary to the
recovery of patients, hospital construction, arrange-
ments, and equipments have become subjects of seri-
ous consideration to both the medical and nursing
professions. It becomes important and necessary that
a trained nurse should understand something of the
plans and arrangements of modern hospitals, for there
is nothing in or about a ward or sick-room that does
not directly or indirectly affect the welfare of the
patients. Many of the rules that hold good in hos-
pitals can be applied with some modifications to private
dwellings. In private nursing the nurse may be the
only one in the house who realizes that there may be
something wrong in the sanitary arrangements which
urgently needs to be corrected. To become familia,
with hospital construction the nurse should read inde-
pendently the writings of those who are authorities on
the subject.

The greater portion of a general hospital is given

THE PUBLIC WARD. 55 \

lip to the wards for free patients, but in a great many
tiicre are, besides, accommodations for a limited num-
ber of private patients. The average free ward ought ■
to contain not more than twenty-five or thirty beds.
The beds should be separated by a distance of at least
three feet, and each patient should be allowed about six-
teen hundred cubic feet of air-space. For a ward of this
size there should be not less than one bath-room, two
closets, and. if possible, one room set apart to contain
nothing but the slop-hopper, racks for holding vessels,
shelves for urine-jars, and catheter bottles. It is de-
sirable to have a separate room for a linen closet,
another for patients' clothes, a small ward kitchen,
and at least two private rooms to be used for ex-
tremely ill and delirious or dying patients, so that
they may be removed at once from the ward. The
effect caused by the death of a patient in the midst
of others is, to say the least, not encouraging. The
necessary articles of furniture in such a ward are, be-
sides a bedside table and a comfortable arm-chair be-
tween every two beds, three or more wheel-chairs for
convalescent patients and two ward tables. If possible
it is best to have a room opening out of the ward
which can be used as a ward office, and in which
the medicine-closet may be kept out of sight of the
patients. Such an arrangement will also remove the
temptation from any who might be inclined to help
themselves to .stimulants or poisons. The walls should
be hard-finished and painted some pretty soft color;
usually pale green, buff, or tcrra-cotta is chosen. If
one room can be set apart as a day-room or .sitting-
room for convalescent patients, it should be fitted up 1

NURSING.

with lounges, a bookcase filled with books, plenty of
games, plants and flowers, and bright rugs: if such a
room cannot be obtained, then the books and games
must be kept in the ward.

As it is desirable for hygienic reasons to have as
little furniture as possible, and that of the simplest
kind, the appearance of a ward can be greatly im-
proved by having potted plants placed in the windows
or in groups. They arc harmless, and are a source of
great pleasure to the patients. They need not add
much to the ward expense, for frequently both patients
and friends arc glad to contribute a plant to aid in
making the room look bright.

The private ward is usually simply a hall or floor
divided into a number of rooms. In a hospital, each
of these rooms should be a model sick-room. It
should be of ample size, away from noises, have
plenty of light and sunshine, and be capable of being
thoroughly cleaned. There should be not less than
two windows in such a room, unless the sun has free
access to it, when one large one will be sufficient. If
there are wards or rooms in use above or below it,
special care should be taken that the floor Is deadened,
so as not to convey sounds. The higher up the room
is situated, the better it is for fresh air and ventilation.
The walls and ceilings should always be hard-finished
and painted, so as to allowof frequent washing; a hard-
wood floor is also desirable. In most cases of acute
illness it is better not to have anything in the shape
of pictures, as they are simply dust-collectors. The ar-
rangement of the furniture also requires consideration.
The bed should be single and moderately high (the

THE PklVATE WARD.

571

Wire mattress being twenty-four inches from the floor),,
and placed so as to be accessible from all sides, awajri
from the door, and in such a position that the light
from the window may fall pleasantly upon it The-
bedside stand should be on the side next the door, the
wardrobe behind the door, the dressing- bureau on the
side or in a corner where the patient cannot see into
the mirror; the washstand on the other side of the
room near the bed; two ordinary chairs, a cane or
wooden easy-chair, a screen, and n lounge complete
the furnishings. Everything should be in good taste
and as dainty as possible, but must be of an absolutely
simple character : intricate and elaborate carvings and
finishings upon hospital furniture arc to be condemned.
Heavy woollen rugs or carpets, upholstered chairs,
pictures, and bric-a-brac must not be permitted,
though, unfortunately, rooms so furnished can still
not infrequently be found in private hospitals and
endowed rooms. This not only entails a useless ex-
penditure, but is really harmful, and a nurse who
understands the value of pure cleanliness will do all
in her power to introduce a hygienic method of fur-
nishing sick-rooms. A simple room such as we have
described can be made to look exceedingly pretty and
inviting by the addition of rugs and curtains. A bed-
side mat and one other rug, large enough to give an
air of comfort and color to the room, and small
enough to be easily taken up. shaken, and cleaned,
are all that may be allowed: art rugs answer the pur-
pose well, but when dealing with infectious or con-
tagious diseases even these should be prohibited.
Long white curtains of some soft washing material

iibited. ^m
laterial^^H

58 NURSING.

at the windows give an air of finish and cleanii
All heavy articles of furniture should be on casters, so
that they can be quietly and easily moved. In a pri-
vate house an adjoining room should be set apart in
which to keep everj-thing in the way of utensils, med-
icines, etc., as everything disagreeably suggestive
should be kept out of the sight of the patient*

The head nurse of a ward, besides being a thor-
oughly trained nurse, should be a woman of executive
ability, economical, and with some practical knowledge
of hou.sekecping. She is held responsible for every
thing pertaining to the ward, and if the patients are
only imperfectly cared for, the blame will not fall upon
the assistant nurses so much as upon her. It is her
duty to see that the furniture of the ward is kept in
repair, that supplies are on hand, that the medicine-
chest is replenished, that the linen is in good order,
that patients are admitted and discharged properly,
that the diet and medicine lists are revised, and that
only what is absolutely necessary is ordered. She
must visit the patients with the physicians, take down
their orders in writing, and see that they are faithfully
carried out. She is responsible to the superintendent for
the leaching and training of the assistant nurses in her
special branch of nursing. She must e.xcrcise a daily
supervision over the work of the maid and of the or-
derly, and see that it is done properly. It is desirable
that she herself should not do any of the work allotted
to others, except when really nece.ssary, as this would
point rather to a lack of executive ability on her part.
While these duties may seem multitudinous and sound
very difficult, they are in reality not so formidable if

*Sb« Aitpvmlu, Note t.

THE HEAD HURSE.

the head nurse knows how to plan out her work and
manage her subordinates, and if she is really interest-
ed in what she is doing. Just in proportion to the in-
terest which the head nurse takes in her ward will be
the interest shown by those who work with her ; and
if she is not systematic and orderly, and does not
always require that others shall be the same, her
patients and ward will soon show the deficiency. Her
standard should be such that those who work with
her shall know that nothing but their best efforts are
expected. She should be careful that no detail of
nursing-work is slurred over by any of the assistant
nurses or left by them to either the maid or orderly.
She should arrange and manage her ward as a part of
a whole system, so that a nurse when changed from
one ward to another will find everywhere the same
order existing. This is absolutely necessary if the
whole institution is to work in harmony.

The assistant nurses, appreciating the responsibility
which rests upon their head nurse, should do all in
their power to assist her by doing their work in the
most thorough manner. They should understand that
she must look to them for many of the minor reports
and details of what is taking place in the ward. They
should therefore be careful to report to her even what
might seem to them unimportant symptoms or cir-
cumstances. The head nurse should know every-
thing that happens in her ward. The accomplishment
of this should not be difficult, as each nurse has spe-
cial work allotted to her, and her share of the respon-
sibility is strictly defined.

A nurse in training should begin at the very com-

mencenient of her work to school herself in habits of
observation : she may do this best at first by noticing
the condition of the ward, whether it is orderly or dis-
orderly, and what she can do to put things to rights. She
should never pass up or down a ward without training
her eyes to observe the condition of patients, beds, tables,
chairs, and window-sills. This may be done by looking
at one side going up. and the other side coming down.
If there is anything out of order which maybe righted
in a moment, she should not fail to attend to it; and
if each nurse were trained to this habit, there would
not be the least necessity for a ward ever to appear
out of order. It is also imperative that whatever she
uses should be put away in its proper place when the
work is finished. If each woman as she enters the
training-school would take this one precept to heart,
il would save many unnecessary footsteps and much
valuable time, not only to herself, but to all those who
work with her. But, sad to say, in everj' training-
school one is obliged to emphasize over and over
again, to class after class, the importance of returning
to their proper places things which have been used.
For instance, if a blanket has been used, it should not
be taken into the linen-room and thrown down on the
table, but neatly folded and at once put on its proper
shelf. If a sheet or towel or night-dress is needed, it
is not necessary to pull down and leave in disorder a
whole pile in order to get the one wanted. If a medi-
cine-glass is used, it should be washed and put back
in its proper place at once before going on to some-
thing else. If little details such as these are disre-
garded, but little time is saved at the moment, the

iroX/r IN TffE WARD.

work is increased instead of lessened, and after all at
the end there must be a general tidying-up time
without the satisfaction of always having an orderly
ward.

So, then, we repeat that the two habits of order and
observation are the most essential points to be culti-
vated in the beginning of a nurse's training.

It may be of some assistance to those who have
wards to manage to give tables of the division of work
for a ward containing, say, thirty patients, a head
nurse, four assistants, an orderly, and a ward maid,
such tables to be modified according to the require-
ments of the particular ward.

If there is an orderly in the ward, his duties should
be carefully defined. He will be expected, in a male
ward, to give patients their first baths in the tub if
they are in a condition to be bathed, and to put them
to bed; to carry all vessels to and from the patients;
to give enemata to convalescent men ; to collect the
sputum-cups and keep them clean; to do the ward
cleaning in a systematic manner ; and to assist in any
heavy lifting. He should have his regular hours on
duty, and should not leave the ward without the
knowledge of the head nurse.

The ward maid should be responsible to the head
nurse from the time she comes on until tlie time
she goes off duty. She should be taught punctuality
in coming on duty, and should never leave the ward
without permission : she should carry out her work
according to written rules. Convalescent patients
should not be allowed in the kitchen at any time
assist her with her work.

The following arrangement may be found useful as J
a guide to the division of time and work :

Order of Work for Nurses.

The temperature nurse takes temperatures and charts
them ; gives medicines and keeps the medicine-closet
in order ; makes out and gives daily to the head nurse
the hst of medicines to be replenished ; gives out meals
and special nourishment; and is responsible for the
appearance of the kitchen.

The nurse on the right side of the ward cares for the
bed patients of that side, gets the convalescents up,
makes the beds, does the dusting, and is responsible
for the general good order of everything on that side.
In addition, she keeps the linen-closet in order and
folds the fresh linen.

The nurse on the left side of the -ward has the same
duties as the nurse on the right side, and in addition is
responsible for the bath-room and lavatory.

The third nurse takes care of the special patients in
the small rooms and looks after the dressing- carriage.
She is also responsible for the preparation of patients
for operation.

The probationer, or junior nurse, assists in making
beds and doing dusting, carbolizes beds, cleans mack-
intoshes, lists soiled clothes for the laundry, lists and
puts away new patients' clothes, and is responsible for
the patients' clothes-closet. She also assists in giving
out meals.

It is also an advantage to divide up the ward nurs-
ing, so that each nurse is detailed for a certain length
of time to each branch ; for instance, in a gynecological

H'OX/r IN THE WARD. 63

ward, where a nurse spends three months, the lime
may be divided as follows :

Work for Three Montlis.
First Month.

Ordinary ward work {half a month on right side of
ward and half a month on left side of ward) includes,
besides bed-making, dusting, carbolizing beds, which
will have been learned by her as probationer,
Bathing of patients ;

Care of perineal and other minor operation patients ;
Removal of packing; repacking;
Simple enemata ; douches ; passing catheter.
Second Month.

Temperatures, medicines, charts ;
Care of medicine-closet ;
" surgical carriage;

'■ kitchen, reporting amount of daily supplies ;
Serving out meals, stimulants, nourishment;
Preparation of instruments and dressings;
■' gauzes ;
" " solutions.

Special Work.
Third Month.

Includes the preparation of patients for abdominal
section, and care of abdominal sections from operation
to tenth day ;

The giving of nutritive enemata;

Passing rectal tube ;

Care of patients on special diet ; observance and

recording of all symptoms, with puSse and temperature
for eight days.

Schedule of Maid's Work (Women's Ward).
Every Day.

6 A. M. Report on duty to night nurse; prepare for
breakfast ; set tables and trays ; cut and toast bread.

6.30 A. M. Breakfast. Return at

7 A. M. Clear tables; carry out tray.=;; sweep ward,
corridor, linen-room, kitchen ; dust.

8.30 A. M. Scrub stairs; wash dishes; scrub lava-
tories, closets, bath-room ; finish cleaning kitchen and
refrigerator,

12 M. Dinner. Return at

13.30 P. M. Assist in carrying trays to and from
ward; clean tables; sweep dining-room; wash dishes;
remove drain from sink and clean thoroughly,

4 p. M. One hour off" duty. Return promptly at

5 p. M. Prepare for supper; set tables and trays;
assist in carrying trays to and from ward.

6 p. M. Supper. Return at

6.30 p. M, Wash dishes, clean stove; leave kitchen
in perfect order before going off" duty.

Maid's Special Work.

Monday. Clean all fireplaces and mantels; scrub
linen-room floor.

Tuesday. Clean basins of lavatories, closet, and
bath-room, and woodwork of closet, bath-room, and
lavatory.

Wednesday. Clean clothes-closet and sweep attic
stairs.

IVOJiK AV 77/i' ll'AKD.

Thursday. Afternoon off duty.
Friday. Scrub porclies.

Saturday. Take refrigerator apart and scrub thor-
l oughly; clean wood-work in kitchen, gas-stove, and
dumb-waiter.

Din 'cUo ns for Ckaning.
Wash paint only with warm soapsuds; if very dirty,
use a little ammonia — no Sapolio for paint ; wash slove,
porcelain, and iron with Sapolio; rub brasses with
"Putz" polish ; wash sink-drain with Sapolio, am! let
it stand to air for some time each day; use strong
solution of washing soda to flush sinks and pipes.

Schedule ok Orderlv's Work (Men's Ward).
I Every Day.

J A. u. Come on duty ; collect and wash urinals and
k sputum-cups ; clean floors and brasses of closets.

7.30 A. M. Sweep and rub floor of ward ; brush ven-
I tilators; sweep porches.

12 M. Dinner. Return at 12.30 p. m.

12.30 P. M. Brush floors of ward and halt.

5 " Light gas (when required).

7 ■■ Off" duty. Leave closets clean and m

1 order before 7 o'clock.

Special Work.
First Week in Month.

Monday- Paraflfine and rub floor in ward.
Tuesday. Paraffinc and rub floors in corridors and
hooms.

<» NURSING.

WtKlncsday. Clean windows on right side of ward I

Ihursday. Clean windows on left side of ward.

Friday. Bathe convalescents.

Saturday. Finish bathing convalescents ; clean chan-
(Micn>.
SiXOMU Wcik in Month.

Monday. Paraftine and rub floor in ward,

'I'lit-sday. Paraffinc and rub floors in corridors andS
ruoni.H.

Wednesday. Clean windows at end of ward.

Thursday. Clean transoms in corridor.

Friday. Bathe convalescents.

Saturday. Finish bathing convalescents; clean chan-
ilctlers.

Third Week in Month.

Monday. Paraffine and rub floor of ward.

Tuesday. Paraffine and rub floors of rooms and
corridors.

Wednesday. Clean windows in corridors and rooms.

Thursday. Clean windows in bath-room, lavatories,
closets, and kitchen.

Friday. Bathe convalescents.

Saturday. Finish bathing convalescents ; clean chan-
deliers.

Foitrlk Week in Month.

Monday. Paraffine and rub floor m ward.

Tuesday. Paraffine and rub floor in rooms and
corridors.

Wednesday. Dust walls in corridors, ward, and
rooms,

HOSPITAL ETIQUETTE.

Thursday. Clean outside woodwork.

Friday. Bathe convalescents.

Saturday. Finish bathing convalescents ; clean chan-
deliers.

Hospital Etiquette.

Relation of Nurses to Hospital Officers and Patients ,
to Patients' Friends; to Strangers; to One Another. —
Here the head nurse is again responsible for the gen-
eral tone of the ward, and she should see that due
observance is paid to the etiquette and rules of thi
hospital by those about her. In no better way can shi
do this than by being particular in her own behavior,
never allowing herself any license that she would not
grant to her assistants. Hospital etiquette consists of
nothing more than the continual and systematic ob-
servance of every-day courtesies. As a ward is, for
the time being, a home for the head nurse, and her
staff" is, as it were, a family, it is only proper that to
every one entering the ward any member of the staff
happening to be present will extend the same courtesy
that she would show to visitors in her own home,
always being pleased to do the honors of the ward.
As at home we should never dream of receiving a vis-
itor seated, so a nurse should not remain seated when
any one enters her ward. This applies particularly to
the medical officers connected with the ward, the su-
perintendent of the hospital, superintendent of nurses,
and strangers. If they enter the ward in an official
capacity with visitors, the nurse should receive them
standing, and in an unobtrusive manner be on the alert
, to accompany them about the ward or ready to an-
r 9wer any questions which they may ask. When the

head nurse is in the ward, this is her duty. If she is
absent, then it falls to the lot of the nurse who has
been left in charge'. But some judgment must be ex-
ercised in regard to the observance of this form. For
instance, members of the medical staff may come into
the ward many times in the course of the day just for
a moment or for something connected with their own
particular duties; in these cases it is quite unnecessary
for the nurse always to leave her work, unless she sees
that she is really wanted ; a movement to show her will-
ingness to give her assistance whenever it is needed
may be sufficient. An assistant nurse should never sit
while receiving her orders from the head nurse. It is
exceedingly bad form to sit while a superior officer is
standing and giving instructions.

A nurse's manner toward her patient should be cha-
racterized always by a gentle dignity. She should be
wisely sympathetic, and, while never familiar nor tole-
rant of the least familiarity, should always make the
patients feel that they are her first consideration, and
that to do anything for their comfort is her greatest
pleasure. Never should she forget to be particularly
attentive and kind to a new patient : the dread of en-
tering a hospital is bad enough, but much of the gloom
can be removed by the bright, cheerful greeting of the
nurse, and the stranger may be made to feel at once
that he has come among friends. One should never
leave a patient to sit unnoticed and uncared for. even
for ten minutes ; for what seems but a few minutes to
the nurse may seem to him to be hours, and leaves an
unpleasant impression of neglect which much kindness
afterward may be unable to erase. The friends of pa-

HOSPITAL ETIQUETTE.

tients are often the greatest trials that a nurse has to
contend with, but fortunately all are not alike trying,
and their importunity is often merely the result of an
ignorant prejudice against hospitals and every one con-
nected with them, so that the quickest and best way to
satisfy them is to assure them in a pleasant manner
that their friends will be well cared for, and give them
practical evidence of it. Du-aling with such people also
affords a good opportunity f^r the development of tact
and patience. The nurse should not try to avoid them
in anyway, but should listen attentively to what they
have to say. particularly if it has any bearing upon her
patient's previous condition, and she should endeavor
to obtain from them whatever information she may
think of value to the physician. She should let both
patient and friends feel that they are considered, and
that they may rely upon her not to keep them in igno-
rance of anything which the doctor Is willing they
.should know.

Very frequently strangers come, wishing to visit
the hospital, and through some neglect at the door
they may be allowed to wander off" by themselves
and appear in the ward unattended. To such the
nurse should go at once, a.sk if there is anything she
can do for them, and offer to show her own ward. One
should never leave a stranger to the e.vtremcly uncom-
fortable sensation that he has unpardonably intruded
in coming into the ward.

In order that the best work may be accomplished it
is absolutely necessary that an esprit de corps should
prevail among the nurses. From the moment that
sonal jealousy, discord, and faultfinding appear,

per- H
the ^H

70 jvi/ssmc.

standard of the work is lowered. It is more than
likely that, during a two years' course of training, one
will be exfiected to work in connection with some per-
son with whom in every-day life one would have little
in common, but it must be remembered that all belong
to the same sisterhood and have an interest in the same
work, and that for the time being the best must be
made of the situation. Absolutely nothing in the way
of personal feeling toward each other should be shown
among the staff of nurses. It is equally objectionable
to be on too friendly or familiar terms while on duty.
A dignified and kindly attitude toward one another
should prevail, and it i.s always best to select friends
or companions among members of one's own class.
For a senior to be obliged to seek the companionship
of a junior or new-comer artjues that she is deficient
in some of the attributes that make people compan-
ionable, and she should try to find out her fault and
overcome it. It is also bad for a junior to be suddenly
promoted : it is best for her to make her position grad-
ually, and not to aspire to a rank which is not right-
fully hers so long as she is a junior. An intimate
friendship between the head nurse and pupil nurse
ought never to exist, if only for the sake of the pa-
tients. One is only a learner, the other a teacher. If
a pupil makes a mistake in the care of her patient or
is careless or negligent in the performance of her du-
ties, it is almost impossible for that head nurse to in-
sist upon her repeating her work until it is done prop-
erly without causing unpleasantness ; and of course if
she fail to do this, then the work must suffer.

A head nurse must never leave her ward for any

HOSPITAL ETIQUETTE, yi

length of time over 6ve minutes without tdling her
senior nurse that she is going and saying where she
niay be found. It is very trying sometimes for the
physician or superintendent to enter and look in vain
for the head nurse of the ward, and find no member of
the staff who is able to tell where she is. If siie is to
be away for the afternoon, she should mention it to the
superintendent of the school. She should never leave
her ward for any length of time without placing her
senior or some other responsible nurse in charge. The
head nurse anj senior nurse should not be off duty at
the same time, except with the knowledge and sanction
of the superintendent, who will then take the responsibil-
ity of whatever may happen. The visiting of other head
nurses while on duty should not be permitted. The
head nurse should see that the senior nurse, or whoever
is acting as senior, has an accurate knowledge of the
entire ward and its patients, who they are, and what
is being done for them, as questions and emergencies
often arise that must be answered and met during the
head nurse's absence. It is extremely awkward to find
a nurse left in charge who does not know anything
about the ward except her own work in it ; but, on the
other hand, this does not mean that the head nurse
should leave any of the arrangements or details of
work that arc hers to be done by an assistant nurse :
all reports, requisitions, and lists of supplies should be
made up by herself. When the head nurse is on duty
all questions should be left to her decision, and visitors
should be referred to her.

There is nothing for a nurse to do but to go on
steadily with her work : general conversation betwe, n

an occft- ^^H
■t is pcr^ ^M

■.

72 Nuxsma.

nurses while in the ward is strictly forbidden
sional question regarding the work is all that is pcr^
missible. The same remarks apply to the nurse's re-
lation to the hospital physicians. The ward is not
the place, and " on duty " not the time, for indulging
in social talk : the time belongs to the patients, and
a right-minded, conscientious nurse will never permit
her patients to be deprived of what is justly theirs.
To have friends to visit one in the ward is quite out
of place. If possible, a time should be appointed when
the nurse knows she will be off duty, else there will in-
evitably be the disappointment of not being able to see
friends when they come. !n caring for private patients
nurses must also be watchful that they do not become
drawn into a lengthy conversation, so that the time
that should be spent on two patients is given to one.
It is the head nurse's duty to arrange the " off-
duty" hours of her assistants. The schedule should
be made out some time in the morning, and pinned up
where the nurses can see for themselves when they are
expected to go : when the hour arrives the assistant
will simply report to the head nurse that she is going,
and not wait to be told to go. for the head nurse may
be too busy at that hour to give her a thought. These
hours should be given, as a rule, in the afternoon. To
thoroughly care for the patients, make rounds with
the physicians, carry out any orders that may have
been left, and put the ward in good condition for the
day will require the full staff for the morning hours,
but a head nurse .should be particular in seeing that her
assistants get their proper amount of IcLsure, If eight
hours on duty represent the day's work, she should see

JtOURS ON AND OFF DUTY.

that they are not kept over that time day after day :
while she should insist that they come into the ward
promptly on time, not five minutes or ten minutes
early or late, but at the exact hour stated in the hos-
pital regulations, it is only right that they should be
sent off as punctually as they came on, except in cases
of emergency or where the ward work is very heavy
and there may be one nurse too few. Then, for the sake
of the rest, any nurse should be expected to stay on
over time. It is false economy, however, to deprive
nurses of hours and afternoons that ju.stly belong to
them. It will be found, if such a course be pursued,
that the work will drag, that it will not be done with
the same energy, brightness, and freshness, and before
long the patients will feel the bad effects.

A written statement of the hours each nurse has had
off duty should be handed by every head nurse to the
superintendent between eight and nine the next morn-
ing, when she makes her morning visit to the wards.
It i.s not a head nurse's privilege to keep her nurses on
duty over time without reporting when and why she has
done so, and no assistant nurse may return to the ward
before the hour specified by her head nurse. When
the assistant nurse is off dutj' she may not go into the
hospital to visit or. in fact, for any purpose without
the permission of the superintendent of the training-
school. When she is off duty she should plan out
her time for study, rest, and recreation. The time of
her two years' training should be very precious to her,
and she should make the most of everj* opportunity
afforded her. Remembering, however, that all ex-
tremes are bad, she should be careful neither to over-

NURSINC.

tax her physical strength nor to allow her mental fac-
ulties to become dulled.

Some nurses carelessly get into such a rut that they
know scarcely anything outside of nursing. At the
end of the two years a nurse should be ready to go
forth to her work strong in body, improved in intel-
lect, and ready to adapt herself to .social conditions.
The study hours should be systematically arranged.
An hour a day spent over lessons or lectures is not
a great deal, but gossipy interruptions should not
be tolerated. To lie down for half an hour and give
perfect relaxation to muscles and nerves is very neces-
sary. One should go out among friends or to dinner,
a concert, or the theatre at least once a week. Such
relaxation is very beneficial, and the change of atmo-
sphere will invigorate one and keep one in touch with
outside affairs. Once a week will be sufficient, other-
wise it becomes detrimental instead of beneficial.

The night nurse and her duties must be specially
considered, as her work differs from the day nurse's in
that she is usually the only nurse in the ward at night,
and so has more directly to do with the nursing of the
patients. There should be definite rules laid down for
her guidance. In hospitals where the nursing is done
by means of nurses in training it is usual to have a grad-
uate appointed as night head nurse for all the wards.
She assumes the responsibilities that head nurses have
during the day, and is indispensable, as very often the
night-nursing staff" is composed of a number of under-
graduates who may be only in their junior year, but
who arc quite equal to their duties if they have some
one upon whom they may call for advice or assistance

THE NIGHT NURSE. y$ ,

when necessary. The head nurse should make her i
rounds through iht- entire hospital not less than three I
times during the night. She should vary the hours,
and remain longest in the heaviest wards or where
a nurse needs particular oversight. Alt reports to the
doctors should go through her, unless in a case of
sudden emergency where an attempt to find the head
nurse would result in the loss of valuable time: in
such a case the night nurse must act for herself and
send for the physician on her own responsibility,
notifying the head nurse at the same time. Night
nurses are expected to report for duty to their head
nurse at a given hour, and, as far as hospital etiquette
is concerned, stand in the same relation to her as the
assistants do to their head nurse in the day-time. Any
deficiency in medicines or in supplies for night use must
be reported to her on her first round through the wards,
and it is for her to see that they are supplied, as a
nurse should never leave her ward for any purpose.
In ca.se of a death she should be promptly notified.
Every nurse is expected to leave all utensils used
during the night in a clean condition and in their
proper places. Medicine-closets must be kept locked,
and bottles containing stimulants or opiates must never
be left where there is the least danger of a patient get-
ting them. Matters not strictly professional must not
be discussed by night nurses on duty with physicians
or private patients, nor must any eatables be offered
unless with the sanction of the head nurse, as every-
thing that is in the wards is supplied for the patients
alone, and the nurse is responsible for seeing that no
one else uses them.

NURsrNC.

A night nurse should so arrange her work
may be finished by the time the day nurses come on
duty: everything should be in order, and she should her-
self be ready and waiting to give her written statement
of the condition of her patients to the head nurse. It is
not in her province to see that convalescents' beds arc
made, but it is her duty to see that convalescents are
wakened in time to prepare themselves for breakfast,
that the faces, mouths, and hands of bed patients are
bathed before breakfast, and to give out the breakfast
with the assistance of the ward maid. She should be
required, besides leaving everything in good order, to
hand in a neatly-written night report When off duty
she is still under the supervision of the night head
nurse, and must not be absent from her room during
prescribed hours without her knowledge and per-

that ^H

ame on ^^

CHAPTER III.

Wakd Suppues.— Nitrses' Toilet -Baskets. — Wakd Work— Daily
Care of the Ward. — Special Cake of thk Ward. — CLtAM.i-
jjs AND Blamcets.— Cark of Ward Utensils.

In addition to the furniture already mentioned as
necessary in a ward, there are quite a number of
desirable furnishings the presence or absence of which
must depend upon the income of the hospital. One
should try, at all events, to have a standard number
of each thing, so as to be able to know just what one
has on hand and what has to be accounted for: any
other plan will lead only to confusion and extrava-
gance. Just here, a word will not be amiss to nurses
in general upon care and economy with regard to
hospital supplies. With these the nurses have more
to do than any one else ; they are the stewards, and
upon them lies the responsibility of seeing that noth-
ing is wasted or used extravagantly. For instance, the
laundry-work could often be greatly lessened if nurses
were more careful when changing beds and using
towels; the gas bill could be much reduced if they ■
would remember to turn down or put out the gas
when it is not needed or when half a flame would do
instead of a full one; alcohol, drugs, milk, and food
should be ordered only in such amounts as are neces-
sary, and one should be economical, although not
parsimonious, in their use. Two bandages should

ncvor bo put on where one would answer. In all
llicse wa)'s the nurse may become a liberal contributor
to charity in that through her efforts two patients can
be cared for where otherwise only one could be sup-
ported.

With a limited number of some articles one can
manage very well, but of such things as linen, toilet
and dressing basins, and vessels of various kinds there
should be a liberal supply. In the average ward of
thirty patients the standard linen list may consist of
the following articles :

ninnkcls (while),

Dr«ucs (women 'a),

Nighiingalcs,

Ni^llt-Bowna, i

Pillow -cases, i

relticoals,

Kulibers (b«d],

" (lonu block),

(dreaaing, med. ward),

Slucklnes, pain,
Slippeia,

surg. \

Slieds (large).

Toble-clolhs,
Towels (padenls'),

Wnippcni (flannel)
Vesis (flannel),
(feulieT).

4«

(hair).

■ the

H out

With suitable modifications the same list will apply to
the male or children's wards,

A general linen-book for all the wards is kept by
the superintendent of the training-school ; in it is
entered a list of the linen originally given out to each
ward. When a ward is once supplied with a full list
of linen, no new articles should be sent in except by
the system of exchange. Thus, for instance, a worn-
out garment may be replaced by a new one, but the

XVAffD SUPPLIES.

new one should ntver be given out until the old one '
has been returned. The day for exchange throughout
the hospital should be the first of each month, and
during the month each head nurse should lay aside
whatever is worn out or needs mending : on the first
of the month the superintendent looks these things
over, and those condemned arc listed and numbered.
They are then sent to the hospital linen-room, the
lists are verified, and the worn-out articles replaced by
new; the other articles are repaired, and during the
second week in the month iire returned to the wards.
For general ward supplies, such as dishes, soap,
matches, brooms, brushes, etc., a requisition should '
be sent in once a week; a small book is kept in each i
ward for this purpose, and every Saturday morning ,
the head nurse writes in it a list of new articles re-
quired, and adds her exchange list of worn-out or ]
broken things. The superintendent also goes over ■
this list carefully to see that economy is being prac-
tised, and finally hands it in to the general store-room.
Each ward keeps its special basket, which is replen-
ished according to the requisition-book, and returned
to the ward on Monday morning. The head nurse
should receive it herself, see that what has been sent
corresponds with the list in the book, and if correct
sign a receipt for the same. At the same time on
Saturday morning lists of surgical supplies and hos-
pital stationery needed for the week shouid be handed
in to the superintendent.

For the patients' toilet each nurse should be sup-
plied with her own toilet-basket. (See Plate I.) This
should be made of strong wicker, 13 inches long, g^

inches wide, and 4j^ inches deep. The requisite
cles are a hair-brush ; combs (fine and coarse); small
mouth-wasli cup; whisk broom; soap-dish; three
small jars for boracic acid, oxide- of- zinc powder, and
vaseline; three six-ounce bottles, one containing alco-
hol for rubbing the back and limbs, one ammonia for
adding to the bathing water, and one listerine or some
pleasant mouth-wash ; besides these, there should be a
rubber cloth ^ of a yard square to be used for protect-
ing pillows, sheets, etc. when a patient is being bathed.
Nothing more is necessary, nor should anything else be
allowed, as the baskets must be uniform, so that when
inspection day arrives the contents of each will be
found precisely the same. Each nurse is held respon-
sible for the neatness of her basket. All necessary
articles are in it when it is given her. and after this
she must attend to keeping up the supply. Worn-out
articles are put on the ward exchange list by the head
nurse, and their place supplied by new ones, but any-
thing lost must be replaced at the expense of the lo.ser.
Nothing in the way of ribbons or binding is needed.
The baskets should be arranged in such a manner that
they can be kept absolutely clean. Since each nurse
is supplied with one, there is no chance for any nurse
to complain that she is unable to leave her patients in
proper condition owing to the general ward toilet arti-
cles being in use or because some of them cannot be
found. The cost of so many baskets in the beginning
is considerable, the price of a basket without the con-
tents being about fifty cents, but they wear well, and
f proper care is taken of them they can, at the end
of the two years, be passed on to the next class. By

te arti- ^H
: small ^^

IVAXJ} DUTIES. 8 1

having 3 proper number much time and trouble is
saved and better work is ensured.

In the previous chapter the division of work in the
ward was outlined. We will now consider how this
work should be done.

The daily care of the ward must come first. The
nurse is to go on duty promptly at the appointed hour
in the morning and begin her work at once. These
first minutes in the morning are precious, and no one
should spend a moment in pausing to chat with the
night nurse, who perhaps is a friend, or with her fellow-
nurses, before beginning work. The ward discipline
in this respect should be very strict. The head nurse
is there to overst;e things in general, and her own par-
ticular work should occupy each nurse at this hour.
It is best to begin by giving the side of the ward
under her care a general straightening up, unless it
already is in order: the chairs are to be put in their
proper places, unnecessary things removed from the
stands, and the coverlets all straightened on the beds.
This takes but a few moments to accomplish, and
gives an orderly appearance at once, and makes the
remaining work less confused. It is necessary to have
the wards neat, quiet, and in good order by the time
the physician enters to make morning round.s. The
hour for rounds varies in different hospitals, but a.s in
many nine o'clock is the time set, for the sake of con-
venience we will consider this as the hour. The con-
valescents' beds have been already aired by the night
nurse, and are ready to be made up at once. If
rounds are early, it will be impossible to make thor-
oughly the toilets of all the bed-patients unless they

82 NUKS/NG.

are few in number, but care should be taken to
that they are all clean, their mouths and teeth washed,
and the beds straightened ; then after rounds each one
may be carefully finished. After the main sweeping
and brushing has been finished by the ward maid, the
daily ward dusting will come next in order, but it will
of course be impossible to have it all thoroughly done
for early rounds, This dusting is done simply to re-
move the Iwenty-four hours' accumulation of dust
For this purpose a damp cloth wrung out of a basin
of a weak- solution of carbolic acid should be em-
ployed. All the chairs, tables, window-sills, bed-
heads, bed-frames, sides, and ends should be gone
over in this manni^r, care being taken to change the
water frequently. The dust-cloth should afterward be
washed out in hot soap and water and wrung out of a
I : 20 {s per cent.) solution of carbolic acid before
being hung up to dry. The bedside stands should be
examined each day, and nothing left in them but con-
vale.scents' clothes: everything in the way of food,
extra clothing, pasteboard boxes, etc. should be
removed.

A ward floor should be made of hard wood, and
then rendered impervious to absorption. Scrubbing
hospital floors is a mistake, for in this way impurities
and germs are constantly being absorbed by the wood
instead of being removed: as a result, as soon as the
floor dries the dust given off from it may contain the
very germs that the washing is supposed to remove.
Hard wood, finished with shellac varnish and then
treated with a mixture of turpentine and paraffine,
makes a beautiful floor and a perfectly smooth resist-

to see ^H

ashed. ^B

IVAXD CLEANING.

ing surface, upon which the dust only rests and from
which it call be easily rubbed off. The turpentine is
also cleansing, since it dissolves and removes any spots
or stains that have appeared ; it has also disinfectant
and deodorizing properties. To make this preparation.

Take of Turpenline, one gallon ;
Paraffine, six ounces.
;o stand (or twenty-four hours till the parafiine is dissolved, then
:e of soft soap before using, mixing all thoroughly.

It can be applied with a pad of flannel fastened on an
ordinary mop-stick. With this the floor is to be rubbed
all over, and before the hard rubbing for polishing
should be left an hour or so until the turpentine is a
sorbed; then it is polished, the rubbing being always
in the direction of the grain of the wood, with a heavy
polishing brush covered with flannel and weighted with
from twelve to twenty-five pounds of lead. (See Fig. i.)
This application should be made every week or ten
days, the floor being brushed up every day with a hair
floor-brush. In brushing a hospital floor it is import-
ant to raise as little dust as possible: by fastening a
flannel over the brush this danger cati be almost en-
tirely obviated. Another excellent preparation for
floors is " Butcher's Boston Polish."

After the patients and ward are in order each
nurse should give her attention to that special part
of the ward for which she is responsible: if it be
the lavatory, she should see that all bottles, vessels,
etc, are clean and in their proper places, and that
the shelves and slop-hopper are in order. If the
laid does not do her work well, the attention of
the head nurse sliould be called to the fact. It is

NUKsmc.

always best to have the criticisai
come from one in authority, but
it is the nurse's place lo see that
the matter is reported, otherwise
she herself will be blamed for be-
ing willing to have an untidy lav-
atory or any other department en-
trusted to her charge. This daily
cleansing keeps the ward in good
condition, but it is not sufficii^nt
to make a more particular and
thorough cleaning unnecessary.
When we stop to consider the
number of patients with their va-
rious diseases who pass through
a ward, with, say, an average
of thirty inmates daily for six
months or a year, besides all
their friends and the people who
come and go in the ward during
that time, we can easily realize
how necessary it is to be con-
stantly on the alert with precau-
tionary measures in the way of
thorough cleaning. This should
be done daily, weekly, semi-an-
nually, and annually. In the
weekly cleaning the bedside
chairs and the window-sills
should be washed thoroughly
with hot water and green soap,
scrubbing-brush being vigorously used. One da>

Hr/iXI} CLEANING. 85

should be set apart for this purpose, each nurse looking
after her own division, and a second day for a thorough

dusting and cleaning of the beds. In doing this one
goes over the bedsteads with a solution of carbolic acid,
and the mattresses are well brushed with a whisk broom.
"^his precaution is absolutely necessary in free wards,
where vermin are not infrequently brought in by pa-
tients or their friends, for if these pests are once allowed
to get a foothold, the task of getting clear of them is
difficult. A bedbug should never be seen in a hospital
ward, and this weekly care of the beds is the only way
by which the bugs can be kept out, The same precau-
tion should be taken in private wards, and patients'
trunks should not be allowed to remain in the rooms,
but should be unpacked and taken to a trunk-room.

The most thorough cleaning of the ward should be
done in the spring, and then, if possible, it is better to
transfer the patients temporarily to another ward:
usually, however, this is not possible, and so one
selects a time when the occupants are few. Walls
and ceilings should be thoroughly washed down and
repainted, all the woodwork well cleaned, windows and
chandeliers polished, and the beds disinfected thor-
oughly with carbolic acid. The floor is to be scoured
at least twice with green soap, hot water, and brush,
before being again paraffined. Every corner and every
portion of the ward should receive this treatment.

Besides the regular weekly cleaning given to the
beds, it should be the rule when a patient is discharged
always to prepare the bed for the next occupant by giv-
ing it a carbolic wash. Bichloride should never be used
for this purpose, as it corrodes and destroys the iron.

The mattresses should be sent to the stenlizing oven,
or thoroughly brushed and left for some time ex-
posed to the open air and sunshine. Blankets are
treated in the same way. When these are too soiled
or for any reason unfit to be used again before clean-
ing, they should be sterilized and put away until a
number have accumulated from the various wards, and
then all sent at once to be cleaned, instead of being
washed at the regular laundry. If one does not do
this, the blankets will become hard and stiff with ordi-
nary washing, and will not wear as long as they would
with proper care.

The ward utensils, such as the patients' basins, bed-
pans, and urinals, should, besides the attention given
them daily, be well washed out with green soap on a
certain day of each week and left in boiling water for
an hour. The general bath-tub is to be cleaned thor-
oughly after each patient.

These are domestic details that must be looked after
carefully and systematically, not in a spasmodic way,
for they all indirectly have much to do with the pa-
tients' welfare. Above all. the ward is not to be made
a .storehouse for unused or broken articles of furni-
ture, for. unless the rule be rigidly adhered to that
only useful articles and those in good repair are al-
lowed in the ward, we are sure to be hampered by an
accumulation of rubbish.

CHAPTER IV.

3eds.— Bed-making for Bed Patients; for Convalescents. — To
Prepare a Bed for an Operation Patient.— Fracture Beds
— Mechanical Appliances for the Relief of Bed Patients
— Head-eists. — Pads. — LirrisfG ami Moving.

The regulation bedstead for hospital puqjoses is
made of iron ; all other kinds are fast falling into disuse,
and are only to be found in the older hospitals, where
they are not sufficiently worn out to justifv the expense
of new and more modern ones. Any household would
do well to have an iron bedstead on hand, and in any
case where there is to be a prolonged illness in the
house one should be purchased. Ten or twelve dol-
lars will cover the expense. There are many varieties
af the iron-frame bed, and just what selection is the
most desirable is often puzzling to a buyer who has
not had the actual experience of testing the merits or
imperfections of the different kinds. A nurse who
works over them daily ought to be a fair judge of
what is required in the way of a bed for the sick.
Four things should be taken into consideration in
making a choice: viz. height, weight, durability, and
simplicity. The height must be greater than that
necessary for ordinary beds, not only because the
continuous bending over a low bed could not be
endured by nurses for any length of time, but because
tor purposes of examination and treatment the doctors

S8 J^UXSIMG.

must have a bed which will not necessitate much
stoopinjj. To the patient the question is really im-
material, for a footstool can be easily supplied for
stepping in or out of bed, or If a patient thinks that
he is more comfortable when sitting on the side of
the bed, a lounge may be placed alongside for the
feet to rest on, A single bed answers every purpose.
It is rare for evtn the largest person to find it uncom-
fortable, and too wide a bed would make it impossible
for the nurse to do her work with any comfort cither
to herself or to her patient.

The beds should be of medium weight. Great,
'leavy. clumsy iron beds are quite out of place, as
it is impossible to move them without extra help,
and they are apt to become wrenched during the
process, and besides are not likely to last any longer
than lighter ones. An iron-frame bed should last for
years without need of repairs, if well put together and
provided with a firm double-woven wire spring. It
should be made with the utmost simplicity, for the
.sake of cleanliness, and should have absolutely no
wood about it. The corners and crevices, where ver-
min or dust can lodge without being easily removed,
should be as few in number as possible. A little more
finish can be given to the bedstead by the addition of
a brass rod across the foot and head and of brass
knobs on the posts. Painting or enamelling with
' some pretty color adds much to the appearance. The
length of such a bed should be 6 feci 6 inches, the
width 37 inches, and the height from 24 to 26 inches.
As its position has frequently to be changed, it should
be mounted on casters. The only objection to these is

THE BEDSTEAD AND BED,

that tht-y ciiakc it hard to keep the bed straight,
or both ends are readily moved by even a slight touch.
It is therefore well to do without casters if enough
men can be procured at a moment's notice to lift and
carry any bed which has to be moved, for then the
floors are not scratched, since the beds remain firm
in their places. Every bed should be placed in such
3 position as to be freely accessible from all sides.
The best form of mattress is one made of prepared
horse-hair, weighing from 22 to 25 pounds, but to
keep this mattress in good order it should, after
being vacated by a patient, be disinfected in a steam
sterilizer, and exposed for a short time to the sun-
shine and air before being again used. At intervals
of twelve or fifteen months it should be taken apart,
the ticking washed, and the hair renovated and made
up afresh. In some hospitals two layers of army
blankets are used over the wire mattress, but thev
do not make so comfortable a bed. Straw mattresses
have this advantage — namely, that they can be re-
newed for each patient, but unless carefully made up
they are apt to be lumpy and extremely uncomfortable.
Feather beds are only met with in private practice, and
a nurses ingenuity will have to be exercised to cflect a
change, since any one who sleeps upon feathers in the
present age is very apt to be " set " in her ways. The
idea of making the mattress in three parts is not a
good one, for if patients are at all restless, the divisions
slip apart, and, although the middle portion of the
mattress can be changed without interfering with the
other two, i* is after all not much easier to do this
than to put on an entirely fresh mattress or to lift the

one ^^1

go fruJisrj^c.

patient to another bed. Each bed should be su]
with two pillows, one of hair and one of fcathi
Frequently only one is required, and in fever cases
or where there is much perspiration this should be
of hair.

The covering should be light but warm, consisting
of an upper and a lower sheet, 2^^ yards in length,
and a draw sheet, 2]^ yards long and 2 yards wide.
These should be made of white bleached cotton, as
linen is more apt to be chilly and damp. Some light
form of white cotton spread should be used on the out-
side, either of dimity or of a light-weight honeycomb
pattern, but in hospitals, at any rate, the usual heavy
white counterpanes should no longer be tolerated.
A patient is often uncomfortable with a counterpane
on, though he cannot discover the cause of his dis-
comfort, and with operation cases and fever patients
they should never be used, a clean white sheet being
preferable. Counterpanes also interfere with the ven-
tilation of the bed ; and, though it is true that they
make a ward look well, the patient's comfort should
be the first consideration.

A nurse should be quite familiar with the best
method of making a bed for a bed patient and with
the manner of changing the sheets, pillows, and pa-
tient's linen, so that the bed may always be kept in
good condition. Only a great deal of practice will
make her quick and deft in the performance of this
work. To make a bed for a patient who must be in
it any length of time, a mattress should be selected
that is smooth and even, not worn to a hollow in ths
centre : the lower sheet is put on first, and should be

supplied ^^1

BED-MAKING.

long enough to allow the ends to be well tucked in,
first at the top and bottom, and then at the sides;
next a draw sheet of rubber cloth 32 inches long and
45 inches wide is put on, the upper edge reaching
to the edge of the pillow, and the lower coming
down well below the place where the patient's hips
will rest The cotton draw sheet (doubled) should
cover this entirely and be tucked in under the
sides : in order that it may be perfectly free from
wrinkles, it can be kept in place by being fastened
with a safety pin at each of the four corners to the
under part of the mattress; the two hemmed ends
should be at the lower end, as there should never be
a seam under the patient's back. The upper sheet
and blanket come next, and lastly the counterpane,
The upper edge of the blanket should be protected
from soiling by being folded in the counterpane.
the top, between it and the upper sheet ; to keep the
coverlet clean a margin of about nine inches of the
upper sheet is folded back over it. In tucking 1
these covers at the bottom one should be careful not
to draw them too tightly over the patient's toes ; they
are to be loose enough to allow the feet to be moved
about with comfort.

The changing of linen should be managed vv-ith as
little fatigue and discomfort to the patient a> possible,
Unless the patient is very ill one person can do this
easily. Only the upper sheet or a single blanket is to
be left over him. The lower sheet and draw sheet to
be removed are loosened at the top, bottom, and at
both sides; one side is then folded along their whole
length as flatly as possible close up to the patient. The

NURSING.

fresh ones should then be folded lengthwise, alter-
nately backward and forward, for half their width, and
placed on the side of the bed from which the soil
ones have been removed, and the loose half tucked in
at the side. The nurse then moves to the opposite side
of the bed and turns the patient on his side with his
face toward her; she can support him in this position
with one hand while she tucks the sheets to be re-
moved as closely and smoothly as possible up to
his back, their place being taken by the fresh ones,
which are made to follow them closely. Using both
hands, the nurse now gently turns the patient toward
the side away from her; the soiled sheets and the
folds of the clean ones are drawn through, the former
being taken away and the latter smoothed down and
tucked in their place, care being taken not to leave
the smallest wrinkle. Patients can often assist in this
changing by means of the crane suspended above the
bed, by which they can raise themselves more or less;
but if a patient is quite helpless, then it is best to have
a second person to assist at the changing of linen.
In changing the upper clothing the fresh sheet and
blanket are to be spread over first, and the others are
then slipped away from underneath. It is quite un-
necessary to expose any part of the patient in changing
the entire bed-clothing. For convalescents it is un-
necessary to have a rubber sheet on the bed, as its
only object is to protect the mattress ; when not
needed for this purpose the patient is better without
it, as it often causes perspiration and may be uncom-
fortably warm. In making a convalescent's bed it
should first be well aired, and, no matter the time of

BED-MAKING.

i patient jjtts up, for a half hour or
louid be opened and aired. Two
used upon which to spread tlie
off the bed : one is not enough. a3
J on the floor or become piled up,
rculate through them. Kach piece
I separately before being laid loosely

the day at which a
more llie bed shi
chairs should be
clothes when taker
they are apt to dr;
so that no air can (
should be shakei
over the two chairs.

In a hospital ward uniformity of appearance must
be maintained in the beds, as it adds largely to the
general neatness of the ward. Young nurses among
their first lessons must practise making beds in such a
way as to have them appear neat and uniform. It
would never do to look down the ward and see some
beds all hills and hollows, others with the spreads
banging farther down on one side than on the other,
or with a comer hanging out in any direction, or to
.■iee the pillows, some showinf^ the f-cking through the
end of the slip, or some lying fl.it ;ind others bolt up-
right After tucking in all the angles and making up
a bed neatly, a general smooth appearance can be pro-
duced by running a flat .stick, reaching across the bed,
with some pressure, from the bottom to the top. before
the pillows are put on. Patients arc very fond of put-
ting things away under the heads of the mattresses:
nothing whatever should be allowed to remain there,
and their towels and bath-cloths should be neatly
folded and hung on the rung of the bed just behind
and below the pillows, where they will be well aired
and dried if damp.

To prepare a bed for an operation patient the same
process is gone 'h.ougb as described in making a bed

for a bed patient, with the exception that a sinj
blanket is put on between the upper sheet and the
patient, to be removed after the patient has reacted.
The pillows should be removed to prevent nausea,
and a towel pinned in their place across the top of *
the mattress, so that the head may lie low ; two other J
towels should be hung over the head of the bed in case J
of vomiting after the anjesthetic, and a small basin placed
on the bedside table. Instead of tucking the bed-cover- :
ings in all around, on one side they should be folded
back to the edge of the mattress, so that the bed may i
readily be thrown open the instant the patient appears.
Three large hot-water cans should be filled, encased
in their flannel bags, placed in the bed, and left there
until the patient is put to bed after the operation.
The nurse should be particular to sec that these cans
are really hot and that they do their work well, for by
the lime the patient is ready to be put in the bed it
should feel comfortably warm throughout. This heat
assists the patient in reacting from whatever shock
may have been sustained from the injury or from the
anjesthetic and operation. But when the patient is
once in bed the cans .should be removed until con-
sciousness is regained, else there is constant danger of
burning him : a limb or arm or the trunk may be tossed
about, or when moved may re.st on the hot can, a bum
perhaps instantly resulting without the patient being
aware of it until consciousness returns. In cases
where there is mich shock after an operation, and all
thfi warmth and stimulus possible is necessary to en-
able the patient to react, then the hot cans or bags
should be put about him, but at a safe distance and

FRACTVRE-BBDS.

separattrd from liim by a blanket; but even then the
nurse should very frequently slip her hand inside to
assure herself that all is right.

Patients with fractures of any kind must have their
beds made with special reference to their condition.
The bed should be rendered firm and unyielding.
This is done by placing under the hair mattress a
fracture-bo;trd, made of slats each 1 inch thick and 3
inches wide. Made in this way, it will be lighter and
afford better ventilation tlian one made of a Single per-
forated board. An excellent fracture bed can be made
of straw, by packing the straw very tightly and evenly
into a firmly-made tick and covering it over with a
long heavy mackintosh. This should be pulled tightly
down and securely tied to the iron bed-frame, and the
bed then made up with draw sheet, etc. in the ordinary
way. Beds are also prepared in this way for spinal
cLrvatures and other orthopasdic cases. If a patient
has to remain in extension or must not be moved from
the bed for a number of weeks, tiie mackintosh should
Ik- kept fresh and clean by an occasional washing, after
which it should be rubbed thoroughly dry,*

Very numerous and often very complicated arc the
appliances which have been contrived for the relief o(
bed patients, but the more simple designs generally
serve the purpose best. Those chiefly in use are head-
rests, pillows, pads, and cushions of various kinds.
It is a red-letter day for the patient when he is allowed
for the first time to sit up in bed. He is raised at an
easy angle, and supported in this position by mean;
of the hL-.id-rest and pillows; hair and feather pillows
combined will accomplish the same result, and these

*>«« Appendix, Nflla I,

^f separate

FRACTURE- BEDS. 95

separated from him by a blanket; but even then the
nurse should very frequ(;ntly slip her hand inside to
assure herself that all is right.

Patients with fractures of any kind must have their
beds made with special reference to their condition.
The bed should be rendered firm and unyielding.
This is done b)' placing uiidi;r the hair mattress a
fracture-board, made of slats each i inch thick and 3
inches wide. Made in this way, it will be lighter and
afford better ventilation than one made of a single per-
forated board. An excellent fracture bed can be made
of straw, by packing the straw very tightly and evenly
into a firmly-made tick and covering it over with a
long heavy mackintosh. This should be pulled tightly
down and securely tied to the iron bed-frame, and the
bed then made up with draw sheet, etc. in the ordinary
way. Beds are also prepared in this way for spinal
curvatures and other orthopEedic cases. If a patient
has to remain in extension or must not be moved from
the bed for a number of weeks, the mackintosh should
be kept fresh and clean by an occasional washing, after
which it should be rubbed thoroughly dry.*

Very numerous and often very complicated are the
appliances which have been contrived for the relief of
bed patients, but the more simple designs generally
serve the purpose best. Those chiefly in use are head-
rests, pillows, pads, and cushions of various kinds.
It is a red-letter day for the patient when he is allowed
for the first time to sit up in bed. He is raised at an
easy angle, and .supported in this position by means
of the head-rest and pillows; hair and feather pillows
combined will accomplish the same result, and these

;! pillows ^^1

96 NURSING.

are gtneraUy used in priv.itu- houses; but more
arc required than when the head-rest is used, and a
comfortable position is with more difficulty maintained.
These rests are of many kinds, but the best is that
made with a simple wooden frame and a canvas sup-
port (vide Fig. 2), which can be used with any kind

of bed. A feather or hair pillow tucked in to sup-
port the small of the back, another for the upper part
of the back and shoulders, and a small cushion for the
head laid against one of these rests, will support the
invalid in perfect comfort. In lieu of anything better
a straight-backed chair may be turned upside down.
fastened in place, and pillows arranged on it To
enable a patient to lift himself or change his position
in bed, a crane will be found very convenient: this
may consist simply of three bars of iron in the shape
of a triangle fastened to the wall above the bed. or of
a single rod fastened to the bed, to which a strap or
handle is attached which hangs down within easy reach

MUCilAA'ICAL APPLIANCES.

of the patient. (See Fig. 3.) This apparatus should be
supplied with a hinge, so that the crane is movable to
ihe right and left, and can thus be pushed aside when

not needed. Beds furnished with patent adjustments
are rarely as comfortable as those which arc less pre-
tentious.

A head-rest is also a great comfort and support to
patients suffering from shortness of breath arising

from heart disease, asthma, or any other
which makes the upright position imperative,
connection with the head-rest the cyHndrical cushion
is used with patients who are inclined to slip down
in bed. This is made of stout ticking 21 inches long
and 8 thick, with rounded ends. (See Fig. 4.) It is

m plaint ^^M
In ^1

stuffed firmly with horse-hair and covered with cotton
slips made to fit. To both ends of this pillow, which
is slipped under the patient's knees, arc fastened broad
bandages which are carried up the sides to the top of
the bed and tied to the iron rod tightly enough to
keep the pillow in position under the patient, and so
prevent him from slipping down. There should be a
number of such pillows supplied to gynaecological and
obstetrical wards, as they often give the greatest relief
to patients after abdominal operations. When placed
under the patient, just so that the knees rest upon
them, they act by relieving the tension of the mu.scles
of the abdomen and back, or when placed at the foo*
of the bed. where the patient can press her feet against
them, they accomplish the same purpose. After ab-
dominal operations, in place of the ordinary pillow.
which is too high if the patient is nauseated, a small
air-cushion or a feather pillow not too soft, and about

MECHANICAL APPLIANCES.

13 inches long and 10 inches wide, should be used
for the head to rest upon during the first forty-eight
hours. With very weak patients, or with those whom
it is necessary to turn frequently from side to side,
support should be given to the back by placing a
pillow closely against it. Very often pressure along
the spine can be relieved by partially slipping a hair
pillow under the patient from either side, thus raising
the middle portion of the back so that it does not
touch the bed.

When a patient is confined to bed the portions of
the body mo.st exposed to pressure should be daily
guarded against bed-sores. The most common sites
are the lower part of the back, the hips, tlie shoulder-
blades, the elbows, the tips of the ears, the back of the
neck, and the inner surfaces of the knees, the heels, and
the ankles. On the slightest indication of redness, even
before any complaint on the part of the patient of a
burning or stinging sen.sation in any of these places,
the nurse should take care, in addition to employing
the usual preventive treatment, to remove all pressure
from the parts threatened. This may be done by means
of cushions, which may be made of various shapes to
suit the part to be protected. Besides the air-bed and
the water-bed, there are on the market a number of
rubber appliances in the way of cushions, among which
wc may mention the air-cushion, which is made square-
shaped for the head and shoulders and circular for the
back. For protecting the heels, ankles, and inner sides
of the knees or the back of the head, a circular pad of
a suitable size can be made of ordinary cotton batting.
The cotton is firmly held in place by a gauze bandage

passed around it several times, a hole being left in the
centre which comes directly under the tender point,
while the surrounding parts rest on the cotton. These
pads are inexpensive and may be renewed frequently.
For a small spot on the back, side, or heel, they answer
every purpose. (See Fig. 5.) A few turns of a band-

age will hold one in place, unless it be on the back.
Where a rubber ring is not available for the back
in a case ol' bed-sore, a very good substitute may
be found in a circular cushion made either of rubber
cloth or of a double layer of oiled muslin stuffed with
horse-hair. This can be washed, and by having two
they may be changed and so kept fresh and free from
odor. Water-beds and air-beds are sometimes ordered
for patients who are predisposed to bed-sores, or for
those who already have very bad ones, or who are in
a perpetual state of moisture, a condition which is also
likely to destroy a hair mattress. For paralytics they
are indispensable. In getting a water-bed ready for

THE WATER-BED.

use, a long heavy mackintosh is placed over the wire
springs of tlie bed-frame, and the water-bed spread on
this ready to be filled. Care must be taken to have it
laid on the bed-frame exactly as it is to remain, for,
when once filled with water, it is too heavy to readjust.
The end with tlie opening, into which the water is to
be poured should be placed at the foot of the bed. It
is filled by means of a hose, or, if this is difficult to
manage, the water may be poured in from a large
pitcher through a funnel. The temperature of the
water should be carefully tested, and should not be
less than lOO" F, This will allow for some slight
cooling when it comes in contact with the rubber of
the bed : if the patient has been ill long and is in
a weak condition, he .should in no case be put on it if
the bed temperature is less than 98° F. To prevent the
patient from rolling off the bed when filled, a wooden
frame should be placed around it, both sides of which
should be bevelled or else the sharp edges of the boards
should be padded. The bed is to be made up in the
usual way. An air-bed is arranged in a similar man-
ner, except that the air is introduced with a force-
pump and attention to the temperature is unneces.sary.
Rubber beds should be washed off and disinfected
from time to time, and the greatest care taken to have
no pins about them, because a pin prick might cau-se
the bed lo collapse and render it useless; this is im-
portant, as these beds are very expensive.

To become expert in lifting and moving sick [jeople
requires a great deal of practice, and a beginner .should
not be left alone to perform this nfl^ce for the sick.
She should at first assist an experienced nurse and

thus learn the proper methods. It seems a difficult
matter for many nurses to understand that, in moving
her simply to change her position, it is of the utmost
importance to support the patient : if this be properly
done, quite a heavy person can be moved with httic
difficulty and without hurting her at all. Occasion-
ally the complaint is made that a nurse has injured
her back or strained herself in some way in moving
a patient. This will generally be because she has
failed to do the lifting properly. To move a heavy or
medium-sized person in bed the nurse should put her
right hand and arm obliquely under the patient's back,
the hand being carried well down under the back, the
patient's shoulder resting in the hollow of her own;
the left hand is next put over and slipped well under
the patient's other .shoulder. The upper half of the
body is now lifted gently and evenly and placed in the
fresh part of the bed ; the right hand being now slipped
under the lower part of the back and the left just
below the hi])s. the other half is moved over. To
lift toward the head of the bed the right hand is
placed well under the back, the heavy part of the
shoulder being supported with the upper part of the
arm and i^houlder. and the left hand being placed
below the hips: one then lifts gently and firmly. In
doing this the greatest weight is thrown upon the
right arm and shoulder. The patient can sometimes
render some a.ssistance by clasping the hands around
the nur.'ie's neck. In the same way support should
be given with the left arm when raising patients to
readjust or arrange pillows, the head being allowed to
rest against the shoulder while the back is supported

CHANGE OF BEDS.

103

with the hand, aiid the other hand is used for putting

the pillows in place. The head and shoulders are then

placed back against the pillows with an easy, gentle

motion. It is the height of awkwardness to pull or

drag a sick person about the bed when working over

her. The idea! way to change a bed patient is to

have two single beds of the same height, one for the

day and one for the night, each being provided with

its own set of blankets, sheets, etc. The patient may

be transferred from one to the other by placing the

beds close together and drawing the mattress with

the patient on it a short distance over that on the

other bed ; the occupant may then be transferred to

the second bed by pulling on the sheet upon which

she is lying. If there be a second nurse to assist, one

can take the sheet at the head and the other at the

foot of the bed, and, both lifting carefully and at the

same moment, the patient can thus be placed in the

middle of the adjoining bed without the least jar, after

which the sheet may be slipped out from under her.

After abdominal operations this method is quite safe,

but, of course, with some surgical cases moving is

I altogether out of the question. If two such beds are

, not procurable, as is often the case, a lounge may be

wheeled up close to the bed, the patient, together with

the sheet, lifted upon it, and left there until the bed

has been aired and changed. Another excellent way

I is to have two mattresses with one bed : one person

[ may draw away the mattress on which the patient is

I until it is half way off the bed ; then the second mat-

[ tress is put on close to the other, and the patient drawn

I by the sheet over upon it. It will afterward be easy

to slide it the rest of the way on the bed. If a patient
is to be carried to a lounge, tliis may be placud at
the foot of the bed (with its head toward the foot
of the bed) in such a position that the carrier need
take only two or three steps from the bedside: he
thus has to do no turning, and can lower the patient
gently. Similarly, when the patient is to be trans-
ferred to it, the invalid chair should always be placed
with its back toward the bed. When one is carrj-'ing
a patient, it is best to straighten one's self up and allow
the weight to fall upon the chest and front part of the
body, since strain on the lower part of the back is thus
prevented.

For the purpose of saving the mattress and bed linen,
and of obviating the necessity of disturbing the patient
at too frequent intervals, a much less expensive
protection is afforded by the rubber protective pad (see
Fig. 5j4) It consists of a flat circular piece of rubber,
29 inches in diameter, around the edges of which is
attached a hollow rim, which when inflated measures
A .square of gauze or old linen
may be spread over it before
placing the pad under the
patient. With this pad it is
possible to keep a bed per-
fectly dry and comfortable in
the worst forms of involun-
tary evacuations; its use will
effect a great saving of the
patient's strength, of time, and
Bu»»M t'.onciiv* P.O. of laundry work. It should
be washed off, dried, and fresh gauze spread ovtr it
before being replaced.

5 inches in diameter,

Fic. %yi.

CHAPTER V.

Hygienb of the Sick-room and Ward.— Air.— Vent [lati on.—
Methods of Vsnti latino. —Sick-room Tem I'tR at u res.— Dis-
posal OF ExcRKVA. — Soiled Dressings and Soiled Linkn.

No department of a nurse's work .shouid appeal
more forcibly to her than attention to the hygiene
of the sick-room. She should thoroughly grasp the
general principles which tinderlie the subject, and
endeavor to apply them in the minutest detail. Thor-
oughly clean surroundings and a constant supply of
pure, fresh air are the ideal conditions, but the ques-
tion how these can best be secured may at times tax
our ingenuity to its utmost. In well-planned hospitals
these desiderata have usually been fully provided for,
and it will be the nurse's duty simply to see that the
means to this end, in so far as they are entrusted to
her care, receive the proper attention.

Nurses are guilty of culpable inattention who neg-
lect at all this daily and hourly feature of their work.
A nurse should constitute herself, as it were, the ward
thermometer and barometer, and train her senses to
note any change in the ward atmosphere. She should
never come into the room or ward from the outside
air without noticing particularly whether any disagree-
able odor be present or if the air be heavy and close;
and if there be any suggestion of impurity, steps should
be taken at once to remove the cause. She should be

io6

JfURSIKG.

perature too^^f
■ rhillv Tt^^

able to detect by her own sensations a temperature 6
high or too low. and air which is damp or chilly. It '
is just as important to charge each nurse in turn, for
a certain length of time, with the responsibility ot
looking after the ward hygiene as it is to detail her
to administer the medicines at the proper hours.
Suitable hygienic conditions will sometimes do more
to cure patients than the admini.stration of drugs.

To render the condition of a ward wholesome, it is
necessary not only to regulatt its temperature, but also
to provide for the ingress of a supply of fresh air when-
ever it is needed. It must be seen to that the ventila-
ting flues for removing any accumulation of Impure air
are open and closed at the proper hours ; that anything
in the way of a disagreeable odor is removed; that de-
odorizers, if they are in use, are renewed ; that the
waste-pipes and kitchen-sinks are properly cleaned
and flushed daily; and that no soiled or infected linen,
no soiled clothing or dressings, are left standing about
in uncovered receptacles, and that all vessels in use are
kept thoroughly cleansed. No nurse can do this prop-
erly unless she trains herself to be always on the alert
to see that no rule of hygiene, which it is possible to
observe, is broken ; and here, again, much will depend
upon the acquisition of the habit of observation.

The limits of a text-book of nursing are necessarily
too narrow to permit a full discussion of so important
a subject as ventilation. It will be possible to touch
only upon the fundamental principles and to describe
in brief some of \hs most important methods.

We cannot insist too much upon the importance of
nurses having a clear conception of the application of

VENTILATION.

ro7

^H and VI
^H those

the laws of hygiene to the care of their own personal
health. Only loo often does the training-school super-
intendent find, on her tour of inspection of the nurses'
sleeping-rooms, that more than one window has been
tightly closed all night, notwithstanding the instructions
that have been given. If a nurse cannot realize the im-
portance of pure air for herself, how much less is she
able to protect the health of those entrusted to her!
how little will she be prepared to combat the errors
and prejudices which she will daily encounter in her
work as a nurse when on private or district duty !

The first division of the subject to consider is vcnH-
latioH, but to clearly comprehend its importance one
must first understand the conditions that call for it.

Air, being a mixture of coloiless gases, is quite in-
visible, but changes in its composition are readily de-
lected by its exhilarating or depressing effects on the
system. As air occurs normally in nature, it consists
of 20.63 parts of oxygen, mixed with 78.49 parts of
nitrogen. Besides these two substances there is always
some water in the form of aqueous vapor, and some
carbonic acid gas. The quantity of aqueous vapor
varies with the temperature, but on an average does
not amount to more than about 0.84 per cent., and
in the open air the proportion of carbonic acid gas
(COj) is never greater than yj^ of i per cent. Of
the two gases of which the atmosphere is fundament-
ally composed, nitrogen is of no biological significance.
except in so far as it dilutes the otherwise too ener-
getic oxygen, upon which all members of the animal
and vegetable kingdom depend for the performance of
those functions which in their combination we recognize

io8 NVJismo.

as life. When we remember that air is a mechanical
mixture and not a definite chemical compound, we
fail to be struck with the constancy of its composition.
Normally, carbonic acid gas is being poured out into
the air from many sources: men and animals breathe
in oxygen and breathe out carbonic acid gas, and in
the combustion of wood and coal large quantities of
oxygen from the air combine with the burning carbon
to form the same substance (carbon dioxide, carbonic
acid gas). This production, which might otherwise be
excessive, is partially compensated for by the action of
plants, since it is well known that trees and plants in
their growth split up the carbonic acid gas which they
find in the air, retaining the carbon themselves and
setting the oxygen free.

It will be readily underi^tood that where anything
interferes with the natural methods of purification of
the air, as must be the case where people are hived to-
gether in cities and manufacturing towns, the propor-
tions above given may be seriously altered by the in-
troduction of impure gases, smoke, dust, and organic
matter of various kinds.

Substances containing carbon are present in the
body, and it is through the oxidation of these, with
the formation of carbon dioxide (a process of combus-
tion), that the body heat is maintained; therefore it is
necessary that the air with its contained oxygen should
enter the body freely in order that these chemical
changes may proceed satisfactorily. The lungs are the
organs set apart to render possible the free interchange
of the gases of the blood with those of the external
air. Each time a breath or inspiration is taken, a ccr-

chanical ^^H

e cannot ^^|

VENTILATION.

109

tain amount of oxygen enters the lungs; thence it
passes through the walls of the capillaries (which ram-
ify over the air-cells of which the lungs are composed)
into the blood, by which it is distributed to the tissues.
Carbon, burning slowly or quickly, is changed finally,
as we know, to carbon dioxide. This finds its escape
into the outer air again principally through the lungs,
so that with each expiration the air breathed out is
charged with a certain amount of impurity in the form
of carbonic acid gas. Moreover, physiologists tell us
that certain extremely poi.s<inous organic substances,
of the nature of which we are as yet in complete igno-
rance, accompany the carbon dioxide and add ma-
terially to the deleterious effects of the expired air.
Unless some provision is made to remove these im-
purities from the air that is being breathed by our pa-
tients, instead of breathing in frcMh, uncontaminated
air. they will take in again the same impurities that
were breathed out ; hence one great necessity for ven-
tilation. Besides this, organic matter is being con-
?4tantly given off by the .skin, as well as by the lungs,
not only in the form of vapor, but also as small par-
ticles of waste or decayed tissue. The atmosphere, be-
sides containing these impurities coming from the bodies
of men and animals, is influenced more or less by the
diRerent localities and surroundings; thus in some
places where there is much decayed vegetation, in
swampy or marshy tracts of land, in overcrowded
communities, where dirt in dark corners and in ves-
sels is allowed to accumulate, where refu.se and offal
of every description remain unremoved, — in all such
places the oxygen in the air is decreased in quanti

sucn H

ntity, fl

.ind the air itself is contaminated with poisonous gases
and compounds, thus rendering it unfit to breathe.
The burning of illuminating gas is another factor to
be considered, since it deprives the air of its oxygen
and gives in return gases unfitted for respiration; thus
in burning one cubic foot of ordinary gas eight cubic
feet of fresh air arc used up. The same remarks apply
to the combustion processes in stoves and furnaces.

These, then, are some of the conditions which
healthy people have to encounter in breathing the air
about them : it is obvious that the conditions become
much more serious in rooms or in ho.spitals where dis-
ease is continuously present. The quantity of impuri-
ties given off from diseased bodies and from the excreta
is enormous, so that the matter found in the air of the
sick-room and in the dust which collects upon the fur-
niture is likely to contain a large proportion of organic
matter, and not seldom the germs of disease.

The necessity for good ventilation and thoroughly
clean surroundings thus becomes at once apparent: in
a word, the foul air must be replaced by pure, fresh

The methods of ventilation may be divided into two
great classes, natural and artificial. In each case the
air must be changed without causing a draught. The
smaller the space through which the air is admitted
the greater the danger of having 'draughts, and the
smaller the room, the more quickly and easily does the
air become impure. The amount ofpure air which should
be supplied for each person in an hour is 3000 cubic feet
— ('. c. about I cubic foot per second. The volume of
a given mass of air varies, like that of all gases, with

Ventila rioN. 1 1 1

changes in temperature; and prossure; thus gases ex-
pand when heated and contract when cooled or when
they are subjected to increased pressure.

Natural ventilation is chiefly dependent upon three
factors, the action of the winds, the movements, pro-
duced by the unequal weight of the different air-strata
(brought about by temperature and pressure changes),
and the diffusive power of gases. As we said above,
heated air expands, and so in a room heated in any
way the air must expand more or less according to
the degree of heat. The surplus will escape in various
ways through doors, windows, and crevices. The out-
side air, being heavier, will now have a tendency to
enter the room and displace the lighter air. but this air
which enters becomes heated in its turn, and thus two
constant currents of air, one going out, the other com-
ing in. are established. This will occur, of course,
only when the temperature of the outside air is differ-
ent from that of the inside air. These air-currents may
at times be so rapid as to produce a draught. If the
room has the same temperature as the outside air,
then there will be no ventilation or change of air. In
summer, when windows and doors are all open, the
atmosphere is much alike both inside and out, and for
any change that is produced we must depend upon the
wind.

But in order to have good ventilation it is neces-
sary that the air which enters should penetrate into
every part of the room, and become well mixed with
that already there. In the case of winds or air-
currents produced by temperature variations, if the
velocity be great, the fresh air may enter one portion

of the room and pass directly through and out

thus affecting only the small portion of the air coming

directly in its path.

Diffusion of gases goes on perpetually according
the well-known physical law.* In whatever part of
the room the air is warmest, the air-currents will be
toward that part, as they always flow in the direction
of the least resistance. No matter into what part of
the room tlie cold air enters, it will always fall. In
ventilating by means of windows the entrance of the
fresh air and the exit of that which has been exhausted
should be regulated by opening the windows from tlie
top only and on opposite sides of the room, one toward
the direction in which the wind blows and enters, and
the other away from it. In this way any draught
that may be caused will be too high up to harm the
patients, unless a door should be left open at the same
time, so that an opposite current is produced. An-
other advantage in having the cold air enter at the top
is that it will become slightly warmed in its descent,
and not be so apt to be felt by those who are up and
about the room. When the windows are open, how-
ever, care should be taken not to have a patient in
bed directly under the one through wliich the air
enters. If there is a fireplace with a fire in it, it will
not be necessary for the .second window to be open to
let out the heated air, as the draught created by the
fire attracts the air to the fireplace and so up the chim-
ney. The fireplace is considered the best method of
extracting the air, but this mode of ventilation is suit-
able only for small wards. Where there is only one

* Gas» diliuse inversely as the square rocil o! ihcir Jensiliu.

: again, ^H

:oming ^^|

ding to ^^1

Mft of ^^^

VENTILATION. 113

Window in a room, or where there aro two on the
same side, a fireplace is necessary, and in summer a
burning lamp or candle should be kept standing in it
to warm the air and produce an upward current. To
avoid draughts and to secure a constant supply of
pure air in a room, various artifices must be resorted
to, somo of which are more particularly applicable to
private nursing and district work, where a nurse often
has to invent her own arrangements and explain away
a great many objections. A simple way is to raise the
lower sash of a window six inches, and place a board
across the opening below; the air will then enter be-
tween the two sashes and be directed upward, where it
becomes diffused and cannot blow directly upon any
one. If the sili of the window is deep, the sash may
be raised until its edge is even with the surface of the
sill, and in this way the same end is accomplished. In
a room with but one window, a pane of glass may be
taken out and a piece of tin or p.isteboard placed in a
slanting direction across the opening, or a pasteboard
box may be so placed that the current will be directed
upward. As another expedient, a window can be
opened in an adjoining room and the room filled with
(resh air, and then the door into the sick-room opened
to admit it. The patient may be covered up, head
and all. for a few moments two or three times a day,
while all the windows are thrown open and the room
is thoroughly flushed.

Natural methods of ventilation are those chiefly em-
ployed in private houses, and the arrangement of some
of the simpler plans very frequently devolves upon the
This is quite right, since she is on the

3on the ^H
spot at ^^1

114

NURSING.

all hours, and should understand just what is required
and what is the best thing to do in any particular case.
In institutions, however, both natural and artificial
methods are used, for no matter what artificial means
may be resorted to in the winter for heating and venti-
lating, in the summer doors and windows are freely
opened, and the natural forces are depended on for
the distribution of air. Here, on the other hand, it
is not necessary for the nurse to plan so much as
to fulfil, and it is her duty to acquaint herself with
the exact method employed in the particular hospital
in which she works, and to make sure that whatever
part of its fulfilment falls to her share is faithfully car-
ried out.

The system by which fresh air can be introduced
into the room at almost any degree of temperature
desired by passing it over hot-water coils or by admit-
ting it without being heated at all. while at the same
time the foul air is removed by ducts, is by far the
most complete method employed as yet. The tem-
perature of the ward can be regulated by proper
observation and with a litde care, so that the absence
of impure air or disagreeable odors is remarkable. A
full description of this plan may be found in Dr. J. S."
Billings' description of the Johns Hopkins Hospital.

A thermometer should be suspended at a central
point in the room or ward, not too near the gas or
the windows, and the temperature recorded once an
hour. The frequency of such observations will much
assist a nurse in realizing what variations of tempera-
ture may take place within an hour, and the noting
of it should train her in the habit of observing atmo-

VENTILATION.

spheric changes. This record should be' kept faith-
fully and punctually day and night; and when the
temperature is found to be higher or lower than the
degree required, the next* step after recording it is
to remedy the condition by either increasing or de-
creasing the heat-supply. It would hardly seem neces-
sary to say this were it not a well-known fact that nurse
after nurse has been known to pause in her work long
enough to look at the thermometer, and, finding the
temperature as high as 76° F. or 80° F., has yet calmly
recorded the same and resumed her interrupted work,
not at all realizing that she has performed but the
smallest part of her duty. She might just as well, in
many cases, omit her patient's medicine as neglect the
regulation of the temperature of the air by which he
is surrounded. In the same way draught.'! may blow
about some nurses, who, if they have not been espe-
cially instructed on the point, will have no idea that
the regulation of them has anything to do with their
duties. These are minor details, and may seem trivial,
but they are important ones. The ward or room tem-
[jerature must be regulated according to the nature of
the disease. In fevers it should be of course lower,
varying from 60°— 65° F., but in lung affections it
should be kept at about 70° F.

Variation.'! in the temperature of the air take place
normally at different times in the day, it being warmer
at high noon and cooling off toward night. Particular
attention should be given to patients in this regard
between the hours of one and six in the morning,
since at this time the sick, and even well people,
often fee! chilly sensations. It is during these hours

that the vitality is lowest and many deaths occur.
An extra blanket should be supplied, warm drinks
given if neces-.arj', and the ward temperature kept up.
not by closing all windows and openings and shutting
in the foul air, but by the addition of more heat in
whatever form it is supplied, whether by means of a
fireplace, steam, or hot air.

Give plcnt>' of sunshine to patients and ward, but be
particular to exclude its glare on hot days or if it is
shining directly upon the face or making itself un-
comfortably felt, it is surprising how many people,
in other respects very intelligent, dread the night air,
and how carefully they exclude it from their sleeping
rooms, forgetting that it is the purest air obtainable at
that moment, and therefore the best, provided it is not
entering directly from some cess-poo! or contaminated
portion of the country.

The disposal of the excreta of a ward or sick-room
is one of the most important considerations in con-
nection with its hygienic condition. The sputum and
other evacuations, improperly cleaned vessels, soiled
dressings, and soiled linen, if not properly taken care
of, are prolific sources of impure air.

Sputum-cups for patients should be made of glazed
earthenware, straight up and down, without any cor-
ners or cracks, and provided with a simple mov-
able cover when in use. They should be sterilized
in the Arnold steam sterilizer for one hour in every
twenty-four hours. Bed-pans and urinals should be
washed out thoroughly, boiling hot water being al-
lowed to run on them for some little time before they
are put away. Soiled dressings should be received

HYGTENE OF THE WARD. WJ

in basins with covers and at once carried from the
ward, and, unless special disinfection is necessary, put
into the soiled-dressing can, which is made of metal
and closely covered, and if possible carried away
directly to be destroyed. Vomited matter or evacua-
tions from the bowels or bladder should never be car-
ried through a ward or from a room without being
covered over either with a towel or rubber cloth. The
rubber cloth is better, as it keeps in the odor: it is
also impervious and can be .scrubbed and disinfected.
If the patient is too sick to use a proper sputum-cup,
the expectorated material may be received in a paper
handkerchief or a piece of cheese-cloth which, how-
ever, should be burned at once.

The object of all these precautions is to reduce to a
minimum the scattering broadcast through the hospital
of those organic impurities which do so much harm.

The above is, of necessity, an inadequate description
of so vitally important a subject, but no pretence is
made to do more than endeavor to direct the student's
thoughts in the right direction. Any woman will
remain superficial if she fail to listen carefully to the
lectures on hygiene and read for herself books that
will enable her to have a deeper knowledge of the
subject.

CHAPTER VI.

MK OF New Patiemts, — Treatment. — Wkat to Oksekve. — Rb-

PORTING TOTHE PHVSICIAN.— CaHE OF THE BED PATlES-n.— FRB-

qUEMcv OF Bathino. — Care of the TEtTH and Mouth. — Th*
Prevention and Treatment op Bed-sores.— Cars of Com-

The first attention a nurse gives to a patient will de-
pend entirely upon the condition he is in when placed
in her care or when brought into the ward. He may
be able to walk, or possibly just strong enough to be
moved if seated in a wheel-chair, or, on the other hand,
he may be so helpless that he has to be carried, and
that, too. in the ea'iiest manner possible. A stretcher
will be found most convenient for carrying such patients.
This should be made of stout canvas, 6 feet 6 inches in
length and 2 feet wide, with hems on either side wide
enough to allow two hard wood poles, 7 feet long and
2 inches in diameter, to be pushed through them ; the
poles are kept in place by means of a movable cross-
bar at each end, which prevents the two sides froin
folding togeiher. (Vide Fig. 6.)

In every hospital with free wards there should be
two receiving- rooms— one for men, the other for wo-
men. Each should be provided with bath-tubs and ail
requirements for giving the first bath, and in addition
there should be kept here a stock of wrappers, night-
gowns, stockings and slippers, gray blankets, and a bed.

A NEW PATIENT.

A patient who is able to walk or to be moved in a wheel-
chair should be taken directly to this room, and at once
given the first bath; a night-gown, wrapper, and slip-
pers are then put on, and the patient enveloped in

blankets and sent into the ward. Except in a case of
emergency no patient should be taken to a free ward
among other patients with his own clothes on : they
should be removed and he should have at least one
bath, either in bed or In the tub, before he comes near
other patients. His clothing should be inspected and
a list taken, after which all articles are sent, to the dis-
infecting oven in a covered metal box. After steriliza-
tion they are sent to the laundry to be washed, or if
' clean enough are hung up carefully in the patients'
L clothes-room — a large room well ventilated and set
I apart for this purpose. Sometimes, however, a patient

120 NUXSI/fC.

is admitted in an extremely critical condition: then no
time .should be lost, and the physician orders such a
patient to the ward at once. In anticipation of this, a
bed should, if possible, be kept freshly made up. so as
to be ready at a moment's notice. If the patient be
very dirty as well as very ill, the upper coverings should
be thrown back and a long black rubber sheet spread
over the bed ; a bath blanket is thrown over this, and
the patient is lifted Into bed. A second bath blanket
is now thrown over him, and the regular bed covering
added when it is necessary. This protects the clean
bed and saves any extra moving of the patient if the
doctor sees fit to order a bath in bed. After the bath,
the rubber and blanket can be easily slipped out, and
the patient rests in a perfectly clean bed.

The bath-rooms and clothes-room should be quite sep-
arate from the wards, but so few hospitals have this sys-
tem that we shall consider in detail the other plan,accord-
ing to which all patients are taken directly to the wards,
where the nurses, besides other necessary attentions,
give them their first baths and look after their clothing
and valuables. If a patient walks in, he is usually
given a chair placed in the hall or room outside the
ward until the doctor has given orders in regard to him.
The head nurse should immediately report the admis-
sion of a patient to the ward, and under no circumstances
should she neglect to do this. A nurse should be de-
tailed at once to look after him. to see that his chair is
comfortably placed out of the way of draughts and of
passers-by. His general condition is then noted. The
temperature and pulse are taken first and reported, and
if any special symptoms are present these should be

A NEW PATIENT. 121

reported at the same time. The doctor will then give
his orders, but if there be any delay while waiting for
him, the patient must still be kept under observation
and made to feel that he is receiving attention and con-
sideration. Possibly he would like a glass of water, or
if he has not eaten for some time and is in need of
food, he may feel too strange and frightened on his en-
trance to a ho.spital to ask for these things, and the
nurse should not wait to be asked, but should inquire
herself. As milk is usually a safe form of diet, a glass of
it may be given without hesitation. If a bath is to be
given, in a woman's ward this duty devolves upon the
nurse, in a male ward upon the orderly. In giving the
first bath any peculiarity about the patient should be
noted, and the presence of swellings, lumps, scars,
sores, or any kind of rash should be reported at once
to the head nurse, whose duty it is to inform the doctor.
After the patient ha'; been cared for, attention is next
given to the clothes and valuables.' The nurse in charge
finds out from the patient if he has money or other val-
uables. She makes a list of these in a book kept for the
purpose, to which she signs her name, and hands them
over to the hospital clerk, who deposits them in tlie safe.
Absolutely no responsibility should be assumed by a
nurse for the valuables of any patient, and whatever is
retained by him remains at his own risk. If nurses do
not adhere strictly to this rule, sooner or later trouble is
sure to follow. The inspection of the clothing is a duty
which usually falls to the lot of the probationer or ju-
nior nurse. She should examine each article carefully
to be sure that it is quite free from parasites, and if such
are present or if the clothes are soiled, tliey should be

^ lo DC am

B are presi

^^^^^H

^^^^^^^^H

122 NURSING . ^^^^^

listed and sent to the disinfecting oven or to the laun-
dry ; in the latter event they should be marked with
the patient's name and ward. If, however, they are
clean, all the smaller articles should be neatly folded
together and wrapped in a large square of coarse
gingham to protect them from dust ; the dresses or
coats should be hung up in the division of the clothes-
closet assigned to them, the small articles being placed ^_
on the shelf below in a compact bundle, to which is ^H
attached a tag on which is written a complete list of ^|
the clothes, with the date and name of the patient and ^|
the signature of the nurse. ■

•

/w.^ © \

K*mt of P.tiint

AjaiolH af Clatliiiie.

DM*. IS9

■ After the pati

■ and quiet — that

U:.TI><G Tun CUTTHB OF A

nt has been put to b
s. in about an hour—

-d and is rested _
his temperature ^|

A NEW PATfENT. 123

and pulse should again be taken, as the first record
may be untrustworthy if, as is likely to happen, one or
both have been influenced by the excitement of coming
into the hospital. A specimen of urine is now obtained
(in women always by catheterization), and kept for the
doctor's inspection ; at the same time one ascertains
whether or not the bowels are in a normal condition.

If a patient is very ill, if he has a chill, or if the
body or feet are cold, hot bags or cans are to be
applied without delay.

It may be impossible to give a full bed-bath at once
to an invalid in a weak condition or to one to whom
the bath is disagreeable, and we often have to proceed
gradually. When there is plenty of time a full bath
should be given to a bed patient every day. and in
some cases this is absolutely necessary; but if there
are many to be bathed in a hmitcd time, each should
have a daily bath at least as far as the waist, particular
attention being devoted to the spaces under the arms.
The surfaces between the thighs should also be cleansed
daily, and a full bath given twice a week. Absolute
cleanliness of the body and of the bed are two most
important factors in hastening convalescence. A bed
patient's hair should be washed occasionally : if pre-
cautions are taken, no danger of taking cold need be
feared. Powdered borax is mixed in hot water, the
pillow and shoulders are protected with a rubber sheet,
the patient moved over to the side of the bed, and two
basins of hot water are placed on the adjoining bed-
table, one containing the borax solution, the other
simple hot water for rinsing. The washing can then
be done quickly and easily. The hair is rubbed thor-

I by

124 Nussrjfc.

oughly and spread out on the rubber cloth until it I
becomes quite dry. To free hair from parasites the
head is bound up for two or three days in a cloth 1
soaked in a i : 30 (5 per cent.) solution of carbolic |
acid, which is kept moist all the time, the pillow of
course being protected by a rubber cloth or else the
head covered with a cap of oiled muslin. After the
hair is dry, alcohol is rubbed in about the roots to
destroy the nits, which soon after drop off! In a free
ward it should be the rule to have every patient's head
examined carefully, and when necessary a preparation
of larkspur and ether applied. In the case of a woman
who is too weak to have all her hair attended to at
once, a part only should be done at one time; thus
one braid might be dressed in the morning and the
other later. The hair, however, should never be al-
lowed to go uncared for more than twenty-four hours.
and if it be handled deftly, the operation will be a
pleasure to the patient instead of the ordeal it some-
times proves to be. Here, again, success comes only
from much practice and perseverance. Every time one
has long and difficult hair to care for. one more op-
portunity is afforded for practice, and the process should
not be hurried through, but the nurse should try each
time to make some improvement in her methods. The
arrangement of the whole head should not be attempted
at onco : it is best to part the hair into two strands at
the back, and then take one side, this again being sub-
divided if necessary. The combing or brushing should
be done gently but firmly : we should begin at the
ends and work upward, the hair being always grasped
by the left hand at some point between the comb and

THE CARE OF THE MOUTH

125

the head, .■io ihat there may be no jerking or pulling.
The beat way to dress the hair is in two braids, care
beiny taken to draw each well over to the side and to
braid low down just below the ear, so the patient may
not have to lie on two hard lumps of hair. The first
two or three turns taken .should be looser than the
subsequent ones.

The mouth and teeth are to be carefully looked
after, and so far as possible kept clean and sweet.
The condition varies very much in different patients.
Where the accumulation of sordes and mucus is rapid,
and where the lips and tongue are stiff and parched,
attention may be needed every hour, but in ordinary
cases twice a day or after each meal will usually suf-
fice. The mouth should be kept as moist as possible,
and the same treatment carried out through the night
as during the day. Night nurses are not so attentive as
they should be in this regard, and often this happens not
so much from lack of time as from want of thought
There are various mouth-washes in use. A weak solu-
tion of borax answers as well as anything. Listerine
is very cleansing and has disinfectant properties ; a so-
lution of lemon-juice, glycerine, and distilled water is
refreshing and softens the tissues; but where fissures
appear they are to be treated with frequent applications
of vaseline or cold cream. Where the gums are .soft
or spongy and sore a few drops of the tincture of myrrh
added to pure water may be used. The best sponges
for washing out the mouth are made of small squares
of dressing gauze or old linen, since these can be
burned immediately after use. One of these squares
should be wrapped about the index finger, dipped

tares h

126

NURSING.

T
m

I I

the wash, and inserted into the mouth. Every portioa*
of the cavity should be well gone over, the sponge
being passed along the gums and inserted behind the
wisdom teeth — a place often neglected — thence over
the roof of the mouth, inside the teeth, and under the
tongue. If the tongue is badly furred, it should be
soaked and then scraped.

To guard against bed-sores is one of the first injunc-
tions given to a nurse who is entrusted with the care
of a bed patient: the danger of sucli an occurrence
varies with the nature of the disease and the weight of
the patient. It is just here that good or bad nursing
tells, and the development of a bed-sore while the
patient is under a nurse's care gives ground for severe
criticism. Bed-sores result from continuous pres-
sure on a certain spot or spots, also from friction
between two surfaces, from moisture, creases in
the under sheet or rubber, crumbs in the bed, and
from lack of proper care and cleanliness ; their
formation is favored in certain conditions where
the nutritive processes taking place in the body are
faulty. Those due to pressure occur most frequently
on the hips and lower part of the back, the shoulders,
and the heels; those from friction on the ankles, the
inner surfaces of the knees, or on the elbows and back
of the head from frequent movements in the bed.
Those resulting from malnutrition of the entire system
may appear in almost any place where there is the slight-
est pressure, and may show themselves first in the
form of pustules, which are followed by a rapid break-
down of the tis.sues. This last variety is the mo.st
difl^cult to keep in check, and even wilh the utmost
care they are sometimes unavoidable. Preventive treat-

lost ^1
eat- H

THE PREVENTION OF BEDSORES.

127

nient consists in absolute cleanliness and the removal
of pressure. The back and shoulders should be bathed
night and morning, and gentle friction employed to
keep the skin clean and active; they are afterwards
nibbed with a 50 per cent, solution of alcohol to
harden the skin; and fioally the parts are dusted
thoroughly with some kind of powder which will
absorb the moisture. For this purpose the oxide-of-
zinc powder or bismuth mixed with borax are of equal
value. If there is much moisture from perspiration or
from involuntary evacuations, this process is to be re-
peated whenever indicated. The sheets must be kept
perfectly smooth and dry under the patient: some-
times even a slight wrinkle will produce redness and
tenderness. The first indication of undue pressure
is redness of the skin ; the patient may complam of
a stinging sensation, but we must never depend upon
him to report this, but must be on the watch all the
while, so that the first sign may not escape us. Any
abrasion of the skin is to be fir.st carefully washed, and
a small pad of cotton sprinkled with aristol and smeared
with a litlle ointment placed over it and kept in position
with celtoidin. For an abrasion, in lieu of anything
better, painting with white of egg is fairly satis-
factory. Another excellent dressing is a mixture
of castor oil and bismuth. The pressure may be
removed by means of rubber or cotton rings, A
change of position is advisable, and where it is pos.si-
ble the patient should be turned on his side, the back
being supported with a pillow well lucked in.

If, however, in spite of all our precautions, a bed-
sore has formed or a patient is admitted with one, the

tAy»tCMUt is tu be told at once, as he may prerer
lUK tbtf tTwotiiient himself: often, however, it is given
uvi;« to the care of the nurse, and then should be
(m^i:\l l)kv any other wound. The part is sponged
ijl44U with soft gauze sponges, a solution of boric acid
(K 4 w«Mk siiliition of carbolic acid being employed, and
XitS C»»V»ty jwckeit with strips of iodoform gauze or treated
wllll io(J(,^>rin or aristo! ointment, over which a layer of
WiAl'f'J cv^tlun is applied. The whole is sealed with a
l«^'V( (.tl'^auie dipped iacelloidin. If the sore is a very
tudl MIV> i' should be dressed twice daity ; for small ones
ttUKV A vlay w'" be sufficient. If there be a .slough, it
iiwy t* removed by poultices, but these are seldom
4M IWVvr o«lei-ed now, as they 'ioftcn and tend to weaken
t)W turixikinding tissues, and thus favor pus-formation.
f\ ^klnt! of gauze moistened in carbolic solution is
b<;tlvr. Weak gr-inulations may sometimes require stim-
uImIIoiI i where they are too exuberant some caustic ap-
^hV4«Uk>n niity be indicated. The formula for the ceU
iMldiil Moliition will be found elsewhere. With this
lUVIMIrtlliin the use of a rubber plaster to hold a dress-
UltJ III (m'«ition is quite unnecessary. The adhesive
uktvlur i" undesirable, not only because it is uncleanly,
hut i>il account of the irritation which it produces and
\\\v illftlculty and pain experienced when it has to be
MUmiVcd,

III llie flr^t stage of convalescence from an acute dis-
WW, wlx'li the temperature has become normal or
lltMrly *o, a limited soft diet is ordered, and if the pa-
(ll'ltl U ullowed tn sit up in bed, he is to be supported
liy rt linml-rcst or with pillows. In the next stage he
lUHy ho ullowed a little solid food and may sit up out

CONVALESCENCE. 1 29

of bed (at first only for a few minutes, the time being
gradually prolonged each day), and from this on there
will be a gradual increase in privileges until strength is
restored. The second stage is more or less prolonged
according to the particular case, but not until a patient
is discharged do a nurse's duties cease. Especial at-
tention is required during convalescence lest too much
be attempted and bad results follow. The tempera-
ture and pulse should be taken and recorded twict in
the twent>'-four hours, the amount of sleep noted,
and the increase in weight determined about once a
week.

When the patient sits up in bed a flannel vest
should be placed under the night-gown, and the shoul-
ders are to be well protected. A loose flannel dress-
ing-jacket is comfortable and looks well. Nightingales
are very convenient to put on and off: they fit well
about the shoulders, and are in every way be.st for
hospital use. They may be made of a double thick-
ness of outing flannel, are inexpensive, and do not
shrink in washing. Unless the weather is very warm.
gray blankets should be wrapped about patients when
out of bed or when in the wliecl-chair. White bed
blankets should never be used for this purpose. If a
patient Can sit up in a chair to have his bed made, his
feet and body are to be well enveloped in blankets.
Long loose warm dressing-gowns are the best to use
for movingto and from the bed, as they are easily put
on and off; thus saving the patient's strength.

Seeing too many friends is one of the chief evils
that maybefill a convalescent: friends in their joy that
the danger is over do not realize that the patii

mat _

l30 NURSING-

strength has not yet returned, and should the nurse
forget this fact and allow two or three friends to visit
him at one time, and another set almost immediately
after, much harm may result. Il is just as important
during convalescence as when he is in bed that the pa-
tient should be protected from excitement and from any
overtax of the nerves and strength : one or two visitors
at the most are sufficient for one day, and even then
the time should be limited, and no visits whatever should
be allowed after 8 or 8.30 in the evening. A patient
should have been cared for and .settled for the night
by 9 or g.30 at the latest ; even if he shows an in-
clination to talk still later, the nurse should use tact
to prevent it. The patient should be bathed, the bed
freshened, the ventilation rL'tjulated, the room settled
and darkened, a glass of milk or some nourishment
given, and finally the back gently rubbed for a few
minutes, without any conversation whatever taking
place.

If the condition of a patient at any time shows a
marked change for the worse, the nurse should at once
notify the physician, and without instructions from
him she should never willingly assume the respon-
sibility of being alone with a dying patient. Whether
she is in a hospital or on private duty, a nurse should
always see that the proper arrangements are made aftei
death. Her duties to her patient do not cease until
the body has been decently cared for and the bed and
room have been left in perfect order. In a hospital it
is desirable to remove all traces of ticath as soon as
[lossible, on account of the other patients. The limbs
ihould be straightened before the rigor mortis

nbs 'H

THE CARE OF THE DEAD.

131

stiffening of the muscles begins, the eyes closed, and
the Jaw held in position by placing a support under
the chin ; for this a roller bandage or a small piece of
wood which has been covered with some soft materia!
is generally employed. The nostrils, mouth, rectum,
and vai^ina should be packed with common cotton or
any soft substance that will absorb, and thus prevent
the escape of, post-mortem discharges. After this has
been done the body should be bathed with a 2 per
cent, aqueous solution of carbolic acid ; if there are
any wounds, they should be covered with fresh cotton
and then neatly bandaged; if it be necessary the hips
may be enclosed in a large triangular binder; the
knees are to be held together by a broad bandage ; the
hair should be brushed smoothly ; and finally .siock-
i and a simple night-gown should be put on. If
the case be one of infectious disea.se. the body should
be wrapped in a sheet which has been wrung out of a
5 per cent, atjucous solution of carbolic acid, and
which should be kept damp. In a hospital, as soon as
these preparations are completed, a card should be
made oul with the name of the patient and of the
ward, together with the hour at which death occurred;
and this should be sent with the body, which is to be
at once removed from the ward. A nurse should
never mention or discuss a death with any of the
patients. When on private duty, as a rule, the
nurse has but little further to do; but if it should
be necessary she should be ready to offer sugges-
tions, so that the arrangements may be made with as
little trouble to the family as possible. She should
not leave the room till all is in order and all traces of

132

NUHS/NG,

her work have been removed. Where there is no one
else to look after the proper disinfection of the room,
the duty of seeing that this is properly done will de-
volve upon her.

CHAPTER Vir.

Baths. — Classification. — TEMrF,KAiL:RF,^ Baths for Cleanli-
ness. — Tub-baths, — Peii-haths. — Koot-baths. — Kaths a-*
Therapeutic Agents. — MirsiARii-iiATH. — Simple Hot Bath. —
Hot-air. Steam, or VAfon Baths.— Salt-water Baths.—
Bkan anp Starch ItATHs. — Sponce-haths and Tur-baths
IN Typhhid Kevei..— The Cold Pack.— The Cuntinuoui
Bath.

The subject of the skin and its functions, with
those of the sebaceous and sudoriparous glands, will
have to be learned by the nurse from her lectures on
Anatomy. An accurate knowledge of the structure
and physiology of the skin is indispensable in order to
comprehend .satisfactorily the indications for and the
action of baths. Baths may be classified according to
the temperature at which they are employed, the special
purpose for which they are used, or the method of
their preparation. Simple baths are usually spoken of
as hot, warm, tepid, or cold. Thu."!, broadly speaking,

A hot balh may vaiy

n temperature Ironi loo° t

^ 112= F

A warn "

,o'l

100' K.

A lepid " "

70" 1

goT.

A cold ■'

33° 1

65- F.

T higher

The baths that come within the province of a nurse's
work are given for cleanliness, to reduce fever or in-
flammation, to induce perspiration, to produce general
relaxation, or to modify the circulation of the blood.

Baths for cleanHness may be given either by spon^-

134 NURSING.

ing the patient while in bed or by immersing him in a
bath-tub. To give a bed-bath a nurse must first have I
on the spot all the things which she will require,
exceedingly bad management, and not a little trying to |
the patient, if, when she has once begun her work, [
the nurse is obliged to stop at intervals to run for 1
something not at hand. The old proverb, " The head \
should save the heels," applies no less here than i
where in a nurse's work. The time for the morning J
bath is also that for changing the bed-linen, so one
should have the fresh sheets, pillow-cases, and night-
gown all warmed and ready to put on; toweh brought
at the same lime .should be either warmed by hang- I
ing them before the fire or by wrapping them around
a hot-water tin. The nurse should have beside her i
a good-sized pitcher of hot water and another of
cold water, a slop-jar for changing the water, a bath ■
basin, and two single bath blankets. The other ne-
cessary articles will be found in the "nurse's toilet-
basket." Everything is taken off" the patient, and she
is allowed to lie between the two blankets. The body
is to be bathed in sections, the face, neck, and arms
being first taken, then the chest and abdomen, next
the feet and legs, and finally the back and surfaces
between the thighs. The entire bath can be given |
under cover, or at any rate no more than one part
need be exposed at a time, and the whole procedure I
should not last, as a rule, longer than fifteen or, at the
most, twenty minutes. The first bath, however, may
of necessity take longer than this, and if a patient is
very dirty a few drops of aqua ammonia or a little
borax powder added to the water will be found useful,

THE BED-BATH.

135

Either of these will also be of advantage if the odor
of perspiration is unpleasantly strong; in any case, a '
little alcohol or eau de Cologne will be found refresh-
ing, though to some patients even this may not be
agreeable. yVfter the bath the finger-nails and toe-
nails should be cleaned and pared. Towels should be
used generously, and cold, damp ones should never be
employed. The water should be kept pleasantly warm
by being changed twice or three times in the course of

bath. If the patient seem exhausted after it, a glass
of hot milk or some form of light food may be given,
and if the feet are at all cold a hot can should be
applied.

Some nurses are extremely untidy about giving

bed-bath. On entering a ward one is sometimes
confronted with a screen about a bed: from under-
neath it. strewn all around on the floor, can be seen,
perhaps, a hot-water can no longer needed, the nurse's
dressing-basket, a towel or two, or the soiled linen
just removed from the bed. Such a scene speaks
louder than words for careless work on the part of
the nurse in charge.

Patients can frequently, if wheeled into the bath-
room, take their bath in the ordinary tub, or at
the bedside if a portable tub be procurable. If able
to give themselves the bath, the nurse must remain
near at hand, lest Ihey should become faint or need
any assistance. In giving a patient a bath a sheet is
spread over her and she is lifted in, leaving the sheet
to cover over the top of the tub. since it would other-
'isc interfere with sponging. (Cf. also the method of
j;givtng the tub-bath in the case of a typhoid-fever

1 36 NURS/NC.

palifnt.) When ready for bed the patient may be lifted
out again under cover of the same sheet, and placedi
on ii second, well-warmed, sheet, in which she is.
wrapped. A blanket is then thrown over her, and:-
she is left for a few moments until all moisture
absorbed and she is rested.

P'oot-batlis may be given in bed by spreading
rubber sheet across the lower part of it in order to^
protect the mattress. The patient lies on her back,
bends the knees, and places her feet in the tub. which
is arranged lengthwise in the bed. The same method
is followed in giving a mustard foot-bath, only then
the knees and foot-tub are enclosed in a bbiiket
Mustard foot-baths are often prescribed for severe
colds where the symptoms are mainly confined to the
head, and for headaches where there may be too much
blood going to the head, the object of the bath being
to dilate the blood-vessels of the extremities, thus
bringing more blood to these parts, and in this way
equalizing the circulation. Hot water alone will do-
this, but the addition of mustard hastens and increases'
the effect. The amount of mustard to be used varieyi
according to the strength of the mustard and the sensi-
tiveness of the skin : it should be first mixed with
small amount of water and made into a paste before'
being added to the bath, or it may be put into a smal
bag and this put into the bath. The feet are allowed
to remain in from fifteen to twenty minutes, the water
being kLpt at the same temperature or even madt
warmer by adding more hot water from time to time
they are tlien taken out, wiped gently, and tucked well
in with blankets. Where it is necessary for any

cd well^H
reasoo^H

THE HOT-WATER BATH.

"3/

to increase the circulation in the lower extremities,
this is usually the method employed — a method often
advantageously combined with friction and the applica-
tion of hot-water bags or cans.

The physiological action of the different forms of
the hot bath (hot-air, vapor, and steam bath) is very
much the same. When given to induce perspiration
(diaphoresis), the utmost care should be taken to sec
that the preparations are thoroughly made and that
each step is successfully carried out, for without such
precautions the labor will be in vain ; and it is folly to
produce but a partial result where only a copious per-
spiration will be of any avail. To give a hot tub-bath
for this purpose, the tub is half filled with water at
IOO° F,, and drawn to the bedside ; the patient is lifted
in and the temperature of the water gradually in-
criased until the thermometer registers about iio° F.
This temperature is maintained for from twelve to
fifteen minutes, after which the patient is lifted out
into a prepared bed, on which a long rubber is spread
with three or four hot blankets over it; these arc to
be wrapped all around her, tucked in closely about the
neck, and watched continually so that no air enters.
Plenty of water Is given to drink, as the more fluid
there is in the body the more profuse the perspiration
will be and the greater the amount of the impurities
removed. After the sweating process has been kept
up for about an hour, the patient is gradually uncov-
ered, sponged under a blanket with alcohol and water.
and the wet blankets arc removed. While in the bath.

_ cloths wrung out of cold water arc applied to the head.

H 1l is well to keep the fingers on the pulse when the

138 MUXS/NG.

patient is in the bath, and on the first indication of I
faintness to remove her to bed immediately. The hot J
water dilates the superficial blood-vessels, the pores of I
the skin or sweat-glands have their activity increased,,!
their orifices are freed from any accumulation, and urea I
and other waste matters in the blood, which normally |
should have been given off by the skin, or which have ]
been retained in the system owing to an inadequate I
excreting power of the kidneys, are carried off with ]
the perspiration. This continues only as long as the J
vessels are well dilated and the skin-gtands active, and,
as we have said, is much assisted by copious draughts I
of water.

Hot baths are frequently prescribed for convulsions
in children, as the heat relieves the muscular tension
and pain, equalizes the circulation, and produces sleep.
When given for influenza they are often ordered hot at
first, the temperature of the water being afterwards re-
duced by the addition of cold water.*

Where a drug, such as pilocarpine, is ordered, its
diaphoretic action should be assisted by wrapping the
patient tn two or three blankets, placing plenty of hot
cans at the sides between the blankets, and over all
spreading a lai^e rubber sheet to condense the heat
and exclude the air.

Unle.ss special appliances are available for giving the
hot-air, vapor, or .steam baths, it is difficult to make
them thoroughly successful with only an average nurse,
and it is better to rely upon the hot-water bath. The
vapor bath presents the least difficulty. The patient is
placed on a long rubber sheet and blanket and her
clothing removed; over her are put two small bed-

THE VAPOR BATH. 1 39

cradles high enough to support the weight of the
covering; the cradles are covered with two blankets.

and over all conies a long rubber sheet, which is
pinned with large safety-pins at short distances along
the sides of the mattress, rendering the enclosure as
air-tight as possible. A small opening is left at the
end of the bed for the introduction of a long tin spout
or rubber tube attached to a kettle of water, which
should be kept boiling by means of a small gas stove
or alcohol lamp. A patient can be left thus for from
half an hour to an hour, and is then sponged as after
the hot bath. The same lamp, kettle, and tube can be
be used for moistening the air of a room in cases of
croup or other laryngeal diseases. Similar methods
may be used for the hot-air bath, air heated by an
alcohol lamp being introduced instead of vapor. The
alcohol lamp is sometimes set inside the bed in a
basin, but this cannot be done without risk. If the
patient is able to sit up. he may be put on a chair with
his feet in a foot-bath of hot water ; the clothing being
removed, he is then covered in closely with blankets
fastened like a tent from his neck down around the

chair and reaching to tlic floor. An alcohol lamp in a
large tin basin underneath the chair is then lighted, and J
if the patient is kept well wrapped up he will soonpeivfl
spire freely. After he returns to bed, he is spongedJ
as after other baths.

Where the ward or house is heated by steam, this 1
agent can be employed advantageously. The pipe '
may be cut at a convenient point, and a T inserted, to
which can be attached a small length of pipe on which
to fasten the hose ; the amount of steam is regulated
by a valve in the T. The other end of the hose 13
introduced under the cradle, and by this means a
thorough steam bath can be given. In a hospital
these arrangements can be carried out with little trou-
ble, but in a private house it may be necessary to em-
ploy a plumber, who will supply the hose or tubing,
or a piece of common garden hose on an emergency '
may suffice.

Local baths are used chiefly to relieve inflam-
mations. Thus for sprains a foot-bath, in pelvic in-
flammations, for pain, or to induce menstrual dis-
charge, a sitz-bath is frequently ordered, in which the
patient occupies the sitting position, and only the
thighs and part of the trunk are immersed. These are
given in tubs specially shaped for the purpose.

A salt bath is ordered for its tonic effects. It can
scarcely take the place of sea-bathing, but where this
is not obtainable or where for some reason or other it
is contraindicated, the following will be found a good
substitute: Salt may be mixed with the ordinary bath-
water in the proportion of from 18 to 27 pounds of sea
salt to 100 gallons of water ; such a bath will be strong

THE COLD SPONUE-SATlf.

141

enough to redden the skin and will genernily hare an
exhilarating effect.* Medicated baths beyond these
rarely come within the province of a nurse, as any-
thing like satisCictory treatment from them is to be
obtained only in sanitaria (hydrotherapeutic institu-
tions) fitted up with all the proper appliances, where
the whole course of treatment is systematically taught
and carefully supervised.

The cold bath as a therapeutic agent is used prin-
cipally for its antipyretic effect. The most common
methods used are the sponge-bath, the cold pack, and
the cold-water tub-bath. These are employed chiefly
for the reduction of temperature in typhoid fever, oc-
casionally in pneumonia and other acute Infectious dis-
eases. In giving a sponge-batli to reduce temperature
the nurse should di.sturb the patient as little as pos-
sible: if the bathing has to be repeated often, the
continual moving irritates a typhoid patient and may
aggravate the nervous symptoms. It is not really
necessary to turn him over and spread a long rubber
sheet under him, the only object being to protect the
bed from any moisture, and this can be done by means
of two large bath towels or a small draw sheet. In
preparing to give a sponge bath there should be ready
(1) two large towels to protect the bed; (2) one of
medium size for spreading over the abdomen ; {3} two
small ones as compresses for the head (or an ice-cap) ;
(4) two medium-sized sea-sponges ; {5) two basins, one
for the towels and compresses, the other for ice-water ;
(6) a rubber to protect the pillow, A wet compress is
kept on the head all the time. Whenever the compress
becomes at all warm, it should at once be changed for

■SkAppcikUi.Mmiv

■ they c
H about

■ her b;
^B closed

NUnSTNG.

a second, which has been put on ice ready for the pur-
pose. Tile temperature of the bath-water is kept at
about 65° F. by lumps of ice; a foot-bath tub is the
best kind of basin to use, as it does not necessitate
chynging the water. The patient is covered with a
sheet, and the body is gone over in sections just as
in the bath for cleanliness : the .sponging, beginning
with the face and neck, proceeds to the arms; it should
be done with long light strokes, as the object is to
bring the water in contact with the body without pro-
ducing friction. One changes the sponge with every
third or fourth stroke. After the arms, the chest and
abdomen, and next the legs and feet, are taken, but
before going on to the latter a wet towel is wrung out
and spread over the chest and abdomen. This should
be changed frequently. Finally, the patient is turned
over on one side with the towels well tucked in. so
that the back may be sponged ; if very weak she can
be supported with one hand while the other is used
for bathing. The exposure of the parts being bathed
to the air assi.sts evaporation, and hence materially aids
in the lowering of the temperature, and it is also better
not to rub the patient dry. Five minutes' time is given
to each section, the parts where large blood-vessels
are near the surface being sponged longest. A piece
of ice wrapped in a cloth and laid in the axillary spaces
and along the carotid arteries is often useful. The legs
from the knees down require less sponging, sii
they cool quickly as a rule. The whole bath occupies
about twenty minutes. The patient is now turned on
her back, a gown open all the way down behind, but
closed in front, is slipped on, and the temperature

\a, Dut ^H
srature ^H

THE COLD PACK.

143

taken. The patient should be encouraged to drink
plenty of cold water during the bath.

The simplest way to apply the cold pack to reduce
temperature is as follows: A long rubber sheet is put
nn the bed ; two sheets are taken, each folded length-
wise into four thicknesses, wrung out of cold water
at 60° F. or 65° F., and placed one under and the
other over the patient, being tucked snugly in about
the neck, under the arms and sides, and extending
to the ankles. The sheets are removed at the end of
fifteen minutes and the proc<;dure repeated. It requires
four such packs of fifteen minutes each to equal one
bath of ten minutes, but in spite of this the pack may
sometimes be preferable, and is more particularly suit-
able for children. The cold pack is also sometimes or-
dered in conditions of delirium, of extreme nervous-
ness, and to induce sleep. In such cases one sheet only
is required. This is wrung out of cold water, and the
patient wrapped in it, the feet being left free. She is
then enveloped loosely in blankets, and left thus from
twenty minutes to an hour ; if the feet are cold, a hot
can may be put to them. This is also sometimes spoken
of as the " drip-sheet." Where symptoms of delirium
are present an ice-cap or wet compresses made of gauze
must be kept constantly applied to the head : in any
case they are a source of comfort.

An affusion to reduce temperature may be given by
wrapping the patient in a sheet and placing him on a
canvas cot, and then sprinkling him with water from
an ordinary watering-pot*

Tubbing the patients is an excellent way to reduce
temperature. This method, introduced by

• SwApjwudiji, Nowj.

reduce ^h
Brand, ^|

1 44 NCMSIA-G,

whose name it bears, was used by him with extraordi
nary results, which have been confirmed by the expc
rience in our best American hospitals. Where it is
used, a temperature of 10^.5° F. is generally an indi-
t:ation for the balh. A portable tub is necessarj',
^Sce Fig. 9.) This is filled two-thirds full of water

fit a temperature of 80° F, and rnllrd to the bedside.
The ni|^ht-gown being removed, the patient is wrapped
in a sheet and lifted in, the feet being immersed first,
and the body gradually lowered until it is completely
covered. The hands remain free, as the pulse must be
watched. A ledge at the head nfthe bath has a rubber
pillow or ring on it, upon which the head, covered
with a wet compress (towel or sponge), rests. A tem-
perature of from 70° to 75° F. is maintained by add-
ing a little ice. When the proper time has elapsed a
dry sheet is spread over the tub, in which the patient,
freed from the wet one, is wrapped as she is lifted out.
She is then placed on a long rubber sheet on the bed
and covered with a single blanket. In about ten min-
utes the wet clothing is removed and she is wiped dry.

THE COLD TUB-BATH.

145

The rectal temperature is to be taken at once, and
a«ain ihree-quarters of an hour later. For ihe ner-
vous tremor or blueness (the latter especially being
not infrequent) during the bath continuous friction
should be applied to all parts of the body except the
abdomen. Either the hand or a long-handled flesh-
brush covered with flannel may be used for this pur-
pose. When in bed, if the shivering should ttill con-
tinue, the patient should not be covered with a number
of blankets, but a hot can may be placed at the feet
and the friction continued, the rubbing being always
toward the heart, and any stimulants or nourishment
that may have been ordered should be given. Some
patients find a temperature of 70° F. too cold and the
siiock too great, in which case one may start with
water at about 85° F., and then gradually reduce the
icmpcralure to 68° or 70° F. by adding ice. The ave-
mge duration of such a bath is also from fifteen to
twenty minutes: the first one should last only about
ten minutes, so that the patient may become accus-
tomed to the treatment. The nurse who has never
seen such a bath given before may be alarmed by the
condition of the pulse, which becomes hard and small,
but this is due to the contraction of the superficial
blood-vessels, with consequent increase in the arterial
tension, and is not serious. A soft intermittent pulse
is a different matter.

The advantages of a cold bath arc — (1) its antipyretic
effect; (2) its quieting effect on the nerve-centres.
whereby delirious symptoms are frequently checked
and 5leep is induced; (3) the modification of the circu-
lation, shown by the slower and stronger pulse ; 1^4)

H^ mom
l| pendi

146

the increased excretion from the body of poisonous

products. Statistics show that this treatment lias greatly
reduced the mortality in typhoid fever, and the same is
probably true also for other febrile disorders. The
increased frequency of breatliing which ensues when
the patient is first immersed gives more oxygen to the
lungs and aids in the propulsion of blood through
them. Ha;morrhage from the bowels is regarded by
many physicians as a contraindication to its use.

Apart from its antipyretic powers, the cold bath is
sometimes ordered to stimulate the circulation or for
its effect on the nervous system ; it should then be
given in the morning and should not last over five
minutes. The patient is to be vigorously rubbed im-
mediately after it, and if reaction does not set in warm
drinks should be given, external heat applied, and the
friction continued.

As accuracy is an important feature, there should be
a bath thermometer to test the temperature of the
water, as one cannot trust implicitly to the subjective
sensation of touch.

The continuous surgical bath is used in certain
cases of large suppurating wounds, in extensive skin
lesions, from burns, etc., and after operations upon the
bladder in which supra-pubic drainage is employed.
The patient's whole body is immersed in water, kepi
clean and at uniform body temperature. This can be best
arranged where a perpetual flow through the tub can
be obtained ; but where this is impossible, warm water
must be added at frequent intervals, the bath ther-
mometer being carefully watched. The patient is sus-
pended as in a hammock on strips of canvas fastened

TUS CONTiNUOUS BATM-

to the sides of the tub ; the head is supported by a
rubber air pillow. In order to keep the temperature
more uniform and to restrict evaporation, the tub is
covered with a rubber blanket supported on a frame-
work of slats. If any dressing or irrigaliim of the
bladder is needed, the hammock is slightly raised
until the necessary portions of the body are exposed
and the manipulations can then be carried on without
taking the patient from the tub. If caiLfiilly looked
to, the patient finds such a bath very cuuifortable and
sleeps and eats as usual. Every morning' and evening
he is lifted out and dried, and before being returned
to the bath the parts to be immersed are anointed
with lanolin. If necessary the bowels may be opened
at this lime by means of an enema. Before he is
returned to the bath the latter is thoroughly cleaned.
The continuous bath is also applicable to a single
iimb or part of a b'nib. For this purpose a foot-tub
or a bowl (filled with water or with various solutions)
of suitable size may be employed.

CHAPTER VIII.

With the development of bacteriology and as a re-
sult of constant experiment the list of disinfectants or
germicides in use is always changing, and what is to-
day accepted as the most valuable drug for destroying:
micro-organisms may in a few months, or even sooner,
be replaced by a new one ; statements made as to the
value of the different chemicals as disinfecting agents
cannot as yet be accepted as final.

Corrosive sublimate was for some time considered
the most powerful germicide in use, carbolic acid com-
ing next after it ; but recent investigations have shown
that the action of sublimate is not so effectual as that
of carbolic acid. The former, it is true, brings about
decided changes in the condition of certain forms of
germs, but does not. as was first supposed, always kill
them. Besides, the drug is objectionable on account
of its intensely irritating and poisonous qualities. Heat
in various forms is now relied upon more than chemi-
cal preparations for sterilization, but certain solutions
are still used for the destruction of germs or as a
preventive against their development

Carbolic Acid (C^HjOH).

The best-known and most frequently employed

chemical disinfectant is perhaps carbolic acid. It is a

W ISO

NUMS/NG.

product of coal tar distilled at a high temperature, a
when purified comes to us in the form of white crys-
tals readily soluble in water, glycerine, or alcohol. Car-I
bolic acid will not dissolve, however, in all proportions]
in water, so that aqueous solutions stronger than jJ
per cent, cannot be made. It is one of our principat|l
disinfectants; at the same time it is a deodorizer, and J
is sometimes applied locally as an anaesthetic.

Solutions of a weaker strength than 5 per cent, will
not destroy all germs, but owing to the irritating qual-
ities of the substance it cannot always be used so ,
strong, and where it has to come in contact with t
skin or mucous membranes, weaker solutions :
employed.

To mix a 5 per cent, or i : 20 solution the bottle con*
taining the crystals is set in hot water until these arel
melted; then 1 part of carbolic acid is taken, 19 parts]
of boiling water are added to it, and the whole isj
shaken vigorously until all the globules of carbolic 1
acid have been dissolved by the water. If the wataj
be not sufficiently hot or the solution not well shaken,]
globules of the acid may remain undissolved — a con-~
dition full of danger, since one of these will bum any
living tissue which it touches. It is a good plan al-
ways to glance at the solution before using it, to be
certain that none of these globules are present. Some-
times I part of glycerine and 1 part of alcohol are add-1
ed to a.ssist in dissolving the carbolic acid. ^

Keith's dressing is a carbolic-acid preparation much
in vogue, especially in abdominal surgery. It consists
of I part of pure carbolic acid mixed with 15 parts of
glycerine.

DISINFECTANT SOLUTIONS.

Corrosive Sublimate (HgClJ.

Bichloride of mercury is soluble in i6 parts of cold
water, and ranks next to carbolic acid as a disinfectant,
being; used in solutions varj'ing in strength from i : 500
to 1 : 150,000. The 1 : 1000 and i : 2000 solutions are
most often employed. Where it is ust-d for washing
out any of the cavities of the budy weaker solu-
tions are used (i : 3000 to i ; 10,000). It is now but
rarely employed for this purpose, as the drug is readily
absorbed, and has frequently been known to produce
symptoms of poisoning. These symptoms are quite
definite, and should be carefully watched for by the
nurse. As a disinfectant for clothing it is objection-
able, because it stains white materials yellow, nor can
it be used to disinfect instruments or anything made
of metal, as it corrodes them.

To make a 1 : 1000 solution i gramme (about 15^
grs.) of the powder is dissolved in 1 litre (about 2
pints) of water; weaker solutions can be prepared
from this. It requires to be made fresh frequently,
as it decomposes and loses its disinfectant qualities
if allowed lo stand a long time. An equal amount of
common salt added to the bichloride will hasten its
tiolution and prevent decomposition.

Boric Acid.
This drug is classed among disinfectants, Tt is true
Ithat its disinfectant properties arc not very marked, but
tit possesses the additional advantage of being non-ir-
Lritating. It is used in the 5 per cent or saturated so-
IJution and in solutions of weaker strength for its
ftdc^insing effects in tlie washing out of cavities,

for its ^H

for su- ^H

tdder. TbJH

152 jiruxsiJVG.

perficial wounds, or for irrigating the bladder.
saturated solution is made by adding i part by weight
of the acid to 19 parts of water. In making the solu-
tion it is much better to use the drug in the crystal-
lized rather than in the powdered form.

Permanganate of Potassium and Oxalic Acid, I

These are used in conjunction in saturated solutions
to prepare the hands before operation and in the final
preparation of the skin of operation patients. The
exact germicidal value of these substances has not yet
been definitely determined, and we must await the re-
sults of further bacteriological investigations before
saying more about them. ^J

Absolute Alcohol. ^

This is used for cleansing and disinfecting the skin
previous to operation and for preserving catgut and
other ligatures. It has but little germicidal power.

There are a number of other preparations in use,
such as creolin, pyoktanin, salicylic acid, peroxide of
hydrogen, and ly.sol, but their comparative merits as
disinfectants have not been fully established, and it is
unnecessary to enter into detailed descriptions as to
their preparation or application.

THE METRIC SYSTEM.
The adoption of the metric system as the standard '
method of weight and measure is the natural result
of the influence of foreign scientific education. In
Europe, except perhaps in England, it is universally
used, chiefly on account of the greater convenience!

lit

In
versally J|
'enience^^l

which it affords. It is being more and more employed
by the public, and is now exclusively used in the exact
sciences. As many modern hospitals and physicians
employ the metric system so constantly, it is absolutely
necessary that the nurse become familiar with it.

The standard taken first was the metre (39.39 inches)
— a standard which can be recovered at any time should
the present rule be lost, since it approximately repre-
sents the ten-millionth part of a quadranl of the earth's
meridian. All the other terms in the system are de-
rived in some way from the metre, which is taken as
the unit.

Any subdivision of the metre is expressed by Lat-
in prefixes; on the other hand, when it is increased or
multiplied, Greek prefixes arc used. The former are
deci- (from deccm, ten), centi- (from centum, a hun-
dred), and milli- (from mille, a thousand) : tlic latter
are deca- (from deka. ten), hecto- (from hekaton, one
hundred), and kilo- (from chilioi or chilia, a thousand).

The two arrangements, then, would be as follows:

Decreasittg.
; Metre.

I decimetre =^ one-tenth, .1, or ^ of a metre,
I centimetre= one-hundredth, .01, or yjj of a metre.
millimetre ^ one-thousandth, ,OOi , or yi^inr ofa metrt

Increasing^.
Metre.

dekametre = ten metres,
hectometre ^ hundred metres,
kilometre ^ thousand metres.

Thus, one decimetre,
ttrn centimetres,
or one hundred millimetres J
The cube of a centimetre is called a cubic centimetre,
and is written i cc.

The standard of capacity is based upon the standard
of length, and is represented by the litre, which is
equal to lOOO cc. The weight of i cc. of distilled J
water at 4° C. is called i gramme, and in this way we-
get the unit of weight.

Thus, we have the metre as the unit of length,
the litre " " capacity,

and the gramme " " weight ;

and the same prefixes as were used for the metre de-
note their division or multiplication.

In the case of the litre the divisions are rarely
spoken of as decilitre, centilitre, or millilitre, but for
convenience the cubic centimetre, the equivalent of
the miililitre. is used entirely; e.g. we say icx3 cc.
instead of a decilitre, or 10 cc. rather than I centilitre,
or I cc. rather than i millilitre.

The relation of the metric system to the weights
and measures of the tables in common use are as
follows ;

I raelre =: 39. 39 inches.
25 millimelies = 1 incli.

■ litre = 33.S1 fluidouDces, 01 about a (Hots.

19.37 cc. = I fluidounce.

4 cc. := I fluidmchm, or 5 cc. =: t teaspoonful (French).

I cc. =: 15 miDiiDS, apjToxiiualeiy.

I gramme = 15^ grains, npjiroximalely.

I pnin = .065 of a gramme.

THE METRIC SYSTEM.

'55

The term micro-millimetre is used in measuring mi-
croscopical distances, and means ■niVs' °f ^ millimetre ;
it is indicated by the Greek letter a ; thus a red blood-
corpuscle is said to be from 6 to 9 /i in diameter.

THE PREPARATION OF SOLUTIONS.

In the preparation of solutions the greater con-
venience of the metric system over the old system
will be made at once obvious by giving a few illus-
trations, since with it the use of vulgar fractions is
entirely done away with.

Solutions of carbolic acid and corrosive sublimate
are the ones ordinarily used in hospitals, and for the
sake of convenience strong standard solutions are
always kept in stock, and weaker ones made from
these, when required for use, by diluting with the
necessary amount of water. It will be found very
useful to adopt as a .standard strong solutions of
both of these, one which contains in 20 parts i part
by weight of the drugs. We speak of these as
" I : 20 solutions." The weaker solutions are made
most easily by simple dilution, although of course, if
one wishes, they can be made by dissolving the anti-
septic substance in water in the desired proportion.

When using solutions of standard strengths (i ; 20)
it is important to remember that 20 cc. of the solution
correspond to i gramme of the antiseptic substance.
We said above that i gramme was the name given to
the weight of I cc. of water. Thus, to make a solution
of the strength of l : 1000 we must have i gramme of
the chemical in icmdo cc. or l litre, of the finished so-
lution ; this is readily obtained by mixing 20 cc.

tied so- ^H

. of our ^1

156 NURSING.

standard solution with gSo cc. of water. The whole
litre thus contains 20 cc. of the standard solution—
1 gramme of the original substance in 1000 cc— and
tlie .solution is thus rightly named " i : looo."

For making bichloride solutions the metric system
is almost exclusively used. Remembering that i litre
equals 1000 cc, and taking a 1 : 20 solution as the
basis for making the weaker one, we take

30 cc. , and uld enougli '

0 make up i litre (ui a

o soIulioQ.

To make more dilute solutions than these it is more
convenient to start with a i : 1000 solution and dilute
this. For instance, to prepare 1 litre for irrigation of
the strength of i : 100,000. one has simply to dilute the
1 : 1000 solution 100 times ; thus, 100 cc. of the new
solution must contain 1 cc. of the i : 1000 solution;
1000 cc. (a litre) would therefore require 10 cc of the
I : 1000 solution ; so by taking 10 cc. of the i : lOOO
solution and adding enough water to it to make up a
litre, the new solution is made. To make a solution
of the strength of i ; 150.000, we must have i cc. of
the I : 1000 solution in 150 cc. of the new solution.
Now, 150 cc. is contained 6.6 times in 1000 cc, so
that for I litre of the new solution we must have 6.6 cc.
of the [ : 1000 solution. Similarly, solutions of anjr
strength can be made.

The old method of using apothecaries' weight still
prevails in making up the various strengths of some

SOLUTIONS OF CARMOLIC ACID.

>5?

solutions, particularly those of carbolic acid. To
make a I : 20 solution of carbolic acid, one has only to
add 1 part of the acid to 19 parts of water; as a rule.
however, not less than a quart is made at one time.

Thus, let it be required to make 1 quart of a i ; ;o
solution of carbolic acid. Now, i liquid quart --32
ounces. If in 20 ounces of the solution i ounce of
carbolic acid is contained, then in I ounce or part of
the solution there will be only -^ of an ounce of acid,
and in 1 quart or 32 ounces of the solution there must
be 32 times ^ of an ounce — /'. *- 32 X 3*5 ^ M ^ ''^
ounces, or 1 ounce and 4J drachms.*

The weaker solutions are usually made in strengths
of 1 : 30, I : 40, 1 : 50, 1 : 60, I : So, i : lOO, and of course
to make up any of these strength.s from the pure car-
bolic acid one proceeds in a precisely similar manner.

For instance, to know how much pure carbolic is
needed to make any amount of a i : 40 solution, one
will require an amount of acid equal to one-fnrtieth
of the whole solution.

Example: Let it be required to make a quart of
I 140 solution of carbolic acid. Now, l quart =- 33
ounces. The amount of acid required is of course -^
of 32 ounces — H o'' J °^ ^" ounce of carbolic acid —
i. e. a little less than 6^ drachms.

We so frequently hear the term " per cent." in con-
nection with the different solutions that to avoid all pos-
sibility of error we will discuss its meaning in deta'l.
The term is best explained by an example. Thus, by

" TLen, (aking this a
e whole up 10 33 01

acid, sufficienl waler is uddeii to rnnke
1 quart, and Ihe "quired solution is

IS8 Ari/ffS/ATG.

a 3 per cent, solution of carbolic acid we mean one I
of which lOO parts contain 3 parts of the acid, Thui
if we have a mixture containing 3 minims of carbolic
acid and 97 minims of water, we have a 3 per cent.
aqueous solution of carbolic acid. A i ; 20 solution
of carbolic acid (i part carbolic acid in every 20 parts
of the solution) will be a 5 per cent, solution. For,

In zo parts of solulion we have I pari carlxilic acid ;
.■. " 1 put of " " jlj part "

.: •• looportsof '* " 100 limes ^(=5)pai1scali>olic ociil.

So that a I : 30 solution is a 5 pei ccni. solution.

Similarly, one can reckon the percentage in any
other solution ; for instance, in a 1 : 40 solution

40 parts contain 1 part of embolic acid ;
■■■ I port conlfliDS Vff "
.'. too parts contain loa X ^ [^= ^}i) pans carbolic >cid.
So ihat a I ; 40 soludon is a z)j per ccnI. solution.

Since the weight of a given volume of carbolic acid
differs but slightly from that of the same volume of
water, these solutions may be made up with sufficient
accuracy by measurement instead of by weight.

When a nurse has once familiarized herself with
these simple points, she will wonder how the process
could ever have seemed a difficult one to her. In
dealing with such poisonous drugs it is necessary to
understand what we are doing, and we should not
always trust to memory, which is apt to fail us at
a critical moment. My experience as a teacher in
training-schools has taught me that any extra time
spent in the elucidation of fundamental principles is
never lost.

CHAPTER IX.

Bacteriolocical Niirts.^DiijNKECTjoN OK Clothing, Rooms,
FuRNiiuRK, Wards, Excreta, Sputum, and Vessels.

The subject of bacteriology as applied to the work
of a nurse is too extensive to be fully discussed in one
chapter of a book on nursing, and only an attempt
will be made to impress the student with the necessity
of clearly comprehending how much it depends upon
her whether or not the great modern discoveries are
utilized in daily life for the prevention of disease.
Next to the physician, the nurse's work is most im-
portant in relation to disease, its causation and pre-
vention, for in every department of nursing she comes
daily in contact with disease in some form, and much
depends upon the intelligence and care with which she
carries out her principles. It is therefore important
that she should not only be taught carefully the prin-
ciples, but also obtain some idea of the technique, of
bacteriology, and that she should acquaint herself at
least with the popular literature on the subject. The
beginner cannot do better than read the articles pre-
pared byT. Mitchell Prudden, M. D,, for general read-
ing in his two small books. The Story of ihc Bac/fria
and Dust and Us Dangers, also the slightly more
elaborate volume by Prof. H. W. Conn, entitled, Tht
Story of Germ Life. These might be read pre-
paratory to attending lectures on bacteriology,
render more interesting the practical demonstrations
of the various forms of bacteria, their methods
IS9

tions ^1

growth, their uses in the arts, and their relation to the
different forms of disease.

Bacteria — so called from the Greek word meaning
rods (sing, bacterium, plural bacteria) — micro-organ-
isms, germs, or microbes {t. e. tiny forms of life), are
among the various terms employed in describing the
many and widely different classes of these organisms.
It has been found that there are almost innumerable
forms of these micro-organisms, and that they are
everywhere present — in the air, in water, and in vege-
table tissues, and consequently in foods.* Although
the majority of the varieties are harmless to man. it is
now known that some of the most prevalent diseases,
not only those which have been for a long time termed
infectious and contagious, but also the so-called blood-
poisoning, indammations, fevers, and abscesses, are
caused by certain kinds of bacteria. Every form re-
quires its own peculiar kinds of nourishment and suit-
able surroundings to enable it to grow and increase.
They are found most often where both heat and moist-
ure are present ; putrefaction cannot take place without
them; in the decay of organic material they play an
important part, so that we shall not be surprised to
learn that the excreta from the body, the sputum,
faeces, and urine, form favorable culture-media for vari-
ous forms. In crowded localities, where uncleanliness
prevails, they grow in abundance, while in hospitals
they are always present, and constant precautions mu.st
be taken to keep in abeyance and if possible destroy
all virulent forms. Bacteria cling to moist surfaces,
and as long as they are in a moist condition they will
not be swept into the air nor be carried from one point

•S<iAp)KiHl>i. Notes.

BACTERIOLOGY.

I6l

to another except by animal agents ; but when these
-surfaces are allowed to dry, so that the organisms can
be blown about as dust by the winds, then it is that
they are carried and scattered everywhere and be-
come a source of danger. If they be introduced into
wounds, they may cause inflammation or suppuration,
or on entering the body may produce blood-poisoning
and various forms of infectious fever.

In hospitals or wherever disease is present the
means taken to prevent the spread of the micro-
organisms must vary according to whether they are
in a moist or dry medium. If the substance which
contains them be moist, as sputum or fjcces, then
precautions are taken to see that it be kept so until
entirely removed from the ward for disinfection ; or the
different disinfectants may be used at once, as some
of these will destroy germ-life immediately, while
others will at least prevent their further development
and multiplication for the time being. If the germs
are dry, as wc know they must be in the dust in
a ward full of patients, then daily care is exercised
to reduce the amount of dust to a minimum.

The measures taken to prevent bacterial contamina-
tion or accumulation include thorough cleanliness, a
free supply of oxygen, destruction of fomites, etc. by
sterilization, and the isolation of infectious cases. Clean-
liness in the ordinary sense of the word relating to
sick-rooms and hospitals has been discussed in Chap-
ter III., but cleanliness in relation to germs has a much
deeper sense; and where there is reason to suspect the
presence of infectious germs we should always be sure
Eo keep on the safe side, and the cleaning done should

k rioU
K and

163 NURSING.

amount to sterilization in regard to vessels, clothing,
and excreta.

Sterilization is effected in two ways — either (l) by
the action of heat or (2) by means of chemical agents
— but the term '"sterilization" is usually employed when
heat is used, and "disinfection" where the action of
chemicals is relied upon.

Bacteria are destroyed by either dr\' or moist heat:
the latter in the form of steam is the means chiefly
used since a moist atmosphere at 100° C. (steam), or
better at iJO° C, in specially designed apparatus will
sterilize much more effectively than dry air heated to
a much higher temperature. With our present appli-
ances steam can now be obtained with little difficulty,
and if fabrics be not exposed to its influence too long
at one time, they are injured less than by dry heat
Dry heat is not so penetrating, and requires a longer
time to do its work, not to mention the fact that such
things as leather and woollen fabrics, if thej' be ex-
posed to it long enough to destroy the germs, will
generally be rendered completely unfit for further
use.

The application of dry heat is a baking process:
the objects to be sterilized are exposed to a steady
teihperature of not less than 300° F. or 150° C. for
one hour.

With. moist heat the objects to be sterilized are
u.sually exposed to the steam on two or three separate
occasions, the length of time necessarj- for the process
depending, csleris paribus, upon the resistance to heat
possessed by the organisms to be destroyed. Bacte-
logists teach that to entirely destroy all germ-life
and all spores, it is necessary to expose whatever is

STERILIZA TION.

to be sterilized to the steam at icx)" C. for three suc-
cessive days for thirty minutes or more (according to
the bulk of tht- arti-
cles) each day. and
during the time inter-
vening to keep them
in a room at a tem-
perature of 30° C* For
smaller articles, instru-
ments, solutions, and
foods the Arnold ster-
ilizer (Fig. 10) is most
complete and inexpen-
sive. For sterilizing
bedding, mattresses,
clothing, and large
articles a regularly-
built disinfecting appa-
«itus is essential. For
public use these should
be provided in various
parts of large cities, but
every hospital should have its own.

Another method of sterilizing is to, boil the articles
in simple water, though usually a chemical substance
is added to the water.

The chemicals used for the destruction of bacteria
are called germicides; those which arrest and prevent
development, disinfectants : the various kinds of these
and the methods of preparing some of them have been
given in the previous chapters, and we will now
consider their action and application. Disinfectants

* Sc* AppeoiTia. Nm 7.

.,|^y.j^ always be fresli, otherwise they may lose thdr

0'*>*>'"-' **^"i "^ """^ °^ ^'"^ most efficient of the
^^^w(l Ji>intectants. but a solution undL-r 5 per cenL
« -Ajvt^th is not capable of destroying all germ-life.
IH^sA^mIU be made to come thoroughly in contact with
jgvvxY t» to be disinfected, and allowed to remain so
KM >iOUK' hours. It is the chemical substance most
l^^oycHtly used for disinfecting clothing.

!*ritlk of lime is considered especially valuable to
kWv'i innocuous the evacuations from the bowels,
, U ^oilld be freshly made, otherwise it is useless :
Ik tuw.-<t be thoroughly stirred up with the contents of
^tH bcd-paii, which must then be allowed to stand for
(kt>t Wh.1 than an hour. This is the best method of
vfMikl^'Ct''iE typhoid stools. The milk of lime is made
^- Moling I part of slaked lime to 4 parts of water.

V'hlrtfidc of lime (chlorinated lime) is perhaps 1
WtUT disinfectant than milk of lime, but 1
iilwiiyi> reliable, as it may be stale, and is objectionaU
vvvliit; to its disagreeable odor. From this substance
(U ihe presence of air and moisture is set free nascei
vhtorine, a most powerful reducing agent and highljH
Inimical to living organisms.

Corrosive sublimate or bichloride of mercury is use
111 «olutions of from i : 500 to 1 : 150,000, but for a
ittvying germs the strength used should not be lei
than I : 1000. It is a powerful irritant poison, and '
niii!<t be used with great care. Its value as a disio-
riTt.int is not equal to that of cirbolic acid. It is not
II i(..IIy iiscil for di-iinffcting white linen or cotto4.a
li'thing, as it discolors llieni.

:>r conoA.^H

Permanganate or potassium and oxalic acid are em-
ployed principally for the disinfection of the skin.*

The principal point to remember in disinfecting with
solutions is that the disinfectant must come in contact
with or be diffusud through tiic substance for a pre-
scribed length of time, in order that it may be effectual
in destroying the bacteria : a mere washing with the so-
Jution or pouring it over the object will be of no use.

Care and Disinfection of an Infected Room. — In a
hospital there should of course be no superfluous
furniture or articles to remove at the beginning of the
disease, but if in private rooms there are such, they
arc to be taken out at once : carpets, upholstered
furniture, hangings, and bric-a-brac, or anj' personal
clothing, the color of which may be destroyed by the
action of steam, must not be allowed to remain. The
daily care of such a room consists in wiping off the
fiimiture with a damp cloth and sweeping the floor
with a broom covered with a damp cloth wrung out
of a 1 : 20 carbolic-acid solution ; besides this, the
floor must be rubbed thoroughly with a damp cloth
every second or third day. If the disease be con-
tagious, further care may be taken by hanging up a
(lamp sheet, kept moist, in the line of air-currents.
All such cloths that arc used daily should be washed
in hot soapsuds, and then, when not in use, left to soak
ja a I : 20 carbolic solution. After the patient has
recovered from an infectious disease he should receive
a hot soap- and- water tub or sponge bath (including a
thorough washing of the hair), followed by a thorough
sponging with carbolic or bichloride solution, after
which he is wrapped in clean sheets or clothes and

ffURSING.

h bf' mfAKt room. The next thing to do \s to
ifcc clothing nnd bedding for sterilization.
>^« !X^>tks the disinfection of the room. The mat-
^^t^ - > tKusited off, wrapped in a damp sheet, and sent
^tiK 'Vmltecr. The clothes are also steamed, and
k '*,<« tw the laundry. Where there is no sterilizer,

t tK^ling must be soaked in i : 20 solution of car-
'%^J)C jri<)^, iind afterward boiled, and the mattresses
■ •^yt jfxtrt and boiled or else burned.

fhc care of the infected room should then be as
igih>w^: Close up tightly and leave it for twenty-four
I^Mi-v until the dust has settled ; then enter very
MfMly. 90 3S not to disturb the dust, and wipe off
^Vf^ thing in the room with a cloth wrung out of
y . UWO bichloride solution. Treat all the woodwork,
l^ftMtt. furniture, and the bed-frame in this way, and
^p} fc^r the crevices about the bed-frame pure carbolic
^-iiJlt applying it with a small brush. Wash down the
v^rtil* with bichloride solution i : 1000, and then leave
thv windows wide open, so that the sunshine and air ■
iiK»,v enter freely.

Where steam can be secured an excellent method is 1
U« fill the room with steam, keeping up the supply till ]
^hc moisture falls on the walls or floor: nearly all the
bacteria will be on the moist surfaces, and the walls |
Aiul floor may be washed off with a disinfectant solu-
(1011 before they are allowed to dry. The old method ]
,.f fumigating with sulphur has been proven to be J
liiite inadequate, as it exercises little if any destnic- J
nvr power on bacteria.*

Kvacuation.-i from the bowels in typhoid fever or I
ilysentery should be received in a vessel, containing I

•SMAppndli, Noicg.

THE DISPOSAL OF EXCRETA. 1 6?

flome milk of lime, which rfiould be closely covered
before being carried from the patient's bed through
the room or ward. An equal amount of the milk of
lime is then added, the whole thoroughly stirred toge-
ther, the vessel covered and left to stand for ono liour.

In hospitals where there are many typhoid patients,
and no conveniences for treating the stools with the
lime for that length of time, they should at least be
mixed with the lime, and when they are emptied down
the hopper a good stream of very hot water from the
hot-water pipe should be allowed to run into the ves-
sel and down the pipes.* In the country, where these
conveniences are still less frequently found, the stools
may be mixed with bran or sawdust and burned.

In regard to the sputum of patients several points
must be carefully considered viz. — the receptacle in
which it is deposited, the manner in which it is kept, and
the final disposition of it ; especial precautions should be
observed with the sputum from tuberculous lungs, the
organism that causes this disease being very virulent
and infectious and retaining its infective properties
for a long time. Direct contact with tuberculous
sputum is one of the greatest sources of infection;
besides, if it be allowed to dry and become scattered
broadcast, the bacilli may unconsciously be absoroeo
with the inspired air into the lungs, and lie quiescent
for months until favorable conditions develop, under
which the germs can multiply and reproduce the
dread disease. Therefore, every precaution should be
taken to destroy the bacilli contained in the expecto-
rated matter. The sputum-cups used for such patients
should be eitlier of china or paper, so that they may

• Sn Appndix, MM* •»■

NURSING.

be boiled or burned, and made simply, with no crevices
in which particles of sputum may lodge. The cup
should be kept covered and the sputum moist, so that
none of it. becoming dry, may escape into the air of the
room. It should be frequently cleansed, and be-
fore the contents are thrown away llic germs should
be destroyed by boiling in a 2 per cent, solution of
carbonate of soda for one hour, or by being exposed
to heat in a steam sterilizer for at least as long. The
paper cups with their contents should he burned.

Two sets of cups should be kept, and boiled in the
soda solution each time before being used again. All
vessels, tubes, or cups that ai-c used for the mouth JB
diphtheria or in syphilis or cancer should be kept in
a I : 40 carbolic-acid solution and boiled before being
used by another patient. Bed-pans used in cases of
cancer, indyscntery, or other infectious diseases, are to
be soaked in a 1 ; 20 carbolic-acid solution, and boilefi
before again coming into general use. Sheets am
clothing stained with typhoid or dysenteric discharj;cs
must be at once washed out. or soaked in a disinfectant
solution and steamed before being sent to the laundr> .
The bedding and clothing from any case of infectious
or malignant disease should always be put to soak at
once in a i : 20 carbolic-acid solution, before being
brought again into general use.* A full description of
the methods of disinfection to be employed under
different circumstances will be found in Dr. G. H.
F. Nuttati's manual entitled HygUnic Measures «r
RelatioH to Infectious Diseases, to wbich the studeat
is referred.

CHAPTER X.

Enemata. — Kinds. — Mkthops of Phepa ration.— Frequency asc
MiiDE ov Admlnistratio.v. — Care of Appliances, — Douches.—
Cathbi

There are various methods employed for injecting
fluids into the body. When they are introduced into
the intestines through the rectum, we speak of giving
enemala (singular enema, with the accent on the first syl-
lable). Since the purposes for which they are used are
manifold, there are many different kinds of enemata.

A convenient classification is as follows :

1. Simple, laxative, and purgative enemata.

2. Nutritive enemata for the introduction of nour-
ishment

3. Sedative enemata for local or systemic effects.

4. Astringent enemata which check ha;morrhages
and diarrhceas {e.g. hot water or ice-water, solutions
of alum or nitrate of silver).

5. Emollient enemata for soothing irritated and fjain-
ful mucous membranes : starch and certain drugs are
used for this purpose.

6. Antispasmodic enemata to relieve flatulence — •
*'. ij. the tuq>entine enema.

7. Anthelmintic enemata for destroying worms ; salt,
turpentine, and quassia are u.sed in this way.

8. Antiseptic or germicidal enemata, used in the
various forms of dysentery.

NUKS/A-G.

9. Stimulating cneniata — c. g. hot water, hot whis- i
key and water.

la To relieve thirst — plain water, Oj., given high.

General Directions for Giving an Enema.

The patient is placed on her left aide with the knees |
flexed, since the sigmoid flexure of the colon lies i
the left iliac fossa, and the fluid will be thus more j
easily retained; the bed is to be protected with a ]
rubber sheet and a towel; a receiving vessel must
be at hand ready for use. In very obstinate cases I
of constipation the knee-chest position is ordered, but
this is rarely necessary. The basin of water is placed j
on the rubber sheet and the enema administered under \
cover.

For a simple enema the amount for an adult vanes
from one to four pints, for a child from a half to one
pint, and for an infant about two ounces are sufficient.
The best time to administer a simple cnen.a is in the
morning just before beginning the morning toilet. ]

To give a simple enema ordinary suds are made with '
common brown soap and water, the temperature of which
'ihould be about 95° F. when ready for use. A bulb
syringe is used, care being taken to fill it to the nozde
before introducing into the rectum, since any air left in
the syringe will pass into the intestines and may cause
pain, The bulb syringe is better than any other form,
as a certain amount of intermittent gentle pressure, which
is necessary, can best be obtained in this way. The noz-
zle is always oiled or vaselined before introduction, as
the soapy water will not lubricate it sufficiently. For-
cible insertion of the nozzle is to be avoided, and one I
must be careful to pass it in, following the natural curve!

ENEMATA. I? I

of the rectum, for a distance of two or three inches.
If the point of tbi; nozzle should meet with any obstruc-
tion, no attempt should be made to force it in, as the
impediment must be either the wall of the rectum or
an accumulation of fsecal matter, which will have to be
removed before proceeding further. The water is to
be introduced in a gentle and steady stream : if rapidly
and .spasmodically injected, there will probably be pain
and an intense desire for immediate rejection. After
the full quantity has been given, the patient should try
to retain it for ten or fifteen minutes in order to obtain
satisfactory results. A folded towel pressed against
tht; anus wilt assist the patient in resisting the desire
to expel the intestinal contents.

If one simple enema is not effectual, it should be
repeated in half an hour and a larger amount given.
Sometimes, after operations or where the action of the
bowels has been sluggish, a laxative enema is given
instead of a simple one, or the laxative enema is fol-
lowed by a simple enema in the courseof half an hour.
The laxatives ordinarily used are olive oil or glycerine,
the former softening the fjeces, the latter increasing
the peristaltic action. If olive oil is ordered, the
average amount given is six ounces in a hard-rubber
syringe ; a simple oil enema is seldom successful
unless followed by the soapsuds, which should be
given half an hour or an hour later. To give a
glycerine enema, half an ounce of glycerine is mixed
with the same amount of water at a temperature of
95° F. and given with a hard-rubber syringe. It is
rarely necessary to follow it up with warm water after-
wards, this amount being as a rule sufficient in tl«

NURSmc.

most obstinate cases. If not successful the first tim^
it should be repeated in an hour. In mild cases from
half a drachm to one drachm of glycerine is eflectual,
and for children and infants the contents of a straight
medicine-dropper is enough. When laxatives per r,c-
tum fail, purgative enemata are resorted to. These are
made by adding drugs, such as turpentine, Epsom or
Rochelic .salts, or castor oil, in certain proportions
to the simple enema:

Formula 1.

Castor oil, SiJ ;

Turpentine, oss.

Mix. and introduce with a hard-rubber syringe, fol-
lowing, in half an hour, with a quart of soapsuds.

Formula 2.

Turpentine, Jss;

Rochelle or Epsom salts, |j ;

Mix with warm soapsuds, Oj.

The Rocheilo salts are the better, as they dissolve
quickly. Sometimes it is necessary to introduce the
oil or glycerine high up. and to do this one may attach
a rubber male catheter to the end of the syringe,
pas.sing it up the rectum six or eight inches.

Of the various enemata above described, undoubt-
edly that with the half ounce of glycerine gives the
best results in ordinary cases, but for very obstinate
constipation or after an operation, where it is impera-
tive that the bowels shall not be obstructed, the
turpentine and Rochelle salts are the best

Nutritive enemata, as the name implies, are intended

NUTRITIVE ENEMATA.

lu nourish the body, and arc ^ivcji when food cannot
be retained by the stomach, or when it is necessary to
give that organ a rest, or where the system requires
more nourishment than can be given by the mouth.
They should not be given oftener than once in four
hours or six times in the twenty-four hours, and the
quantity administered at any one time should not ex-
ceed six ounces; the frequency and amount are, how-
ever, generally regulated by the physician according to
the nature of the case.

A nutritive enema should never be given just within
the rectum, as maj- be done with an ordinary enema.
Absorption by the mucous membrane of the large
intestine goes on slowly, much more so than in the
small intestine.whcre this process normally takes place;
moreover, the absorptive power of the rectum is less
than that of any other portion nf the large intestine.
Thus we shall not uncommonly find that a part at
least of a nutritive enema may lie unabsorbed. and as it
decomposes cause irritation of the mucous membrane,
until a second one is given, when a portion of both
wil! probably be rejected. This kind of enema should
therefore always be introduced as high up as possible,
and for this reason should be given through a rectal
tube made of heavy rubber about a quarter of an inch
in diameter, of which at least eight inches should be
inserted into the rectum. This thickness will be suf-
ficient to prevent the tube from coiling up on the inside,
;n very often happens where one of soft rubber is used,
The tube, however, must not be so stiff as to endanger
the integrity of the walls of the intestine when mode-
rate force is used in introducing it. After being well

'74

NURSING.

oiled the tube is inserted, and to the outer end a small
funnel is attached. The enema, having been previously
mixed in a half-pint or pint pitcher, is poured very
gently and very slowly into the funnel, which has
been elevated, and is allowed to trickle through the
tube. In this way no air is introduced. A folded
towel should be slipped under the patient to catch
any drops and to receive the tube when withdrawn.
After each time the tube is to be washed out thor-
oughly by allowing warm water to run through it,
and then kept in a weak solution of boric acid. To
prevent irritation of the mucous membrane where the
enemata are to be given for any length of time, it is
well to irrigate on each occasion with simple warm
water, using the tube in the .same way as for an enema,
and then by lowering it to allow the water to run out
This precaution will enable us also to make sure that
the bowel is empty before giving a nutritive enema.
Food given in this way should be very nourishing, and
concentrated foods, such as extracts of beef, beef-juice,
eggs, and milk, are generally used, stimulants of some
kind being often added. Two excellent formula are—

I. One whole egg;

Table salt, grs. xv

Peptonized milk, 5iij ;

Brandy. 3ss,

Or, 2. The whites of two eggs ;

Peptonized milk, Sij.

This makes about four ounces. The addition of salt
aids in the absorption of the egg.

Brandy and whiskey arc very irritating, and

should ^^1

RECTAL MEDICATION. I7S

be given only every other lime, unless especially
ordered; if omitted, the quantity may be made up
by adding another ounce of milk. The milk should
always be peptonized, and can be rendered so by add-
ing twenty grains of Fairchiid's prepared pepsin to
one pint of milk. The vessel containing this is allowed
to stand for fifteen minutes in water at a temperature
of roo" F., and afterwards placed immediately on ice.

The pure beef-juice is given in quantities of from
an ounce to an ounce and a half twice in twenty-four
hours, or six ounces of beef-essunce may be given a
repeated once. For thirst a pint of water is given at
at one time, and should always be introduced high up.
After a nutritive enema the patient should be kept
quiet for twenty or thirty minutes.

Sedative medicines are sometimes given by the
rectum. Among these bromide and chloral are ad-
ministered for their systemic effects, and opium in
some form more especially where there is localized
pain. If a patient is nauseated, these drugs are some-
times ordered by enema, which should be always giv-
en with the tube inserted at least six inches.

In shock or collapse brandy and hot water are often
thus given, and should also be administered high up.
If no rectal tube is at hand, a large-sized flexible male
catheter will answer ihe same purpose. A small pillow
placed beneath the hips will help the flow upward.*

In haemorrhage from the bowels hot-water or ice-
water injections may be ordered. These are best
given with a fountain syringe. This can be hung up,
and the flow of water can then be regulated by the pres-
sure of the fingers on the tube, and the bag may be

the most con*^
.uch as nitrate
• quantities of

,76

refilled as soon as it is empty. This i;
venient method also where astringenlSj
of silver and alum, are dissolved in lar]
water for irrigation of the intestines in dysentery.

Emollient enemata are prescribed in diarrhteas and
dysentery ; probably the best, where there is much
tenesmus, is that made of starch and opium. The
starch is bland and unirritating, while the opium
soothes the pain, not only by lessening peristalsis,
but also by its direct action on the nerves. In the
diarrhcea of children more particularly, it fjives ex-
cellent results, but the action of the laudanum must
be closely watched. To prepare a starch enema one
takes a sufficient quantity of laundry starch, and adds
enough cold water to dissolve it ; then boiling water
is poured on until a thin paste is formed which is
free from lumps; after this becomes cold the exact
quantity ordered is taken (usually two ounces), and
into it is stirred the required number of drops of
laudanum. The injection is given slowly and gently
through a small rectal tube.

Turpentine enemata for flatulence may be given
according to the following formula:

Mucilage of acacia,
Spirits of turpentine,
To be administered high 1

3ss;

gtt.x.

Nurses should be most particular about the care
they take of the appliances employed in giving ene-
mata. These should always be thoroughly cleane<
before being put away, and this can best be done b

cleaned^l
done bj^^l

DOUCHES. 177

allowing first hot soapsuds, and afterwards simple hot
water, to run through the tube. Tht-y should never
be put away damp, but hung up lengthwise to drip
and dry. The nozzle is to be left for sonjc hours in
a 5 per cent, solution of carbolic acid, and then well
washed off or boiled before being used again.

By a douche is generally meant a jet of fluid directed
with a certain amount of force upon a limited surface,
external or internal. Among those given internally are
the vaginal, tJie na^al. and the aural douche. Douches
are given for cleanliness, for their stimulating effects, or
to relieve inflammation ; like other baths, they may be
either simple or medicated. The vaginal douche is
very frequently used in hospitals, and is usually made
by adding some disinfectant to the water, preferably a
solution of carbolic acid. If it is for cleansing pur-
poses, a I per cent, solution is usually the strength
ordered; to allay inflammation, a hot solution of tile
same strength, the temperature ranging from 105° to
115° F. or even higher, can be employed. The foun-
tain syringe with a gla.ss douche-nozzle attached is the
best instrument to use. Before the nozzle is inserted
the stream of w.iter .should be allowed lo flow through
it until it is warm, and it should then be introduced
well up toward the po-sterior wall of the vagina. If
no special amount is ordered, a quart or three pints
will be enough. The douche should always be given
with the patient in the recumbent position ; even if she
be up and about, she should be made to lie down for
such treatment.* Glass nozzles are the only ones that
can be kept quite clean, and they should be of the
simplest possible construction. After being used hot

• S« Appcndlii, NgU 13.

NURS/NG.

water is allowed to run through them, and they a
kept in a small open-mouthed bottle filled with i :20
carbolic-acid solution, with the patient's name on the
label. Each patient in the hospital requiring douches
should have her own douche-nozzle. Before being
used for another patient the nozzle is to be washed thor-
oughly with soap and cold water and boiled for five
minutes in a i per cent, solution of carbonate of soda.
Catheterization. — As it is important for a nurse to
know early in her training how to catheterize a pa-
tient, the subject will be discussed here. Cystitis is
an inflammation of the mucous membrane lining the
bladder, which may be due to many different causes.
One of the prolific sources of this inflammation is the
introduction of foreign material into the bladder on
a catheter. If germs are introduced, the urine will
be decomposed, more germs will be developed, and
inflammation will result. When this is the case, the
fault rests with the doctor or nurse, in most cases
with the latter, since she is usually entrusted with the
work. To avoid this, therefore, every nurse should
make sure, when an order has been given her to ca-
theterize a patient, that a cystitis, if such unfortunately
should occur, will not be traceable to any neglect on
her part ; otherwise she may feel that she has been the
cause of weeks or months of intense suffering to a
patient through her carelessness. Let her, then, see
that the utmost cleanliness is exercised. The glass
catheter is by far the best for women, but, of whatever
material it be made, the instrument should be abso-
lutely clean before use. The glass, metallic, or rubber
catheter may be rendered thoroughly sterile by first
washing with soap and cold water and then boiling

CA THE TERJZA TION. 1 79

in a I per cent, solution of carbonate of soda for five
minutes ; it is then laid in a clean basin containing a
warm solution of boric acid, where it remains until it
is needed. A gum-elastic catheter should be soaked
for one hour in a I : lOQO bichloride solution, then
washed off thoroughly in hot sterile water, and placed
in the boric-acid solution.

In preparing to catheterize a patient the nurse is to
wash her hands with soap and hot water, and after-
ward soak them in a i : looo bichloride solution.
She then takes sterilized gauze sponges, the basin
with the boric solution and catheter, a vessel to re-
ceive the urine, and some sterilized oil. The patient
lies flat on the hips with the knees somewhat sep-
arated; a sheet or blanket is next thrown over each
knee, leaving the vulva exposed : this is necessary, as
one must see that the parts are clean. In bathing,
gauze sponges should be used to separate the labia,
and the region of the meatus urinarius carefully
washed. The catheter is then dipped in the oil and
introduced, care being taken to touch with the hands
only the portion which will be left outside. With a
glass catheter no oil is necessary.

The urethra is situated just above the vaginal out-
let, and can be easily seen as a rule: the end of the
catheter should enter the bladder quite readily. If
any obstruction be met with, the instrument should
not be pushed forward, but withdrawn slightly and the
course changed. If the urine ceases to flow, the cath-
eter is to be withdrawn a little or the position changed,
when it may flow again. If the bladder is very much
distended, it should not be emptied entirely the first

i8o

NURSING.

time. When removing the catheter the finger should
be placed over the end, so that any drops of urine re-
maining in it may not &11 upon the bed. After the
urine has been drawn oflf the parts are bathed and
dried. Hot water is passed freely and with some
force through the catheter. Glass catheters may be
boiled in soda solution, and then kept in a 5 per cent,
solution of carbolic acid. The others, after being thor-
oughly washed and dried, are laid aside, folded in a
clean towel, and must be sterilized in the manner de-
scribed above before being used again.

If a specimen of urine be required for examination,
it should be drawn directly into a sterilized bottle, the
top of which is to be plugged with clean cotton.

CHAPTER XI.

The temperature, pulse, and respiration of the body
in health bear a certain ratio to one another, and any
variation in one will usually be found associated with
changes in one or both of the others. Thus it be-
comes necessar}', when considering the condition of
one, to bear in mind at the same time that of the other
two. A knowledge of the functions of the skin, of
the circulation of the blood, and of the chemical
changes that take place in the body and produce heat,
is necessary for a full comprehen.sion of the establish-
ment and maintenance of the bodily temperature, by
which we mean the degree of heat found in any part
of the body. This is nearly equal everywhere, since
the blood which penetrates all portions of the system
has for one of its functions the general distribution of
the heat. In health the temperature varies constantly
within certain narrow limits, although a normal tem-
perature by no means indicates that a person is free
from disease. The normal temperature of the human
body is 98.6° F. {57° C), but under certain circum-
stances may bt- anything between 97.5° and 99.5° V.
A temperature above or below these points is to be
considered abnormal, that is, as denoting a departurt^

I S3 Ac/xsmc.

from that of the normal or healthy condition. These
variations maybe classed under three different headings:

First : those dependent upon the time of day at which
the temperature is taken, as definite daily changes take
place within the limits mentioned above. During the
greater part of the day about the mean temperature
of 98.6° F. is maintained, but by four or five o'clock in
the afternoon this is found to have increased to 99° F,,
or may even be a little higher; at eight o'clock in the
evening the fall begins, which continues until the lowest
point, 98° or 97.5° F., is reached by 2 a. m. The tem-
perature may continue low imtil between six and seven
o'clock, when it again rises to 98.6° F. These fluctu-
ations are easily accounted for, since during the day
food and exercise tend to gradually elevate the tem-
perature slightly, while after eight o'clock in the even-
ing, when there is rest of body and mind and the hours
are passed fasting and in sleep, there is naturally a
slight decrease.

Secondly : those dependent on the part of the body
in which the temperature is taken ; thus the tempera-
lure in the axilla is always lower than that of the
mouth by three-tenths of a degree, while that taken
by rectum is half a degree higher than that taken in
the mouth.

Thirdly: those dependent on other causes. Thus
the ingestion of highly-seasoned, stimulating foods
elevates the temperature. Again, certain general or
local causes may exercise a decided influence on the
heat of the whole or of certain parts of the body ; for
instance, profuse perspiration reduces temperature, or
if the hands and arms are dipped in cold water, while

THE TEMPERATURE.

the axillary temperature may be subnormal, that taken
by the mouth may give a normal reading.

Any departure from the normal temperature, beyond
certain limits, indicates a deviation from health or the
invasion of disease, and in many instances the intensity
of the morbid process is directly proportionate to the
elevation of the temperature.

Abnormal temperatures are recognized as (i) sub-
normal, (3) elevated. A subnormal temperature may
range from 96'^ to 98° F. In conditions of collapse it
may go as low as 95° F., but this is extreme, and there
is little hope of a patient rallying with such a temper-
ature. A general depression of the vital forces may
produce a subnormal temperature, or local causes —
e. g. traumatism by producing .shock — may have a
similar effect. In paralysis, after .severe hatmorrhage,
in some diseases where there is a continual tissue-
waste going on. in chronic malaria where the blood
has been mucli impoverished by the malarial organ-
ism, in some nervous disorders, and in certain poison-
ings that affect the heat- centres, in heat exhaustion, —
in any of these conditions there may be a depres-
sion of temperature.

Elevation of temperature means an excess cf heat in
the body, due either to an increased production or to
an over-accumulation from imperfect dissipation.

The range of temperature compatible with life may
be fairly placed between 95° and 109° F,, either of
these extremes usually being a fata! symptom. Some
extraordinary cases, however, with remarkably high
and low temperatures, have ultimately recovered. We
may then classify the temperature conditions as follows :

1 84 NURSING.

Tempcraluce of collapse 95°-97° F-

SubnormiJ temperature 97°-98'' F.

Normal " g8.6° F., wiih vnrialions.

Subfebrile ■' gg-S'-ioo.s" F.

Fever of moderate degree ioo.5''-lOj° F.

High fever I03°-los'' F.

Hyperpjrexia above 105° F.

The temperature should be taken at least twice a
day, owing to the diurnal variations; thus, a morning
temperature may be normal, and the evening tempera-
ture found to be considerably elevated. The instru-
ment for measuring the heat of the body is called a
clinical thermometer, to distinguish it from the ordi-
nary ones. The Fahrenheit scale is the one princi-
pally used in America; in Europe the Centigrade and
Reaumur take precedence.

The rule for converting Fahrenheit degrees into
those of Centigrade is to subtract 32, multiply by 5,
and divide by 9. For instance,

104" F. = r(l04° — 32°) X n C. = 40° C.

To reduce Centigrade to Fahrenheit multiply by 9, di
vide by 5, and add 32 to the result.

Thus, 40° C. = r(40° X ^) + 32°1 F. - 104° F.

To reduce Fahrenheit to Reaumur subtract 32, multi-
ply by 4, and divide by 9.

The instrument should be accurate, self- registering,
and clearly indexed. Hicks' thermometer with a Kew
Observatory certificate is considered the best, but all
thermometers change with age, and should be tested
by a standard frequently and the necessary corrections

THE TEMPERATURE. 185

The best way to test a thermometer is to place
it, along with one of known accuracy at the same mo-
ment, in the mouth or rectum. After these two have
been left long enough to register, they are taken out
together and the results compared. The mercury
should be shaken down below 95° F. on the index.
The temperature may be taken cutaneously between
two folds of the skin in the axilla or groin, or in some
of the cavities of the body, either the mouth, vagina,
or rectum. The length of time necessary for obtain-
ing the registration depends upon where the tempera-
ture is taken and upon the thermometer used. None
register under three minutes except the special one-
minute thermometer, which is too expensive for hos-
pital use. The time allowed for registration in the
axilla should be ten minutes at the very least, in the
mouth or rectum from three to five minutes. The ax-
illary temperature will be from one-tenth to three-
tenths of a degree lower than that taken by the mouth.

The rectal temperature is the most accurate, as by
this method the patient is not required to assist; in-
deed, for children it is the only one feasible. Precau-
tions must be taken to have the rectum free from
fiEces. The bulb of the instrument is to be oiled and
inserted gently for about one and a half inches : the
only disadvantage lies in the inconvenience of the pro-
cedure, unless indeed there be any disease of the parts,
since then an elevation might be due merely to local
causes.

For obvious reasons, however the temperature is
most commonly taken by the mouth. The ther-
mometer should be placed under the tongue, the pa-

186 l^VRSINC.

tient being instructed to close the lips tightly over it,
but not to bite it. If the lips be dry, they should be
moistened, and one should be careful not to take the
mouth temperature directly after a hot or cold drink.
If a patient is too weak, or the lips and mouth so dry
that they cannot be kept tightly closed, air will be ad-
mitted and the record will be inaccurate. Moreover,
the method is not a safe one for unconscious or delir-
ious patients, since they may bite off the bulb and
awallow it. Should this accident happen, it should be
reported at once to the physician, though as a matter of
fact he can do nothing, and the results are not likely
to be serious. In several cases which I myself have
seen, and which were left to nature, no harm re.sulted.

In taking the axillary temperature the arm-pit should
be wiped thoroughly dry from perspiration and the
thermonietei placed in the hollow : the arm is then
held closely to the side with the elbow flexed and the
hand resting on the opposite clavicle. If the patient
is very weak the arm should be held in place by the
nurse. Sometimes there is too much emaciation to
admit of the close contact of the skin surfaces : in
such cases or where there is excessive perspiration an
axillary temperature should not be relied upon. It is
convenient at night, since it can be done with but
little disturbance to a sleeping patient, whereas if it is
taken by mouth when half asleep he is liable to allow
the lips to open. In recording a temperature one
always states where it has been taken, unless ordered
to take it only in one particular place.

Before using the .same thermometer for another pa-
tient the nurse should be particular to wash it ofT

thoroughly with some antiseptic solution and wipe
with a clean napkin. When thermometers are not in
use they should be kept in a glass filled with a fresh
solution of bichloride of mercury (i : looo), the bot-
tom of which is covered with absorbent cotton as a
soft bed for the mercury bulbs to re.it upon.

It is an excellent thing to learn to judge of the con-
dition of a patient's temperature by the touch, training
the fingers or hand to feel differences, and controlling
the impressions thus received with the results obtained
with the thermometer, since the attention of a nurse
with a well-trained touch may sometimes be drawn to
an unusual condition in a patient that otherwise might
pass unnoticed. It should be remembered, however,
that the surface temperature is not a reliable index to
tile general bodily temperature: the skin may feel
comparatively cool when the thermometer in the rec-
tum shows an elevation of several degrees.

The thermometer is of great value in diagnosis, and
in any doubtful case the temperature should be regu-
larly taken at short intervals until other symptoms
manifest themselves. In hospitals one occasionally
meets with a malingerer who, if not watched, will
shake the mercury up, producing an unaccountably
high temperature. With children a high temperature
is not necessarily so serious as the same would be in
an adult. In hysteria the temperature may reach 104°
or 105° F., and then fall without a recurrence.

In recording a temperature or pulse, where any doubt
exists as to the accuracy of the observation it is ad-
visable to place a question-mark (?) after the record, in
order that the attention of the physician may be called

to the possibility of an inaccuracy. But extremely
high temperatures actually do occur. These are in-
stances of the so-called " paradoxical " temperature,
and are more likely to occur just before death. Ob-
servers whose reliability cannot be called into question
have reported temperatures (in the last stages of dis-
ease) as high as 112° F. In sunstroke 109° F. and
even higher temperatures have been recorded. Hilton
Fagge cites a case of a young woman (observed by
Teaie} in which on four different occasions the mer-
cury was buried in the bulb at the top of the ther-
mometer at a point above 122° F. Whenever, how-
ever, the thermometer registers an extraordinary
temperature (whether above or below normal), the
results should be controlled more than once, and sev-
eral different instruments should be employed, before
we are convinced that no error on our part has been
made.

Fever or pyrexia may be classed as continuou':, re-
mittent, or intermittent. A continuous fever is one in
which the temperature is uniformly above the normal
line with but slight variation, such as is seen in pneu-
monia. In a remittent fever there is a rise and fall as
in typhoid fever, although the temperature never
reaches the normal line. In intermittent fever the
temperature is high, but at some time during the
twenty-four hours drops to the normal line or even
below it, as in malarial fever.

A febrile temperature may fall by crisis or by lysis.
By crisis it drops suddenly to the normal, as is usual
in pneumonia, while by lysis the fall is gradual, as in
typhoid fever. A convalescent's temperature may be

CHARTrNG. 189

influenced by apparently trivial causes, such as slight
over-excnion, a cnange in the diet from light lo more
solid food, or by excitement of any kind. A sud-
den and decided increase generally indicates some
complication, and the doctor should be informed at
once; in fact, any rise of temperature above 103° F.
should be reported. More than this, a sudden drop
from a high temperature to a subnormal point (unless
in pneumonia) most probably indicates collapse, and
the physician should be notified.

Before death the temperature in fevers may be very
high, while in chronic malignant diseases and cachex-
ias it may be subnormal.

Charting temperatures should be done with neatness
and accuracy : one nurse at a time should be set apart
to take temperatures and pulse-rates and record the
same for the whole ward.

The lines should be lightly and evenly drawn, and
the jioint at which the temperature stands indicated by
a small (not too heavy) dot. The night and morning
records are best done in black, while the temperatures
taken in the intervening hours may be marked in red
ink.

A patient should not have access to his chart, nor
is it right to keep a patient informed of the course of
his temperature, since it may have a bad effect upon
even the most sensible patient to know that his fever
still continues high.

The specimen charts of typhoid fever, pneumonia,
and malarial fever given at the end of this chapter, and
taken from actual cases, show the variations ai d dif-
ferent types of temperature in those diseases, anc also

the method of charting (Plates III., IV. and V.). Plate
VI. is an example of a bedside record.

THE PULSE.

The examination of the pulse is an important guide
to the patient's condition, since from it one may draw
conclusions in regard to the strength and action of the
heart. One of the most difficult things a nurse has to
learn is to count the pulse accurately and to understand
its variations and their significance. This requires much
practice, and the proper skill can only be acquired by
much perseverance and cIosl- study. She should be-
gin by counting the pulses In normal cases until she
becomes thoroughly acquainted with the characteris-
tics of the healthy pulse, and whenever she has an
unoccupied moment she should count the pulse in va-
rious patients and note their differences and peculiar-
ities. When she has heard the pulse of a patient de-
scribed, she should examine it repeatedly until she
feels that she could recognize another like it. Fre-
quently it is necessary to watch the pulse of a sleeping
patient : this should be practised until it can be done
without disturbing the sleeper.

The pulse is dependent upon the rhythmical con-
traction of the heart. With each heart -beat the blood
is sent through the arteries with more or less force,
distending the arterial walls, and it is the sudden ex-
pansion of the artery, felt under the fingers, that we
call the pulse. This distension takes place only during
the systole or contraction of the heart, and the diastole
or period when the ventricle rs filling with blood is rep-
resented approximately by the interval between two

THE PULaE.

pulse-beats. An artery can be recognized by the in
termittent pulsation in it and by the elasticity of its
walls The rise of the pulse-wave is clearly defined,
but can be arrested in most cases by firm pressure
made with the fingers. The points to note in taking
the pulse are —

1. Frequency;

2. Rhythm {regular or irregular);

3. Whether or not it is intermittent ;

4. Size of artery ;
J. Degree of distension between the beats, if any

exists ;

6. The character of the pulsations —

[a) Whether the rise is sudden or gradual ;
{i>) Duration of impulse — long or short;

(d) Dicrotism ;

7. Compressibility —

(a) Low tension ;
{6) High tension;

8. Thickening of the vessel-walls.

The character of the pulse depends upon the action
of the heart, the condition of the arteries, and the
amount of resistance in the capillaries.
The action of the heart determines —

(1) The frequency of the pulse; ■

{2) Its rhythm and regularity ; ■

(3) Its force and strength.

By frequency is meant the number of beats in a given

time. The normal number of beats in a minute varies

m different people, and the pulse is slower and stronger

in men than in women, and in women than in children

193

ffUJlS/yG.

The average pulse in

Men is from 60 to 70^

Women " 65 to 80 > beats per minute.

Children " goto 100 J

The normal pulse is recognized by — ■
(t) Its perfect rhythm ;

(2) The equal force of successive heart-beats;
{3) The medium size of the artery.

The pulse :s usually taken at the wrist, where the
radial artery is easily felt pulsating because it lies
directly over a bone and is superficial. The index
and middle fingers are placed over the artery, pressing
firmly enough to feel the beat. One counts usually
for half a minute. After long practice it is possible
to count accurately a pulse as frequent as 160. It is
sometimes more convenient to take the pulse in the
temporal artery.

The normal pulse may be affected by the same
causes which produce variations in the normal tem-
perature. Its frequency is increased by —

(n) Food or exercise. The pulse will be fuller and
more forcible, and the vessels of the surface relaxed.

f^) Excitement It is quickened, but the acceleration
lasts only while the excitement continues.

{c) Position. The rate is higher when the patient
is standing than when sitting or lying down.

It should be noticed whether the pulse at both
wrists is the same, as often the volume or frequency
of one is greater than that of the other: in nneurism
there may be almost complete obliteration of the pulse
in one wrist. One may be startled at times, on feeling
for the pulse of a newly-admitted patient, to find abso-

lutely no pulsation over the spot usually palpated.
This is frequently due to an anomalous distribution
of the vessels in one arm or to a previous injury which
has severed the radial artery on that side.

In illness the pulse indicates the effects of the dis-
ease on the system and the existing amount of endur-
ing power. One of the most marked differences be-
tween the pulse in health and in disease is that in the
latter there is an increased susceptibility to the same
influences that cause variations in health. In most
diseases the pulse is accelerated, and the more fre-
quent the number of beats the weaker, as a rule, the
heart's condition.

The terms used to express the quality of the pulse,
"quick" and "slow," "strong" and "weak," are
vague, inaccurate expressions, as qmck or sltnv might
refer to the length of each beat or to the rate at which
the beats follow one another, and strong and zecak are
quite indefinite. We use the term frequent for a pulse
up to no or 115; a pulse from 115-140 we call
rapid ; a pulse of from 140 upwards we call running.

We speak of a pulse being long or short when de-
scribing individual pulsations. The terms forcible,
vehement, sluggish, or feeble are also used to express
the condition of the heart. There are several different
types of pulse; thus a pulse may be — ^

1, Irregular (either in force or in sequence) ; |

2, Intermittent;

3, Dicrotic,

In an irregular pulse the beats differ in length, force,
and character: the term may apply to the strength or
to the rliythm or to both. An intermittent pulse may

194 NUKsmc.

be present throughout life in a healthy individual. An
intermittent or an irregular pulse may be induced by —

1. The condition of the respiratory organs;

2. Acute disease where it may be a grave symptom ;

3. Certain conditions of the nervous system.
When the pulse is intermittent a beat is lost from

time to time. Where this occurs in health the causes
are not fully understood. The condition may be brought
on by nervousness or exhaustion.

A dicrotic pulse indicates a relaxed condition of the
arterial system, and consists of one beat followed by a
second, which is in reality a wave in the biood-current
produced, not by another contraction of the heart, but
by the closure of the aortic valves. This secondary
pulse-wave is usually less forcible than the iirst. but
sometimes resembles it so closely as to be counted as
an individual beat. Nurses have been known, in count-
ing a pulse of this kind, to obtain a result exactly dou-
ble the actual number of heart-beats. The error be-
comes at once apparent if one hand be held over the
point of maximum impulse of the heart on the chest-
wall, while the other is at the wrist. A dicrotic pulse
is found frequently in the acute fevers, particularly in
typhoid fever.

The tension of a pulse is determined by the degree
of resistance which the artery offers to the pressure of
the fingers, and the terms used in this connection are
"high" and "low;" if the resistance is considerable,
we say that the tension is increased or that it is plus
(T +); in the opposite condition we have a decreased
or minus tension fT — ).

The remote causes of hijjh tension are —

THE PULSE. 19S :

1. Excess of animal food or of alcoholic drinks;

3. Sedentary habits with the resulting imperfect |
oxidation ;

3. Constipation.

High tension may be present as a result of obstruc- *
tion in the arteries or capillaries, caused by —

1. Changes in the vessel-walls or deposits of lime ,
due to age;

2. Gouty conditions ;

3. Organic disease of the heart or kidneys;

4. Chronic lead -poisoning.

Sometimes also there is a pul.,c of high tension i
pregnancy-

In a low-tension pulse the arterial tension is diniii
ishcd, owing to the weakened condition of the heart or
to a relaxed state of the peripheral vessels, and the
pulse becomes easily compressible: it may have the
feeling of being large and full, but this does not always
indicate an energetic and strongly-beating heart. In
extreme cases, where the heart is very weak and the
amount of blood .sent out with each systole small, the, •
pulse becomes easily compressible, and we have what
is known as the running pulse. This may be produced 1
by prolonged exertion, mental or bodily fatigue, and
certain conditions of the nervous system.

The special characteristic of a high arterial tension
i^i the non-compressibility of the pulse- wave ; the artery
may remain full between beats, and may be rolled
under the finger like a cord. The pulsation for this
rLMson may not be very marked, and may convey the
ini|)rp'5sion that the pulse is not stronij, but on c.vami-
nation it will be found to resist more strongly the \

196 jvuRsmc.

more it is compressed. The immediate causes of this
condition are —

1. Increase in the force of the heart's beats;

2. Contraction of the smaller arteries (c, g. from
the application of cold to the external surface of
the body).

One should be very observant of the effects pro-
duced upon the pulse by therapeutic measures. In
giving medicines which affect the heart any difference
in the pulse before and after administration should be
carefully noted. If a bath is ordered the pulse should
be watched closely. Stimulants increase the frequency
of the heart's action, while antipyretics have a depress-
ing effect.

The ratio borne by the pulse to the temperature and
respiration is of much importance. If a pulse is more
frequent than the temperature would lead us to expect,
this is usually an indication of a weak heart, and the
weakness is. as a rule, in proportion to the deviation
from the normal ratio of pulse to temperature.

THE RESPIRATION.
External respiration is the act of taking in and
giving out air by the lungs. This permits of the
interchange of gases in the lungs, the blood in the
small capillaries being separated from the air by an
extremely thin membrane. The venous blood brought
to the lungs by the pulmonary artery is oxygenized,
and returns through the pulmonary veins to the left
heart as bright arterial blood. The average number
of respirations to the minute in an adult is eighteen,
m a child from twenty to twenty-four. Any marked

THE FHSPIHATION.

197 I

variation from this is abnormal. A single breath con-
sists of two parts, characterized by alternate expan-
sion and contraction of the chest; with dilatation we
have inspiration; with contraction, expiration. There
are normally four heart-beats to one respiration. In
disease there are marked variations in the character '
of the respiration. The breathing is slower in nar-
cotic poisoning, shock and collapse. On account of ,
pain it is restrained in pleurisy and peritonitis; it is
shallow in ascites, abdominal tumors and advanced
pregnancy. In some diseases, such as peritonitis and
pneumonia, the respirations may be very rapid ; when
over forty the symptom is considered grave. There
are cases, however, in nervous and hysterical patients
where the respirations may be e.\ceedingly rapid, per-
haps over sixty per minute. In some pulmonary dis-
eases the respiration may often be out of proportion
to the pulse-rate. In taking respirations one should
note —

I. The frequency; 2. If regular or irregular;
3. Whether difficult or easy; 4. Noisy or quiet;
■;. Dee]) or shallow ; 6. Symmetry of che-t and its
movemenis; 7. The type, abdominal or thoracic.

The mo^it peculiar type of breathing is that found ■]
in the dyspncea of certain diseases of the heart and I
kidneys, known as Cluync-Stokes respiration. There ]
is an increase in the frequency and intensity of the
respirations up to a certain point, then a gradual de- ]
crease until they entirely cease for several moments,
when the cycle is repeated.

Stertorous breathing is that in which there is a loud |
snoring sound with each inspiration.

In taking the i-c.spiration one must not allow the I

W >98

NURSING.

patient to be aware of tiie fact, for he will unconsci-
ously control it. After taking the pulse the fingers
may be left on the wrist, and while apparently count-
ing the pulse the rise and fall of the chest may be
noted.

Tn some affections, such as asthma and heart disease,
tiicTe is dyspncea — that is, difficulty in breathing — and
a sitting position is the most comfortable. At times
the breathing is so bad that the patient cannot assume
the recumbent posture at al! — a condition known as
orthopncea. The ear should be trained to detect dif-
ferences in breathing, so that even in the dark the
slightest change may be at once noticed.

In diseases where changes in treatment are few, as
■H typhoid fever, a brief note of them can be made on
the temperature chart at the time that they occur,
[Vide specimen chart.) After operations, however, par-
ticularly after abdominal sections, and in certain dis-
eases where the treatment varies every few hours, a
bedside or hourly record-sheet should be kept, each
step of the treatment being neatly and accurately put
down by the nurse. Such a sheet should not be ar-
ranged for more than twenty-four hours, so that at the
end of that time a summary of the treatment may be
made. The physician on his morning and evening
visits will then be able to see at a glance just what has
been done, without having to enter into a detailed re-
port before the patient. The temperature should never
be reported to the physician nor the symptoms dis-
cussed in the presence of a patient : if it is necessary
to see the physician alone for a moment, one tries to
do so outside the room either before or after the visit,
though, as a rule, the record should be clear enough
oa all points to fully explain the case.

BED-SIDE RECORD.

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CHAPTER XII.

External Appucations (generai. a
Bacs anu Cans, — lloi
■ACS.— Moist Heat.— Kim km a
— IcH. — Cold WAiti

a local).— Dmv Heat. — Hi
BoTrLKs. — Flannels. — Salt-
lOKs. — Poultices. — Cold f
— Lotions.

External heat, whether applied generally or locally,
is intended to give additional warmth to the body, to
allay inflammation and relieve pain, to promote suppu-
ration, or to act as a diaphoretic. Cold applications
are used chiefly to reduce temperature and inflamma-
tion, but are employed besides for their stimulating
effect.

It is a matter of every-day experience that warm
weather makes itself felt much sooner and more se-
verely when the atmosphere is saturated with moisture
than when it is dry. Just in the same way hot moist
applications have a much more marked effect and are
more depressing than dry heat at the same tempera-
ture.

Dry heat when required for its general effect is ad-
ministered by means of the hotair bath, and is often
ordered when the kidneys are failing to do their work
well : the waste products, not being excreted in the
normal amount, are accumulated in the system, and
the hot air. acting upon the body by dilating the
superficial blood-vessels, produces copious perspira-
tion and brings about in this way the elimination

DJiy HEAT.

of much of the poisonous material. Its application
is described in the chapter on Baths.

When dry heat is applied for the sake of warmth
alone, it is best to use hot bags, bottles, or cans. Such
bags are made of india-rubber and are of difterent
shapes and sizes. When required for use, they should
be filled not more than about half full of hot water,
for when quitu full they would be heavy and difficult
to adjust: before screwing on the top the air must, ;
far as possible, be expelled. Hot-water bags must be
watched, as they are liable to leak and make the bed
wet, if the top be not tightly screwed on.

Except for applying heat to flat surfaces like the side
of the face or abdomen, hot-water bags are not so ser-
viceable for hospital use as the hot-water tins, bottles,
or bricks. With tin cans particular care must be taken
lest the patient be burned : they are especially valuable
in warming the bed for an operation patient, but on no
iiccount should they bL- left beside an unconscious pa-
tient unless they can be constantly watched. In inva-,
lids the vitality of the tissues is lowered, and it is an
easy matter for them to sustam a burn which in their
case may prove very troi.blesome, though in a healthy
person it might heal .it once. This is especially true
of paralytics. Hnt bottles are not very safe, as they
are apt to crr.ck or burst. If they must be used,
they should be placed with the corked end away
from the patient, and should not be filled more than
two-thirds full. The chief recommendation of bricks
S "ihat they retain the heat a long time; on the other
hand, it may be objected that they are uncleanly and
Mumsy. Like the hot-water bag, these cans or bricks

rilould be protected by cases made either of ordinary
flannel or or canton flannel, and placed in the bed with
« blanket between them and the paiitnt These appli-
Mces arc used in tiie warming of beds for operation
|»tien(N, for cold extremities, for pain, during a chQI,
in CAnvt of coll<i|)sc or shock, or for very ill patients
I in the cnrly morning houri.

Hot flannels arc Nutiictimes ordered for inSamed
lointH and abdominal |>ains. The flannel should be
made very hot, wr,ip|)ed in a heated paper or cloth,
tmd applied quickly, the whole being covered with a
|H)'er of cdtlon-wool and oiled muslin. Salt-bags are
UIHmI for the same purpose, for neuralgias, and more
Cf>|t«cially for earache. They arc simply flannel bags
fillrd with Nca-nalt, heated just as hot as can be
iKtme, and covered with a pad of cotton-wool and
Itiltfd niUMlin. They retain the heat a long time, and
«IV wry Honthintt. In earache competent authorities
ivcomiliend the uhc of the sO'Catled "Japanese hot

Mi)iM hoAl 'h more ;>enctrating and has a more pro-
Untinucid effect than dry heat. It is applied where
(liyrtJ m ]mU\ from tnuHcular spasm, since by dilating
\)Hv m\\\ivtf\(\'i\ hlood-ves^els it relaxes the tissues.

SUltkt^n* thi' tirciiLition in the affected part, and by
frtWiHtC ''*" l'l"od to the surface vessels relieves the
^jUlon of th(i*c more deeply seated, and thus eases
^$ lullti Mtiitt hi-»t iit better in acute inflamma-
VfiW Whipll w« cuniiol prevent from going on to sup-
BMtMlMll ihp dpplicalion should be as hot as can be
|t(i(lli< ll hiiNtDUM Diippuration by increasing and pro-
KldMlIK Mto tti'tivity of the leucocytes or white blood-

(

MOIST H£A T. 2O3

corpuscles, the relaxed condition of the blood-vessels
caused by the heat and moisture perhaps facilitating
their escape through the walls of the vessels.

For a general systemic effect warm tub-baths are
ordered: they relax the muscles, relieve nerve- tens ion,
equalize the circulation of the blood, and induce sleep.
For sleeplessness they should be given in the evening
after all the arrangements for the night have been
made, so that the patient will not again be disturbed.
The vapor bath is another method of applying heat
generally, and is used for the same purpose as the hot-
air bath. For localized pain, fomentations, stupes, and
poultices of various kinds are prescribed, their action
being precisely the same, since they relieve pain and
inflammation by dilating the blood-vessels in the
neighborhood of the painful part. Poultices arc best
used in cases of deep-seated pain or continuous in-
flammation. They may be made of any non- irritating
substance which will hold and convey moist heat, both
of which conditions are fulfilled by linseed, which is per-
haps most commonly used. To make a linseed poul-
tice the meal is stirred slowly and evenly into water
which is already boiling: the mixture is then boiled
for several minutes, being stirred briskly all the time,
until it is thick enough to be beaten well with a spoon,
by which process the lumps are removed and a certain
amount of air incorporated with it, making it light. If
well beaten and boiled, when finished it will make a
light smooth pa.ste. just stiff enough to drop away
from the spoon. A layer half an inch thick is spread
on a piece of muslin or coarse cloth of the required
size, a margin of an inch being left to be turned in ;

204 A'CXSAVC.

the surface is vaselined and covered with a layer of
thin gauze ; the edges are turned over and the whole
covered with a rubber cloth or rolled in a towel to
keep it wami, and carried to the patient One poultice
should never be removed until another is ready to be
put on. Before it is applied the skin is to be wiped
dry. Oiling the poultice with vaseline prevents irrita-
tion of the skin and the formation of papules. The
poultice when in place should be covered closely
with a layer of cotton-wool and oiled muslin to pre-
vent the escape of the heat and moisture. It must
be changed at least every three hours, and where It is
desired that a uniform temperature be maintained it
should be changed oftener — every hour or so. A
poultice should be applied as hot as the patient can
bear it : it should never be left on until it becomes
cold, and should never be reheated and used again.
Bread is seldom if ever used, as it retains the heat
only a very short time.

Linseed poultices are sometimes ordered to remove
.sloughs from a wound, and then arc best made with
I 140 carbolic-acid solution. They are not so useful
for this purpose, however, as gauze wrung out of a I
per cent solution of carbolic or a saturated solution
of boric acid, laid in light fluffs against the parts and
changed frequtntly. If poultices are ordered for such
a purpose, they should not be left on after the slough
has come away. One sometimes sees them used until
the granulations and surroundii\g tissues look pale and
flabby, a condition which indicates a lack of vitality
due to too much moisture, the tissues having become
water-soaked. Charcoal as a deodorizer is occasion-

ally ordered where there are sloughs which give off ^
an oftensive odor. One part of powdered charcoal
is mixed with two parts of linseed, and the poultice
made as above : before applying it is well to sprinkle a
little charcoal over the surface. The application, how-
ever, is a very untidy one, and for this reason is seldom
ordered. Instead of it we would recommend gauzff
dipped in a saturated solution of permanganate of
potassium, which makes an excellent deodorizer.

A starch poultice on account of its soothing prop- !
erties is used in skin diseases where there is much irri-
tation. The starch is mixed first with a little cold
water, and then enough boiling water is added to make
a thick paste. It is spread on muslin covered with a
layer of gauze and applied like other poultices. If
there be a great deal of pain, a few drops of laudanum ^
may be sprinkled over the surface just before it is
applied.

The most pleasant way of applying moist heat is by |
means of fomentations, but they are somewhat trouble-
some, as they require to be changed very frequently.
Where heat is the first requirement, this should be
done every ten or fifteen minutes, but if they are used
principally for their moisture, then every twenty min-
utes will be often enough. In no case should they be
left on until they are cold and clammy, and, in fact,
unless very thoroughly applied, fomentations do little
or no good. The best materials to use are coarse old
flannel:* an old blanket answers excellently, as the |
fibres are thick enough to retain the heat for some
time, while the meshes are coarse enough to allow the
circulation of warm air through it. Two layers of

■ Sec Appcndii, Nmv if*

206 JVU//SWG.

flannel are taken, dipped in boiling water, and lifted
into the wringer. The latter is made of a stout piece
of ticking 18 inches long and 15 inches wide, with a
hem at each end through which runs a stick. This
is called a "stupe-wringer," Another form of stupe-
wringer may be made according to the figure here
presented (Fig. 1 1). By twisting the sticks in oppo-

Srura-WiiiHGm

site directions the flannel is wrung out so tightly that
it will not drip, and then carried in the wringer to the
bed. By keeping two stupes in use, one need not be
removed until the other is ready to put on. The skin
having been first dried, the folds of the flannel are
shaken out: the stupe is then put on and covered with
a thick layer of common cotton-wool and one of oiled
muslin, such a covering being always allowed to over-
lap the poultice or fomentation by at least two or three
inches. After stopping the use of stupes a layer of
cotton-wool or flannel over the part for a day or two is
advisable. Small hot compresses for the eye, breast,

^M or ne

^M a len

H throc

^H modi

m be u

MOIST HEAT. 207

or neck can be wrung out tightly, and perhaps best, in
a lemon-squeezer. Hot comprLssus are applied to the
throat for spasmodic closure of the glottis or in spas-
modic croup. Either hot sea-sponges or flannel may
be used instead. Since it is the combined efTect of
heat and moisture that is desired, they should be
changed evL-ry ten or fifteen minutes.

The material u.sed for hot fomentations for the brea.st
should be cut in circular pieces large enough to cover
the breast, and should have a small round hole in
the middle for the nipple; the latter should never be
covered.

The action of heat differs from that of cold, in that
heat expands and dilates, while cold contracts. Heat
increases the bodily warmth, cold decreases it. Cold
may prevent suppurative processes, while heat tends
to promote them. They both act as sedatives to pain-
ful nerves.

In inflammation a portion of the tissues is injured
and certain changes occur, which are evidences that
Nature is endeavoring to repair the injury done.
These changes are associated with redness, heat,
swelling, and pain, which in their combination are
largely the expression of an increased supply of
blood to the part. Unfortunately, Nature in hei
efTorts loo often goes beyond what is useful to the
organism, and, when the inflammation threatens to
become too acute, it may be desirable to check it
in its progress. It is just here that the value of cold
applications is most marked. Acting as they do by
contracting the small blood-vessels of the part, they
lessen the amount of blood directed thither, and so

x-ssful in pivvL'nting thu formation of

are often
pus.

Cold is applied either by means of the cold bath or
by compresses, packs, sponging, coils, or ice. The cold
bath best allows of the general application of cold.
When this is used for its stimulating effect, it should
not as a rule be continued over five minutes, and a
vigorous rubbing should follow, in order to secure
reaction. The cold pack and ice-water sponging arc
used, as well as the cold tub, to reduce fever in the
manner described in the chapter on Baths. Cold com-
presses are made of two or three thicknesses of lint or
linen wrung out of cold water and applied over the in-
flamed surface, being changed frequently. If iced
compresses are ordered, a small block of ice par-
tially wrapped in flannel is placed in a basin : there
should be two compresses, one of which is kept on
the ice, while the other is on the patient. They arc
thus kept constantly cold by frequent changing. Com-
presses are particularly useful where little weight can
be borne.

The most effectual way to apply cold continuously is
by means of the india-rubber ice-bags. These can be
made in different shapes; for instance, helmet -shaped
for the head, but long and narrow for the neck and
spine. Perhaps the most useful of all is the simple
ice-cap. The ice should be crushed into small pieces
and mixed with a little common salt to intensify the
cold. The bag should never be more than half filled,
and one must be particular to expel the air, as far as
possible, before screwing on the top. A layer of moist
lint or cotton is always placed between the skin and the

K lint or c

bag ; otherwise the extreme cold is not only painful,
but is apt to irritate the sliin, even producing " frost-
bites." If possible, it is better to suspend the bag, as
the weight is sometimes a source of discomfort to the
patient. Thus a bandage can be fastened to the neck
of the bag, and the two ends pinned to the pillow just
high enough up to allow the cap to barely touch the
head. At times a piece of ice is wrapped in moist lint
or old linen and passed gently over the head in order
to cool it. When using the bags, care must be taken
to refill them before the ice has melted; nurses are
not always thoughtful enough about this, and a doc-
tor's confidence in a nurse is justly shaken when he
sees such neglect.

Ice-water coils can be made of rubber tubing, which
if necessary may be sewed upon a piece of rubber cloth
(in circles) about an inch apart for five or six rounds:
a yard or two of tubing is left at each end to be used
as a siphon. A large pan of ice-water is raised above
the patient, into which one end of the tubing is placed,
witli a funnel inserted into it covered with gauze to
prevent clogging, while the other end is laid in a sec-
ond basin on the floor which receives the water. The
method is very- cumbersome, and attention is needed
to see that the upper pan is kept full. Coils are some-
times ordered for the head in delirium and for the
abdomen in tj'mpanites. The stream of water may
be regulated by a stopcock, thus making the same
amount of water last as long again.

The process of crushing ice necessarily takes place
in a hospital every day, and for the purpose a stout
canvas bag should be kept on hand, in which the ice

^" 2IO

may be placed and beaten with a mallet when a lar^
quantity is needed. For breaking up small pieces, an
icepick is best, but in doing this at nifjht the nurse
must take care not to disturb her patients. Ice may
he easily and noiselessVy cracked with a stout hat-
pin. In private nursing, where only a small quantity
is needed, it should be preserved from melting by
being wrapped in flannel.

Lotions are medicated moist applications, and may
be either hot or cold. In using an evaporating lotion,
one thickness of lint or muslin is saturated and left
exposed to the air to promote evaporation. The ap-
plications are changed often enough to keep the lint
moist.

Where other — /'. f. non-evaporating — lotions are or-
dered, lint or muslin, folded as for an ordinary cold
compress, and wrung out of the required solution, is
applied and covered with oiled muslin.

CHAPTER XIII.

OpUNTKB-IRRCTANTS.^MvSTABD POULTICES (PljtXTKIlS AND LEAVES).

— TuHPENTisK.— Iodine,— Liniments.— Cupping.— Canthak-
IDES. — The Cautery.

CouNTER-iKKtTANTs are therapeutic agents applied
externally to produce a coodition of irritation or in-
flammation, in ordi:r to rtiicve a diseased condition in
some adjacent or deep-seated part of the body. By
the application of a substance to the .skin which will
irritate the ends of the sensory nerves and dilate the
blood-vessels of the part, the flow of blood through
these vessels is increased, and the tension in those
which are more deeply seated is lowL-red as a result
of reflex nervous influences which are as yet imper-
fectly understood. If an irritant be placed directly
over an affected part, relief is often quickly obtained,
and irritation applied to a part distant from the one
diseased is also frequently beneficial. Thus, for in-
stance, pain in the head or abdomen may be relieved
by a mustard foot-bath, since the vessels of the lower
extremities, dilating, attract large quantities of blood
to them and relieve any congestion in those of the
head and abdomen.

By the use of counter-irritants we may produce at
will—

(1) Mild irritation;

(2) Irritation producing inflammation;

(3) Vesication or blistering.

^j2 A'L-XS/JVG.

Mild inrilants are called rubefacients, since they cause
redness of the skin by distending its capillaries. A'l
classes of irritants act as rubefacients when applied
only long enough to produce such an effect, but those
commonly employed are mustard, turpentine, iodine,
and aqua ammonia. Dry cups may also be used for
the same purpose.

The mildest mustard application is the mustard poul-
tice: it is made with linseed meal in the same way as
an ordinary linseed poultice, except that i pait of
mustard is well mixed with 6 parts of the meaL
This may be left on as long as the poultice is warm.
Its action is more gradual and less irritating than
that of the mu.stard plaster, which is made of mus-
tard mixed with flour in different proportions ac-
cording to the effect desired. The usual formulae
call for from i to 6 parts of flour or meal to i of
mustard, and the nurse should be able to state the
exact amount of mu.'^tard used. These ingredients are
rubbed thoroughly with cold water into a paste, which
is spread between two layers of muslin or linen of the
size required: the plaster is applied for from ten to
twenty minutes, the outside being covered with folds
oi linen or cotton to absorb any superfluous moisture.
The skin of one patient may be much more sensitive
and respond more quickly than that of another, and
when the stinging sensation is acute and the skin well
reddened the plaster may be removed. Care should
be taken not to leave it on long enough to blister the
skin, as may happen with delirious or unconscious
patients if the effect is not closely watched. Where
the skin is very tender, as with children, the proper-

I
I

tion of mustard should be diminished by one-half and
the plaster left on only a few minutes, just long enough
to produce redness, after which a warm linseed poultice
should be substituted for it. After a mustard plaster
has been removed, the skin is dusted with rice pow-
der, anointed with cold cream or vaseline, and covered
with a soft piece of muslin.

Mustard leaves are frequently ordered, but, though
far more convenient, tliey do not take the place of the
old-fashioned mustard plaster. They cause so much
discomfort from the time that they are applied that
they frequently have to be removed, before the desired
effect is produced. Their chief recommendation is that
they are ready at a moment's notice, as they need only
be dipped in tepid water and put on. A thin piece of
muslin or gau^e placed between the mustard leaf and
the skin renders its effect more gradual. When the
skin is thick and its action sluggish, the surface should
be first scrubbed with hot water and soap to remove
fatty substances, and then rubbed briskly before apply-
ing the mustard, otherwise the result obtained will be
very slight and the process will take a longtime. Mus-
tard should not be mixed with hot water, as this de-
stroys or lessens the strength of the volatile substance
which gives the drug its irritating properties. As soon
as the necessarj- reaction has been produced the plas-
ter should be at once removed. The effect should be
watched carefully, lest the action be more extensive
than was intended and a blister result Where the
skin has been over-irritated, the white of an egg will
be found very soothing. It may also be incorporated
with the plaster before the latter is applied.

m-'RSING.

'. prepared^H

TurjieDtine is nlso m common use as a «
Initiinl, l»iu is chiefly applied in the t'onn of s
Mlnloiuiniil [wiii or tympanites. These are preparedl
tiiul apptit^tl much as hot-water stupes : half an ounce
III lurpcnlinc is mixed with about a pint of boiling
Wrtli^r, Ihe flannel dipped in it and wrung out very
MKl>''y' rhe mixing with the water tends to emulst^
thu turpentine (of course the oil will not disserve in
llic water), and renders its application to the skin moic .
lIDJfQrm than it would be if it were sprinkled over t
flftnnel, and also lessens the danger of causing blisters.!
The stupes should be applied as hot as the patient caal
licar them, and should be covered snugly with cotton^ I
w»i>l and oiled muslin. They may be repeated
titteuii or twenty minutes if the pain or distension \a\
i)itt rL'lieved, provided that the skin is not >
hcnsitive.*

A third counter-irritant is the tincture of iodine I
ll JH applied both to the skin and mucous membranes, I
•I k-'iiiiitflVhair brush or a swab being used to paint the f
lluiil lightly over the scat of the pain. This first coat-J
JhK is allowed to dry, and a second may then be 9^ I
plied, More than two coatings are apt to blister, and
un w.'iiiiitive fikins one will bo found sufficient. If the
Hiimrting is intense, sponging with alcohol will relieve
llie (lain.

A'lua ammonia may be ordered, as its irritating
iliialities serve at a stimulant where immediate re-
Atlinn is required, as in conditions of shock or uncon-
m: loudness. A piece of lint saturated in the solution
IM ap|ilied, tuing closely covered with oiled silk, and
lull un fioni live to ten minutes. Ammonia is also

COUNTER-IRRITANTS. 215

used as an application after bites or stings from insects
or poisonous reptiles.

Chloroform is used alone as a rubefacient. It causes
redness and smarting of the skin, and will blister if
left on too long. It is also employed in liniments,
both for its irritating and sedative qualities.

Liniments are of various kinds. They are frequently
used to allay muscular pain, and can be applied with
friction and well rubbed in: a piece of lint soaked in
the solution and bound on over the aching part for a
short time often answers the same purpose.

Croton oil is a powerful irritant, producing an erup-
tion in the form of little vesicles that may become
pustules. From two to four drops, rubbed on with
a small piece of flannel, are enough to apply to a sur-
face of from i^ to 3 inches square. Its action is so
powerful that physicians frequently dilute it with an
equal amount of olive oil or oil of sweet almonds.

Cupping is of two kinds, wet and drj', and is most
often ordered to relieve inflammations of the eye, lung,
or kidney, or even muscular pains. Small glasses are
made especially for the purpose, and come in sets of
about five, but if these arc not obtainable, wine-glasses
or medicine-glasses will answer. To prepare for dry
cupping a spirit-iamp, matches, and cups are neces-
sary. The usual method is to take a stiff metal probe
or piece of wire, wrap about the end a small piece of
cotton, dip this in alcohol, ignite it, swab the inside
of the glass, remove, and apply the glass. The heat
causes the warm air to expand, .so that some is driven
ofl". ami the partial vacuum formed is filled by the skin
and tissue over which the glass is placed. The main

nber ts that die edges of tim cup mast
t be lUoweii to tMxome warm -isiougfa Eo bom ihr-
S ilpplied. Five to iseven cups are applied
( ami aUowed to mnain on frve minates,
r Itlkdk dtey jre Femoved by makiitg prcssuie
■ the g^ass -ind insertiiig the tip of Efae fiagcr
e 9(ige, so js Co let Ld cfae 3ir, Linseed pout-
t soiaebrngs applied after cfae removal of the
it; in ttiL5 way dw ililataDoo of the blood-vessels
UM^ b« kept up for 5umt: bme. The process of wet
tiM|>ftU|C '^ cimed out in much the same manner: one
•wtitis •!! addthon 4 scanccuor or small scalpel, a few
>,u^U|[v% and a dressing of lint for the wound. After
ttK ditit ha» been ^scrubbed with hot water and soap
lumI witshed otT uich a t : ^ carbolic solution, the
\ui){vott ntokcs a tvw small sapeHrdal cuts, over which
DK' tup '» applied. AftxT a sufficient quantit>- of blood
hiitM b*}v« withdrawn, the bleeding may be checked by
«iH>iitE'<iV^ ^ V^'^ ^' '>''' '^ placed 00 the sur&ce. and
)wh.l 111 ^K»lt^<^n by a covering of gauze dipped to cel-
loldlU ^H by rubber strapping.

Ci*>ithAri\k:» ).« used (or blistering. It is used either
i(|t A [J*tlvr \vr in the liquid form : in the latter the pow-
tltivtl tttiulMrH'f!* is contained in solution in collo-
vhwt ^vvictiliny collodion). The plaster is the prepa-
\aA^'*i >«•.«( ^»ftvn used. The physician usually orders
It ^lU^tvH- i»f u definite siie and designates the part to
wKit h il t« to be applied, but if no definite directions
hi»vv Knn yiven the nurse must not use one largci
\tMit Umv inohctt square. The object of scrubbing
Vhi' 'k'n 11'*' with hot water and soap is to removt
thv i'il\ iHlwIaiKcs or anything else that might inter-

CO UNTRR-IRRITANTS.

fere with the action of the plaster. The plaster is
vented from becoming displaced by passing a bandage
around it loosely : there must be no pressure, as plenty
of room must be left for the formation of the blister;
and for this reason the plaster should not be held in
place by adhesive strapping, for if it cannot yield pain
will result from this tension. The plaster is left on
from four to eight hours, according to the effect de-
sired. If it is necessary to blister, and vesication has
not appeared at the end of eight hours, a linseed poul-
tice may be put on over it to supplement its action.
Great care should be exercised when blistering appli-
cations are used over the region of the kidneys, or any-
where, in fact, in the case of patients suffering from
kidney affections: cantharides is a most violent irri-
tant, and not infrequently causes strangurj', or may
even set up an acute nephritis. In applying the can-
tharidal collodion, the space to be covered is first out-
lined with oil to prevent the spreading of the vesicant;
the collodion is painted over the surface by means of a
camel's-hair brush, and afterward covered with a layer
of soft lint and oiled silk.

To dress a blister, the lower part of the bleb is
punctured with a scalpel or the scissors, and the fluid
V/hich comes from it received in absorbent cotton ;
when it is empty a simple dressing of oxide-of-zinc
ointment or vaseline on lint is applied and held in
place with celloidin or strapping. One must never
remove the skin from a blister at the first dressing.
Sometimes it is desirable to have the fluid reabsorbed,
in which case precautions are taken to prevent rupture
af »Jie vesicle.

is pre- ^^1
inda^e ^^

218 ■ f/URsmc.

Leeches are seldom if ever ordered now-a-days,
wet cupping is more cleanly and usually answers the
same purpose, but it may be as well to understand how
they are used. A leech is capable of removing from
a drachm to half an ounce of blood. The skin, after
being scrubbed briskly with soap and water, is dried
and rubbed, and the leech applied. This is done by
placing the animal in a medicine-glass with its pointed
extremity (the head) toward the orifice of the glass,
which is inverted and applied to the spot where we
wish the leech to fasten itself. If it is slow about
biting, a little cream rubbed over the spot or a drop of
blood from a needle-prick will cause it to take hold.
It may be left on for from half an hour to an hour,
according to its activity: if very sluggish, it is to be
gently stroked with a bit of linen. When full it gen-
erally lets go of its own accord; if not, a little salt
sprinkled on its head will cause it to drop off An
attempt to pul! it away may result in the breaking off
of its teeth, which when left in the flesh may set up
inflammation. To increase the bleeding after the re-
moval of the leech, hot poultices or stupes are useful ;
where it is too free, a compress snugly applied or ice
wrapped in lint, and held in place by a bandage over
the wound, will usually be sufficient. Leeches should
not be applied over large blood-vessels — bony sur-
faces, over which pressure can be applied, should
rather be chosen. The same leech should never be
used twice. Leeches are best kept in a jar of water
covered with a perforated top and having a little mud
at the bottom : it is not necessary to change the water
often. Those of the American species are the best to

THE ACTUAL CAUTERY.

219

use for children, since they abstract less blood and are
less vicious than foreign leeches.

The Actual Caukry. — By the application of the ac-
tual cautery, as opposed to other methods of cauteri-
zation, we mean the use of the heated iron or some
other apparatus in which actual heat is used. The
most valuable form of cautery and the one most oftien
employed in hospital practice is that known as the
thermo-cautery. The instrument invented by Paque-
lin of Paris is perhaps the most suitable (Fig. 12).

The principle of the apparatus is based on the prop-
erty possessed by platinum of remaining incandescent,
when heated red-hot. as long as the vapor of some
highly combustible carbon compound is thrown upon
it. Platinum points of shapes varying according to the
purposes for which they are to be used arc attached
to a tube connected with a bottle of benzine, the vapor

of which is pumped slowly by meaDs of a rubber hand-
bulb into the hollow platinum poinL

When not in use the different parts are kept in a
box in special compartments which allow the instru-
ment to be safely carried about

About the employment and care of the Paquelin
cautery wc shall now say a few words :

I. The preparation of the instrument for use: (a)
A small quantity of benzine is poured upon a piece
of absorbent cotton which is placed in the bottom of
the bottle, only as much as is sufficient to saturate the
cotton being used. This precaution prevents the es-
cape of any excess of benzine when the cautery is in
use, for if a bottle containing benzine as an ordinary
fluid be used, the liquid occasionally gets into the
rubber tubing and an explosion may occur. (6) The
rubber tubing with the bulb is connected by means of
the stepper tf> the bottle containing the benzine ■""\
the platinum up is ^crewed io ihe handle, the other
end of which is attached to the rubber tubing, {r)
After firmly adjusting the handle to the platinum
point selected for use, the tip should be held in the
flame of a Bunsen burner or of an alcohol lamp:
then the nurse should attach the benzine bottle by
the flange on its side to her waistband, and be ready
to force air through the bulb by squeezing it with the
right hand. As soon as the platinum point becomes
red hot, she should squeeze the bulb gently, thereby
forcing the air charged with benzine vapor through
the tubing to the point where it ignites and maintains
the heat. The nurse is frequently called upon by the
surgeon during an operation to prepare and to take

THE ACTUAL CAUTEfiy

221

charge of the cautery and keep it ready for use: to
accomplish this she must squeeze the bulb gently and
at regular intervals, as directed above. If the ])res-
sure is too forcibly or too quickly made, more ben-
zine than is necessary is burned and the platinum
point becomes red hot. The tips are not often used
in this condition, being generally employed at black
heat.

3. The therapeutic application of the cautery; As a
counter-irritant it .sometimes serves to dissipate effu-
-sions around or in joints, and is of great value in re-
lieving the pain attending stiff neck and the various
forms of so-called muscular rheumatism.

To produce counter-irritation with the cautery, tiie
parts to be treated should not be actually touched, but
the heated tip is passed quickly to and fro close lo
the surface, without, however, ever coming in contact
vitl' *he skin. Such an applicntinn nf the cautery is
at times rbllowed by the most gratifying results, as it
will relieve pain a/moat anywhere, and at the same
time is not accor*panied by ■mj- blistering or marking '
of the surface o .he Sfci.i.

Very frequently the actual cautery is used im con-
trolling h.Tmorrhage in abdominal surgery, where sur-
faces from which adhesions have been separated per-
sistently bleed; thus, for instance, where there is a
broad area of oozing; the cautery lightly applied will
often control the haemorrhage.

3. Tlif Care 0/ the Instrument. — Since the cautery is
an expensive instrument, great care must be tiken in
returning; it to its case after use. The points in p;
ticular are very delicate, so that the apparatus c;

be ruined much more easily than one would imagine.
The following rules, then, should be observed:

First: If there should be burnt particles of tissue
clinging to the platinum tip, the metal is brought to
a white heat so as to consume whatever is adherent,
and while the tip is still hot the handle which is at-
tached to the rubber tubing is to be removed at once,
so as to prevent any benzine from being carried into
the tip while it is cooling.

Second : After the handle with the attached tip has
been removed from the tubing, it should be so placed
that the tip does not come in contact with any surface
which might indent and thus occlude it. When it has
sufficiently cooled off. the handle is unscrewed, and
each part immediately placed in its proper compart-
ment in the case.

Third : Under no circumstances is the platinum tip
to be placed in water for the purpose of cooling it.

Fourth : Finally, the instrument should be carefully
arranged in the several compartments in the box and
the latter kept in a safe place. If the cautery is to be
packed in an instrument-case, the nurse must be care-
ful to place it securely in a position where it will not
be jolted or in any way come in contact with hard
surfaces, so that any chance of injury to it may be
avoided.

CHAPTER XIV.

The administration of medicines is a duty that
begins early in the first year of a nurse's instruction,
and is associated with more or less fear on her part
lest some error be committed. To be quick and
accurate at the same time is an impossibility, when
attempting to give medicines at first, and there is no
cause for discouragement because it takes so long to
make quite sure that the quantities are correct. A be-
ginner should first act as an assistant, being allowed to
measure out any harmless doses ordered, until she has
overcome her early awkwardness and is familiar with the
different measures. It is necessary that each woman,
who is a nurse or who wishes to become one. should
know more or less arithmetic, at least enough to com-
prehend clearly the different standards of weight and
measure, and their relations to one another. Thus it is
often necessary to deal with fractions of doses and to
know what is meant when the strength of a solution
is stated in percentages; frequently a nurse will be
required to dilute a solution of a certain percentage to
another of quite different proportions. If the principles
on which these processes are based be not understood,
then the reckoning must be done mechanically, and
with little knowledge as to whether it is correct or not.

jT witt always be attended by a certain
mK 4f i|»j;i T ir there be any one thing that
^^ Mwdcd a^nst, it is the habit of careless-
. \MiL >i ' "'^y have become so familiar with the
t 3t mistake would seem an impossibility,
>>A >£ it^ K'* be remembered that a mistake is always
^^tJMn ITbc rule made in the very beginning, and
■Mf ijiym hit from, should be this — viz. to look at
^ WttAcM^UbcI and dose twice before giving any
e before it is measured out, and a second
t ^«n bdorc administering it to the patient. A
(should never be recorded as given, before the
IiIas ttctuaily taken it. It may seem more con-
t to record it a little earlier, and the intention
Mil]- b« perfectly good, yet this is a rule which under
V^ ^iKUnutances should ever be disobeyed.
ItHteare some medicines that act simply upon the
I vrith which they first come in contact — upon
t *kin if externally applied, or upon the mucous
lane of the stomach or intestines if given inter-
it; but the majority of drugs when introduced into
n are first absorbed into the blood, and by it
^^Ificd to the tissues and organs upon which they act,
jKWillcing certain changes in them. The activity of
%WCh drugs depends largely upon the rapidity with
which they ar? absorbed into the blood. Tliere are
9v« paths c. .'ntrancc for medicines into the circu-
^lon: by the digestive tract, the ceKular tissue, the
Kctum, the skin, and the iungs. The route most fre-
quently chosen is by the alimentary tract — ^the most
Ijlld, and the one therefore most often employed in
nergencies, by the subcutaneous tissue.

THE CAVING Oh' MEDICINES. 225

Medicines given by the mouth are absorbed for the
most part in tlie stomach, but also to some extent, and
in a few cases almost entirely, in the intestinal tract
They are yiven in solution, powder, pill, capsule, or
triturate. In giving solutions the bottle is first well
shaken, then uncorked, and the dose prescribed poured
mto a medicine-glass, and diluted with as small a quan-
tity of water as the nature of the medicine will permit.
A dose is often rendered much more disagreeable and
nauseating to the patient by the addition of a large
quantity of water: sometimes, indeed, it is desirable
to have the preparation well diluted, but when the
action is to be rapid the dilution should not be great.
If the medicine is very disagreeable, a small piece of ice
held in the mouth just before taking it. will lessen the
sensibility of the nerves of taste and render the flavor
of the dose less noticeable; or if the medicine be
mixed with crushed ice or seltzer water, the same
effect may be obtained. Brandy or whiskey held in
the mouth for a few minutes, or holding the nose while
the dose is given has been recommended. A little
cold fresh water or seltzer to take away the taste
may be given immediately afterward. Oils and fluid
i^xtracts are readily taken in capsules; this is the most
pleasant way to take castor oil, but if preferred it may
be given in a little sherry, brandy, or strong coffee.
Thus, two drachms of sherry may be placed in a med-
icine-glass, the rim and sides being moistened with
it, and the oil then poured carefully into the centre;
lastly, another drachm of sherry is poured on the
top, and the whole taken in one swallow. Another
way is to take equal parts of the oil and ]

iw. ,/inotner «
.nd glycerine^H

V 336

H and flavor with a few drops of the oil of

^T o'' some other aromatic oil.

Powders and pills conceal the flavor of medicines,
and are therefore much in vogue, but their action is
slower than that of solutions, and patients sometimes
have difficulty in swallowing them. Tasteless powders
may be given mixed with a little water; those with a
disagreeable taste, such as quinine, are wrapped in
wafers of rice-paper or enclosed in capsules of gela-
tine. The wafers come in boxes ready prepared and
I are about two inches square. One is moistened and
spread over a teaspoon, the powder dropped into its
centre, and the wafer folded over it; the spoon is now
filled with water, and the bolus allowed to slide well
back on the tongue, and a drink of water taken. If
wafers are not obtainable, a small square of thin tissue-
paper will answer the purpose. Gelatine and wafer-
paper are dissolved rapidly in the stomach. EHerves-
cing powders are always given in from a half to two-
thirds of a glass of cold water and taken during effer-
vescence. Insoluble powders, such as calomel or ace-
tanilid, should be placed on the tongue and washed
down with a drink of water. If a patient be very ill
or if it is difficult to get him to take his medicine,
the admixture of a little milk or glycerine with it
will often enable him to swallow it. In giving pills
one must always be sure that they are freshly made
up, as they are apt to become hard and dry from
standing, and then will not dissolve if taken into
the stomach, but be carried through without produ-
cing any effect. Compressed pills arc free from this
objection and dissolve readily. In giving a pill it is

THE GrVING OF MEDICIffES.

placed far back on the tongue ar.d followed quickly
a drink of water. If the patient cannot swallow
it, as happens in some cases, more especially with
children, the pill may be concealed in a small piece
of bread or jelly, and if this method does not answer,
one has to crush it up and give it as a powder.

It is convenient to give some medicines in the form
of triturates or tablets. By trituration we mean the
grinding and rubbing of solid substances until they
are finely pulverized. They are prepared by adding
sugar of milk or sulphite of soda in certain propor-
tions to the drug and triturating thoroughly. For
convenience in pressing into tablets the powder is
mixed into a paste with weak alcohol, and the latter
is subsequently allowed to evaporate.

The word "subcutaneous" (from the Latin sub,
under, and aitis. the skin) and the word '" hypoder-
mic " (from the Greek bi^h, under, and iJio/iO, the skin)
are identical in meaning. By iiypodermic or sub-
cutaneous medication we mean the giving of drugs by
injecting them under the skin. 1 lie advantage of this
method consists in the rapidity with which absorption
takes place: a drug that requires fifteen or twenty
minutes to act through the stomach will require only
five, perhaps, when given by hypodermic injection.
Usually only solutions of the active principles of
drugs are given in this way (c. g. solutions of mor-
phine), but other drugs, such as whiskey, brandy, or
ether, are sometimes given hypodermically when rapid
stimulation is necessary. The injections are given with
a fine syringe to which a hollow needle is attached.
Three points must be kept in mind in hypodermic

I
I

. '^exiivni mAy be rcdticed W a aaiai
are grrm in the line cf SMpofi
: r!-iid may enlera veiB.aiM] tbc(kvg,boi^
cstfTied directly to the heart, may reach the bctwc-
ccotyq in coacentrztioa in a Sew seconds, piuJuuag
alarming symptoms. If injected over a booy proa^
ioence. the bone maybe injured; so one always sdetfs
the outer side of the arms, thighs, or h^K, or llic ^>do>
men as the place (or an injection. The soltttiotts are
generally arrai^cd so that the doses vary from one to
fifteen minims, the tatter quantity brtn^ usually the
outside limit except in the case of stimulaots (whis-
key, braiMly, and ether), of wbich a sjTingeful b given
at one time. Before giMng a " hj-podermic " the
skin is to be cleansed with absolute alcohol, the
syringe loaded with the number of minims ordered,
and all the air expelled by pointing the needle upward
»nd gently pressing the piston until a small drop
appears at thepoinL AH being now tcady.a £ur-si2ed
fold of skin U pinched up between the thumb and
finger of the left hand, and the needle insetted

■ quick
H for at

■ ly an
^f needl<

THE HYPODERMIC NEEDLE.

2^9

quickly in a slanting direction deep into the tissues
for at k-ast half an inch ; it is then withdrawn slight-
ly and the fluid injected slowly ami gently. The
needle is quickly taken out and the thumb pressed
lightly over the spot to prevent the fluid from escap-
ing: very gentle rubbing upward assists in the distri-
bution and consequently in the absorption of the fluid,
but if at all painful to the patient, this need not be
done. There are various methods in vogue for pre-
paring liypodermic needles for use. The three prin-
cipal ones are —

First : To pass the needle through an alcohol flame
just before inserting it. This method undoubtedly
renders the needle sterile, but it is objectionable, be-
cause it blunts it, and makes its insertion more difB-
ciilt, and hence more painful to the patient.

Second: To soak the needle for a few minutes in a
1 : 20 carbolic solution, and afterward in sterilized nor-
mal salt solution or absolute alcohol to remove the
'"arbolic acid. This of course must be done before the
syringe is loaded.

The third and best way is to boil the needle for a
few minutes in simple water or in a i per cent, soda
solution, taking care that afier being boiled it is not
touched with anything but a clean piece of sterilized
gauze, with which it can be held while being attached
to the syringe. If no better plan be at hand for boii-
infi. when required for use the needle may be put in
a tablespoonful of water and boiled over an alcohol
or gas flame.

To clean the instrument before putting it away, it
IS washed in water and absolute alcohol is drawn

d needle ^^|

230 NURSING.

through it If in frequent use the syringe and
may be kept in a I : 20 solution of carbolic acii

The substance to be given must be completely dis-
solved and the solution freshly prepared, since one that
has stood for some time is liable to be decomposed, and
may have a sediment in it which will render it totally
unfit for use. The principal drugs used hypodermically
arc now made up in the form of compressed tablets,
witli the help of which one is enabled to make a fresh
solution at a moment's notice. A tablet should be dis-
solved in a sufficient quantity of distilled or boiled
water. A teaspoon is probably the most convenient
thing to use, as from it every drop of the solution can
be easily taken up, so that no portion of the alkaloid
will be lost and a smaller dose given than is ordered.

Medicines are given by rectum only when it is de-
sired (o obtain local effects or where the stomach can-
not retain anything or must have its work lessened.
The mucous membrane of the large intestine does not
absorb quickly, and as a rule requires twice as long to
do so as the stomach. For a stimulating effect medi-
cines should therefore be given in solution, and in-
jected as high up as possible in the manner described
in the chapter on Encmata.

Suppositories are solid conical preparations, made
generally of cacao butter, with which the drug is in-
corpor.ited. They are firm and should not melt at
the temperature of the air, but when introduced into
the rectum or vagina will gradtialty dissolve. They are
usually ordered for their local effect, the most com-
mon perhaps being those containing some preparation
of opium, which is much used in this way as a local

MEDICINES.

231

sedative. The suppository is first oiled and then
sHpped in without force : the patient should lie on
the left side, and care must be taken that it be made
to pass beyond the internal sphincter muscle; the anus
may be pressed with a towel until any desire to expel
the suppository has passed away.

The practice of introducing medicines into the sys-
tem by inunction is now rare. Hut in some conditions
the rubbing in of various substances is sometimes or-
dered; in syphilis mercurial inunctions are often indis-
pensable ; and in conditions of emaciation, such as are
seen in tuberculosis and inanition from other causes,
cod-liver oil used in this way is frequently of value.
Before an inunction is given the circulation of the skin
is rendered active by a warm bath.

To obtain absorption through the lungs it is neces-
sary to finely subdivide the medicament and give it
by inhalation, by means of atomizers or insufflators.
Although the spray from an atomizer is most com-
monly used, the inhalation of vapor is also a favorite
method. The drug should be mixed in hot water in a
small steam kettle that can be kept over a lighted gas
or alcohol lamp with a flame just large enough to al-
low a small stream of steam to pass constantly through
the spout, over which the mouth is held at a comfort-
able distance. Or the drug may be mixed with a quan-
tity of boiling water sufficient to about half fill a quan
bottle, which is wrapped in cotton-wool to preserve the
heat, and the vapor breathed in. Volatile drugs like
ammonia or eucalyptus are poured on a sponge or
doth, and held near the nostrils or placed in a respi-
rator which covers the mouth. If an irritating sub-

232 NURSING.

Stance be used, great care with unconscious patients isj
required to sec that it is not held near enough to do ^
any injury. Nitrite of amyl is best inhaled from a small
piece of fine linen or handkerchief.

It is necessary for a nurse to understand the effects
of the drugs in common use and to recognize the or-
dinary indications for their discontinuance. She should
also be familiar with the maximum and minimum
doses of drugs, remembering always that variations
from the rule exist for individual cases and according
to special circumstances. Thus the nature of the dis-
ease, the age of the patient, his temperament and hab-
its, the time of administration — all influence the action
of remedies. Children require much smaller doses
than adults, and the old have less resisting powers than
the middle-aged for depressing drugs. The most gen-
erally-accepted rule by which to calculate the doses
for children under twelve years of age is as follows:
Make a fraction the numerator of which is represented
by the age of the child in figures, the denominator by
figures representing the age of the child with twelve
added. This will represent the part of the adult dose
which is required. Thus, for instance, for a child six

years old we have ^-, - - = „ ^ of the adult dose.
■' 6+ 13 18 3

Roughly speaking, we may say that between the ages

of twelve and twenty-one the dose is one-half of the

full dose. Exceptions to the above rule are made in

the case of purgatives like calomel or castor oil; of <

these half an adult dose may be given to children. I

With opium, however, a smaller dose than the rule]

calls for should be given at first, since children bear itj

very badly, while, on the other hand, they are very
tolerant of belladonna.

As physicians cannot always speak of the details of
the action of medicines to each nurse, it is necessary in
;Tiving drugs to bear in mind some of the results which
may follow their use. Thus a drug may not act in the
.same way with every one. Some people iiave an idio-
syncrasy in regard to a particular medicine, by which
we mean that it affects them in some peculiar way that "
would not ordinarily be expected. This is particularly
true of individuals with highly nervous temperaments;
and. since such an effect cannot always be foretold,
nurses should be very careful to note the symptoms
following the first dose of a medicine. Where an idio-
syncrasy exists, the susceptibility to the drug will prob-
ably be increased, and peculiar symptoms may manifest
themselves with the first dose, which can then be re-
ported to the physician. In such cases the dose should
not be repeated without further instructions. Again,
certain medicines, if given regularly for .some lenjjtli of
time, gradually accumulate in the system until finally
marked symptoms of poisoning appear. With such
powerful drugs as .strychnine this accumitlalivc effect
must be watched for. On the other hand, there are
other medicines to which, when given for some time,
the system becomes accustomed, .so that the dose
may have to be increased to obtain the desired result
When this tol(rnlion becomes established, the increase
in the dose may go on until the habit of taking the drug
is acquired, and the patient think.s he cannot do without
it, as is so frequently seen with opium and its alkaloid
morphine. Whenever unusual symptoms of any kind

r234 NURSING. ^^^H

have become at all evident as the result of treatment, ^H
the nurse must be particular to keep the physician in-
formed, as often only through her can such things be
detected, and she should understand the symptoms
which may follow the use of the various drugs.
Frequently, where a habit is becoming apparent, a
placebo is resorted to in order to quiet the mind of
the patient, but the custom is to be deprecated from
a moral standpoint, and no nurse should resort to
hypodermics of water or salt solution or any of the
various substitutes without direct orders from the
physician.

The time to give medicines must be carefully con-
sidered. Absorption is of course more rapid when the
stomach is empty, and if a prompt action be desired
a time is selected when the stomach is not filled with
food : for this reason purgatives, which act quickly, are
usually ordered in the morning an hour before break-
fast; more slowly-acting cathartics are taken at night;
irritating or acid substances should only be given when
there is food in the stomach, and certain other drugs
only at a time when the process of digestion is most
active. Alkaline tonics may be given before meals ;
narcotics should be given the last thing after the
patient has been prepared for the night, and nothing
should be done to rouse or disturb him after the
drug has been taken.

Some forms of food and medicine do not combine
well — that is, they are incompatible; thus, for instance,
if milk and acids are given together, the milk is apt to
bi; rejected or to cause pain. Some drugs are also either
physiologically or chemically incompatible with others ;

■ thus, I

^M minou

^P from

MEDICINES. 235

thus, corrosive sublimate is incompatible with all albu-
minous bodies, and sliould be given alone.

Medicines ordered before meals should be given
from twenty minutes to half an hour before the
il-tiine; those ordered after meals should be given
either immediately after eating or fifteen minutes later.
Medicines ordered for a certain hour should be given
promptly at that hour ; an order given for three o'clock
does not mean five or ten minutes before three or half-
past three; and it is not the privilege of the nurse to
administer a medicine before or after the hour marked
on the schedule. One should not attempt to give an
unconscious patient medicine by the mouth, for it may
enter the larynx and cause suffocation.

In hospitals, accurate lists should be written out by
the head nurse with the names of patients, medicines,
doses, and hours conveniently arranged, and one nurse
should be set apart and held responsible for their prompt
and correct administration. A nurse under no circu
stances should take upon herself the responsibility of
suggesting or prescribing a medicine. If consulted as
to what would be best to give, she should always refer
the consultant to the physician in charge, whether she
be in the hospital or engaged in private nursing.

Medicines for hospital use should bo ordered only
in small quantities — not enough to last three or six
months — since it is always best to have them fresh.
They are liable to evaporate, and the solutions may
become more concentrated when allowed to stand on
the shelves, and, as supplies can be ordered daily, there
is no necessity of having too much of anything on hand.
The medicine-closet is not to be converted into a small

236 Ncfismc.

drug-shop; unused drugs must not be allowed to nccu-
mulate in it, but should be returned to the hospital phar-
macy, as they may possibly be used in another ward, and
thus expense be saved.

The mcdicinc-closct for hospital use is usually made
with glass doors, and should be kept scrupulously neat.
If heavy glass shelves cannot be liad for the bottles, it
will be found of great advantage to cover the wooden
shelves with sheets of ordinary glass cut to fit; these will
prevent stains on the wood, and the closet with but lit-
tle trouble can be made to presunt a neat appearance.
The size of the bottles should vary according to the
drugs which they contain. All extracts, active prin-
ciples, and powerful drugs should be kept in very
small quantities in bottles holding no more than two
ounces, and each should be supplied with two labels,
on one of which the name of the drug and the strength
of the preparation is clearly shown, another, a bright
red one, being marked " Poison." The same precaution
should be used with external applications, and the bottle
should be of glass of some striking color and have a rough
surface, so that the moment the fingers touch it it will be
recognized as one containing a poisonous substance. If
the medicines be always poured out on the side remote
from the label, the latter will not be disfigured and will
not be so liable to be rubbed off Where many medicines
are given a small damp cloth should be kept to wipe the
bottle before it is returned to the shelf; of course all
bottles must be carefully corked to prevent evapora-
tion. A -small tray, a pitcher of fresh cold water, a
glass rod for stirring, glass tubes for mixtures which
would injure the teeth, a dropper, and plenty of grad-

AIlF^RE VIA TIONS. 237

uated medicine-gl.isses ought to be kept near tlie
medicine-closet. No one but a nurse should perform
the duty of giving out medicines in a free ward, and
a drinking-glass after having been used by one patient
should be carefully washed before being given to an-
other. After use the medicine-glasses are washed thor-
oughly with hot water and soap, those that have been
employed for oils or emulsions being washed sepa-
rately: the nurse should never entrust this work to a
convalescent patient. Small medicine towels made of
old linen napkins nr tabie-cloths are necessary, The
medicine-closet is 10 be always kept locked, and on no
consideration should a patient (no matter who he be)
have access to it.

aa. ana (avi) of each

Ahilr., Ahtracltim, absirac:.

Ad. up lo. 10 amounl 10 (li.e full

phrase being quantum sullicil

ad).
Adde, add.
Ad lib., ad libilum, as much as de-

Ali. hor,, allemUi horis, every sec-
ond hour.

All. tux., aitenia node, every olhcr
nighl.

Aq,, aqua, water.

Ai/. dtsi,, aqua dcslillntn, di^lillcd

Aif.fur., aqua pura. pure wnler.
Bii. ind., Us indieE, twice daily.
C, Ceng., COITUS, a eallon,

{'., cubic centimetr*'

Abbreviations.

ifi,. capiat. Let him take.

Comf.. CI
Cm/. CO

DeiHb., decubitus, the lying-dowu

position.
Dfl., delnr. Lcl il lie given.
Dil., liiluIUB, dilute.
Dim., dimidiiu!, one-half.
Div., ilivide, divide.
Div. in /•. iri/.. di\idBlur in piulei

ai)UBlcs, Let il be divided into

equal parts.
Drachm., drachmn, a drachm.
Emp., empUilram, a plaalcl.
Enrm., enema, injection.
F., Fahrenheit.
F., Tac, make.

^^^^^^^^^H^^^^H

238 miRsmG.

I-I. FM^ fluidus. fluid.

f. J., quantum suflicil, as much as

■

II.. fiflt or fiant, I*t there be made.

is sutiiGicnI.

Garg.. EBTKarisma, a gargle.

a., recipe, lake.

Gr,, granuni c.r Erana, a grain or

A'ad-, radix, root.

grains.

i*. or .S(^-., signa, wtile— j. f. Give

^^1

(jV^.gultaor gull:E. 3 drop or ilrnps.

the following directions.

^^*

Gmlat , giiltaJim, ilmp bj- drop.

Stm., seincn, seed.

/b/, infusiq, an infusion.

Sfi. ^„ specific gravity.

/»>■/.. inJMiio, an injection.

Sfi. or Spir., sprilus, sfaiiL

ii., libra, a pound.

&.. semissis. 0 half.

Lif.. I,q««t.

S. i'. S.. spirilus vini rectificams,

LM., lMi.i. a luion.

alcohol.

J/., mUcc, mix.

S. V. C. spirims vini gallici, brandy.

;!/.«/.. mislura, a mixture.

S. F., spirilus frumenti. vihisliey.

A'., node, at niehl.

Syr., synipus, syrup.

T. i. d.. ler in die. three limes a

a, octorioi, a pint.

day.

OT,. oleum, <»l.

Tr., Tim/., linctura, tincture.

TrMA; Irochisci, lozenges.

0/. e/to., oleum oljvrr, olive oil.

Unf., unguentum, oinlmenl.

0?'.. ovum, an e|^.

ITL. minimum, minim, the 6olh port

/>,/., pilula, a pill.

of a drachm by measure.

/". r. n., pro re nata, !■; occasion

3. ilrachma, a dmchm.

nrise.1.

j uncia. an ounce.

r-.h:. [mWU. a po<y<k-!.

A, scrupulum, a scruple.

Apothecaries' Weksmt.

30 grain.s = i scruple.

60 " = 3 scruples— I drachm.

480 " = 24 scruples = 8 drachms = 1 ounce.

Apothecarie.s' Mfj\si;re.

60 minims = 1 fluidrachm.

8 fluidrachms = i ounce.

16 ounces = I pint.

3 pints ^ 1 quart.

8 pints or 4 quarts ^ 1 gallon.

MEASURES.

239

Approximate Measures.

I common teaspoonful of distilled water contains about
60 minims = I fluidrachm.

2 tablespoonfuls == i fluidounce.
I wine-glassful = i j^ ounces.
I teacupful = 4 fluidounces.

CHAPTER XV.
SmoicAL Nursing. — Aseitic and Antiseitic Suicfky,—

I'ATIENTS FOR OpERATlOSS {CAPITAL Al

Patients after Operation. — Inflammation. —
Method of Heaung— Sukcical Rounds.

In order that a nurse may appreciate the technique
of modern surgery and the importance of carrying it
out in its minutest details, she must trj' to understand
the underlying principles which have been established
by scientific research in the field of bacteriology.

It has already been stated that decomposition or
putrefactive changes cannot occur in the albuminoid
tissues of the human body without the presence of
some form of microscopic life, and that the organisms
that produce such changes in the tissues are of dif-
ferent varieties, the most important being cocci and
bacilli. The micrococcus is a spherical, the bacillus a
rod-like, organism, and there are many varieties of
each, which can be distinguished by differences in
shape, motility, growth on culture media, and the
pathogenic effects resulting from their introduction
into animals. In abscesses the organism most fre-
quently found is a coccus, groups of which are seen
arranged in the form of little grape-like bunches, and
which produce a bright-yellow color when grown on
the surfice of a boiled potato. Hence it has been
named the staphylococcus pyogenes aureus (golden
pus-producing coccus in grape-like clusters).

ASEPSIS AND ANTISEPSIS.

For acute septicaemias, which cause death in a few

days, usually without pus- formation, a coccus is also
often responsible, but this kind, instead of growing in
grape-like clusters, generally forms chains, and has
been named streptococcus pyogenes (pus-producing
chain coccus).

Wound-infection cannot occur without the presence
of some organism, and wounds, whether operative or
accidental, afford favorable conditions for ihe reception
and development of germs, for in them micro-organisms
find nourishment, moisture, and a suitable temperature,
the three essentials necessary for their growth. The
ways by which they may enter are numerous. In an
accidental wound, germs may be introduced by the in-
strument causing it, by the clothing, or by dirt which has
been allowed to enter before the surgeon sees the case.
In operation cases, if infection takes place, the organisms
have been introduced into the wound by the surgeon,
by his assistant, or by the nurse through some fault in
technique; thus the instruments, dressings, and hands
may not have been completely sterile. There is one
exception, however, to this rule, since it is impossi-
ble to thoroughly disinfect the skin, and wound-
infection may arise from organisms which have their
habitat there.

Although, as has been proven, chemical agents are
capable of causing pus-formation, yet, clinically, they
never do so. Chemical antiseptics, however, if used
in strong solution, are very irritating, and may injure
or destroy the tissues, lessening their normal resist-
ance, and forming a favorable medium for the growth
of "erms. Wounds, then, which have become the seat

24* NURSING.

of bacterial growth are called infected wounds, and arc
in a condition of sepsis, poisons being produced which
are carried into the circulation by the lymphatics and
blood'Vesscts, causing an inflammation in the wound
and septic fever — a condition usually indicated first by
a rise of temperature and an increased pulse-rate. Oc-
casionally not only the poison enters, but germs them-
selves get into the blood-current; then we have to do
with a general blood-/;i/ir/w«, and not simply with a
localized wound-invasion with secondary blood-m/tfjr-
kation.

Modem surgery aims at the prevention of wound-
infection by bacteria, and attempts the destruction or
inhibition of the growth of germs already present Two
expressions commonly used with reference to the treat-
ment of wounds are asepsis and atttisepsis. By an aseptic
wound we mean a clean wound, free from germs, while
antisepsis refers to the measures employed to destroy
organisms which may be present either in the wound or
on the skin, hands, and instruments, all of which must
be sterilized and made free from germs before coming
in contact with any, but more especially with a clean
wound. Hence the most minute precautions must
necessarily be taken by both surgeons and nurses in
prepaj"ing themselves or anything that will come in
contact with a wound during an operation.

The terms "clean" and "surgically clean" have,
then, two widely different meanings, since "surgical
cleanliness " should signify a complete absence of
germs. To secure this aseptic condition, both chemi-
cal and natural agents are depended upon, and with
the patient the first steps are taken some hours pre-

I
I

ASEPSIS AND ANTISEPSIS.

243

vious to the operation by rendering the skin of the
body over and around the seat of the operation as

clean as possible. Practically, " surgical cleanliness"
of the skin in the strictest sense of the term, is at
present impossible, for in spite of all known methods
of disinfection, in the glands of the skin certain bac-
terial forms arc constantly present.

The preparation of a patient should be begun the
night before, from fifteen to eighteen hours before the
time appointed for the operation. A general bath should
first be given with hot water and soap. Ne.\t, not only
the part where the incision is to be made is shaved, but
also a large area around, which perhaps will be louched
by the operator's hand; the skin should be left smooth
and quite free from hairs, and then scrubbed with
green soap (a soft potash soap very strong), and a
green-soap dressing applied and left on for an hour and
a quarlei.* If the surface be thick and hard, like that
over the patella, it should then again be well scrubbed
and the green soap reapplied for another hour, when it
is to be sponged off with t : 3000 bichloride solution
and enveloped in a sterilized dressing securely put on.
This may be .saturated with i : 3CXXD bichloride solution
or carbolic solution i : 80, about three hours before
the operation. A purgative should be given the night
before, and be followed by a simple enema in the morn-
ing, and. unless a stimulant or a cup of hot beef-tea is
ordered early in the morning, nothing should be given
by mouth after midnight. The urine should be either
voided or drawn off by catheter just before the patient
is sent to the operating-room, and she should be attired
in a fresh night-gown, warm wrapper, and .stockings,

• >M Appendii, Note i«.

I
I

// ,-.r/.

IF the natiiEe o£ the cfaa^um mSL pcnnit; a
umienressr :>liouid aLways^ be wan or & loose ftumel
jacket. Tbe iiatr siHmidaL«a3r» be iweil brushed and
bnudcii (SUTTQ^ taken, onk; and any arttfidal teeth re-
luovi^l rtie iiune pwrpararians apply (or a minar
o(x:ruuoa u chete ut timr. hut die purgative m^ be
otinctrrtl imierstfr aa anaesdietic is to be giveiL It is
iicctr^suy tu do aanv uunor operations at very short
iK>ctv:c. vUid lit these csbscs die prepatatioit should coor
^>t la :>crubbutg the :sur&ce with green soap and hot
waicr. 4u\ i»^ the part: ami washing it with warm per^
iiuit^;utate-or*^ca;»b and 03Ctiic-actd solutions ; finally.
it "^ s*«>'i^v;'^ 'i w:ch other and alcohol and covered with
.1 kiuv^jH'^ -acuiuted in bichloride solution I : lOOG^
.UK I I Ik- [.w I rent is ready tor the operation.

Ill i;ctKi.ii <urt;cn the otter-care ot the patient is, as
.\ Mile, vcix ^uiipic, unlc^is complications arise, and
i;iH»vl miiN4tij^ will d*^ much toward a rapid restoration
u» iKalth. the pieparatton of the bed tor such patients
h.i> K \*ii iiKMittv>iKxi bctore : immediately after the opo-
idlioii In v>v\'i. the patient is placed in bed and a nurse
iKlailed to teiiNun beside her until the effects of the
aii.i^lheliv htive worn away. It* there be much nausea,
w Jt I Nhv>uKl Iv *iiven s^viringly at first, as it only
«>-:\:* «^ »i'"* the tu>uble: small pieces of ice or sips of
omIi w \\\'t .lie Ix'tter. A condition bordering on col-
lap,* i»i a complete pr^vstration of the vital forces may
MU*\s a seveie ojvration. the pulse being ver>' small
ii».l hiMv\ the taee and lips pale, and the body cov-
\».4l >\iili a volil jHTspiration. Such a patient should
t.i wi ippiil III wami blankets, with plent>' of hot-water
Im^^ about lu'i» the boJy rubbed with alcohol, and a

HEALING OF WOUNDS. 24S

stimulant, either whiskey or brandy, must be at hand
ready to be given if ordered. After major operations
hsemorrhage should be watched for during ihe first
twenty-four or forty-eight hours; indetrd, thL- possi-
bility of such an occurrence should be borne in mind
until the wounds have perfectly healed, as secondary
hjemorrhage may occur several days after the opera-
tion. The nourishment ordered at first is usually in
the form of fluids or a light diet — milk, eggs, and
broths — but, as a rule, full diet is allowed very soon
after the operation. The pulse and temperature are to
be recorded twice daily, unless the symptoms require
that this should be done more frequently. As soon as
ever her condition justifies us in doing so. the patient
should be lifted out of bed into an invalid chair, or
carried out of doors into the fresh air and sunshine,
as it is important in every way to keep up the general
good condition of the system while the process of
repair or healing is taking place. Unless a serious
rise of temperature necessitates an early change, a
first dressing is usually kept on for a week or ten
days, or even for a fortnight, according to the nature
of the operation.

But the healing of wounds depends first upon the
kind of wound, and secondly upon its a.^^iptic condi-
tion. A wound may be defined as a solution of con-
tinuity of the soft parts. Wounds are classified as —

Inci'icd, such as are made with a sharp instrument;

Conlu.sed, such as are made with a blunt instrument ;

lacerated, when the tissues are torn and ragged;

Punctured, when made by a pointed instrument—
€. g. stab wounds.

2+6 NURSING.

Wounds are also spoken of as infected or non-in-
fected, according as they do or do not contain path-
ogenic or disease-producing organisms in sufficient
numbers to disturb the process of heaiing.

With a wound there may be pain, gaping of the
edges, and bk-eding. Pain varies in different people
and in difiercnt parts of the body.

A lacerated wound beneath the skin, where the sur-
face of the latter is not broken, is called a contusion or
bruise. Contusions are caused by direct violence. The
symptoms are discoloration or ecchymosis, indicating
an extravasation of blood, pain, and swelling. In a
contusion or bruise, the object in treatment Js to pre-
vent further effusion of the blood, to control the pain
and inflammation, to preserve the vitality of the tissues,
and to promote absorption. Heat applied at some
distance from the bruise relaxes the surrounding ves-
sels and promotes absorption. Cold has the opposite
effect; it contracts the blood-vessels and prevents ab-
sorption.

Until recently it was thought that the healing pro-
cess in an incised wound differed from the repair that
went on where a cavity had to be filled up by means
of granulations, and the healing of a clean incised
wound was called healing by first intention, or primary
union; where the process was brought about by the
filling up of a cavity, this was called healing by sec-
ond intention, or secondary union; and wounds where
two granulating surfaces came together were cla.ssified
under those which healed by third intention. It is
now taught that the process of repair that goes on in
wounds under any circumstances is precisely the same,

HEALING OF WOUNDS.

Z47

the only difference being that in an incised wound, lit-
tle injury having been done, only slight reparative pro-
cesses are necessary, while, where there are large cav-
ities which must be filled up by granulation -tissue,
much more extensive regenerative changes are needed.

The healing of wounds should therefore be divided
into only two divisions — aseptic wounds, in which the
healing is not retarded by bacterial poison and growth,
and infected wounds, where there is delayed healing
due to the action of bacteria. In wounds that heal by
first intention, as in a clean incised wound, no gran-
ulations are visible. The two edges are kept in close
apposition, the blood and lymph on the cut surfaces
join them together, the healing process takes place
rapidly, and there is very little opportunity for the
entrance of germs.

Wounds which heal by granulation, or by second
intention, are much more difficult to keep quite
free from infection, although every care should be
taken to do so. Healthy granulations are small red
elevations which spring from the fixed cells of the
connective tis'iHe. They gradually fill up a wound,
starting from the sides and [he bottom. Granulations
may grow too rapidly and increase beyond the desired
point, in which case they must be reduced and kept in
check by the application of some astringent: nitrate of
silver, cither in pencil form or in solution, is the one most
frequently used. On the other hand, the granulations
may be pale and flabby and need stimulating: balsam
of Peru is then most often applied. Where there are
very large granulating surfaces, as after large burns,
skin-grafting is resorted to to hasten the healing. The

24S NUSSINC.

iintirt aurtace is covered with thin layers of skin as J
largi; as can conveniently be shaved from some other J
portion of the patient's body, the leg, thigh, or an» |
being generally chosen. To prepare skin for grafting*
purposes, the same antiseptic precautions must be rig-
idly carried out as in preparing a patient for operation.
When all is ready the skin is shaved off with a large-
sized knife with a very keen edge ; the graft is at once
transferred to the wound, and spread over it, unless it
becomes doubled up, when it is first floated out in
normal salt solution. Strips of rubber tissue should
be laid in salt solution in readiness to cover the
*ound before applying the pads of gauze. The tissue
prevents any disturbance of the newly-formed skin
surface, and the granulations are not torn when the
dressing is removed.

A navity formed by the removal of a quantity of tis-
sue may be allowed to fill with blood, which forms a
clot, and this blood-clot gradually becomes organized.
the fibrin forming a delicate scaffolding upon which
new blood-vessels and granulations find support. This
method of filling up cavities and dead spaces is some-
times made use of by surgeon.s

Where granulating wounds have a tendency to heal
over from the top they may be kept open by means of
drains or gauze packing. Sterilized rubber tubing of
various sizes and strips of plain or iodoformized gauze
or bismuth gauze or rubber tissue are kept for this
fiurpose. The plain or bismuth gauze is considered
rather more suitable for granulating cavities.

Inflammation is sometimes found in connection with
ivounds, and is a condition of great importance. All

^r inflai

INFLAMMATION. 249

diseases the naracB of which terminate in " itis " are
inflammatory in character. Inflammation comprises
those changes in the tissues which result from the
action of certain irritants. The causes art; —

I. Mechanical — blows from difierent sources;

3. Chemical — various corrosive poisons ;

3. Physical— heat, cold, or electricity ;

4. Infectious inflammation (caused by micro-organ-

isms).

The phenomena of inflammation are dilatation of the
blood vessels, increased flow of blood to the part, the
appearance in the tissues of leucocytes or white blood-
corpuscles, and of red blood-cells which have passed
through the walls of the vessel-s, and the exudation of
blood-plasma.

An inflammation is said to be fibrinous, serous, or
purulent according to the nature of the exudate. The
symptoms are heat, redness, swelling;, pain, tenderness
and disturbance of function of the inflamed part.

The object in treatment is to remove the cause, or,
if this cannot be done, to protect the tissues as far as
possible from further irritnion. If the inflammation
subsides, resolution has taken place, but if the inflam-
mation continue, the termination is usually in abscess
or suppuration. Inflammation in connection with
wounds is most often due to infection, and if it results
in suppuration, the abscess should be opened up freely
and allowed to drain thoroughly.

For the regular surgical dressings (or. in hospital
parlance, for "surgical rounds") one nurse should be
especially appointed, for a certain length of time, to
make the necessary preparations, and before the hour

2<io ffuasmc.

for rounds the head nurse should see for herself thai
nothing has been forgotten. There should never b
anycliing wanting in the form of a dressing or appli*^
ance that may be asked for by the surgeon; it showsl
either lack of management or carelessness.

Dressing-carriages or trays are of many styles, but \
should be made witii regard to cleanliness as well i
to convenience. The accompanying figure shows the J
one used in the Johns Hopkins Hospital, and is made \
of har<i wood, the top shelf being covered with glass. '
(See Plate VII.) There are others made almost en-
tirely of glass. If dressings are made from bed to ■')
bed, a portable washstand is also convenient, as the 1
surgeons wash their hands before each dressing. The l
articles that should always be ready for surgical rounds 1
in a ward are —

The dressing-carriage, fully equipped with solutions, 1
bandages, etc.

A portable washstand, with plenty of hot and cold 1
water, soap, and brushes for scrubbing the hands.

White-rubber sheets, from six to twelve in number. ^

A covered granite-iron pail for soiled dressings.

One dozen granite-iron basins.

Irrigation-bags,

Sterilized dressings.
Besides the head nurse there should be two assistant'!
nurses, one to go ahead and prepare the next patient, '
the second stationed near and ready to wait upon then
head nurse, whose duty it is to see that the surgeon ii
promptly supplied with whatever he requires. It doe
not do for a nurse to wait to be told what the sui^eoo^
will use next; she must train herself to anticipate his J

INFLAMMATION.

251

wants and have everything in readiness. Nothing
should be done in a hurried or excited manner, but
coolly and collectedly. Talking at rounds should be
limited to necessary questions and answers, and a
quiet dignity observed in accordance with the serious-
ness of the work engaged in. To do good work a
nurse must give it her undivided attention, and laugh-
ing or chatting before a patient, who perhaps is in pain,
is quite out of place.

Where practicable, it is better to do all dressings in
a room of medium size adjoining the ward, since the
appliances can be kept more easily in a surgically clean
condition than when they must be carried about. Other
patients are then not disturbed by the sufferings of the
one who is being dressed, and the ward can be kept
free from soiled dressings and the accompanying dis-
order. Patients can be transferred from their beds to
a wheeled stretcher and rolled into the dressing-room,
or else, if the bed is on casters, it may be wheeled to
the dressing-room door, and the patient lifted directly
from his bed to the dressing-table.

CHAPTER XVI.
Gyn.«coloct.— General and Spbcial Prei'aratio-i of Patients

FOR. EKAMINATIONS AND OPERATIONS.— POSITIONS. — InSTRU-

) Dressings.— Cake after Ahdominal Section and
Minor Operations. — Gynecological Tkrms and Defimtioms.

Now-A-DAvs the treatment of gj-njecological patients
is so largely made up of operative procedures, that the
preparation of such patients for operation and the after-
care of them by the nurse require some especial teach-
ing over and above what she has had on the subject of
general surgery. The anatomy of the pelvic organs,
their functions and relations to each other, should be
well understood by a nurse, in order that she may have
an intelligent comprehension of the features pecuhar to
this work. She must be able to recognize the import-
ance of any physical change that may take place in her
patients during treatment, whether before or after ope-
ration, and .she must be familiar with the nomenclature
used in this department of surgery. Education in this
branch of nursing can hardiy fail to impress a woman
with the importance of using her influence among other
women to bring about a broader knowledge of their
physical construction, so that they may have a better
appreciation of the general laws of hygiene, and more
especially of those applying to the pelvic organs.

Treatment in g}*n (ecological cases may be general,
local, or both general and local, but in the majority

ity M

CYN.-F.COLOGICAL POSITIONS.

253

of hospital cases some operative measure in addition
is generally indicated. The general treatment con-
sists in putting the patient to bed and keeping her
perfectly quiet, both mentally and physically. The
nurse's duties under such circumstances are to sur-
round her patient with a quiet, cheerful atmosphere,
to keep from her any causes for excitement, and
build up her system by special attention to the
diet, giving milk in abundance and plenty of simple
nourishment in an attractive form. Such a patient
.should have plenty of .sleep; all arrangements for
the night should be finished by 9.30 P. h., the lights
turned low, and the patient left undisturbed, when,
as a rule, she will quickly go to sleep. If she awake
during the night, a glass of hot milk, cocoa, or broth
should be given. Frequently with this form of treat-
ment are combined some local measures, such as the
making of applications by the surgeon. When this
must be done, a well-trained nurse should know just
what is necessary to have on hand, and .she must
avoid any awkward delay, which may be very trying
to the patient, especially if it be her first experience
of the kind. It will also fall to the lot of the nur.se to
make proper preparations for the examination of the
patient and assist the surgeon, all of which .should be
done in a quiet, dignified, and thoroughly professional
manner. The nurse's deportment will go far toward
reassuring the patient and helping her to restrain
any signs of nervousness that she might otherwise
be inclined to show, and which would prevent the
surgeon from proceeding with his work. The nurse
should always be present during the doctor's profes-

254 IWRSING.

sional visits unless tbere should be any special rea-
son to the contrary.

Before either an examination or application it is the
nurse's duty to see that her patient is first in a pre-
sentable condition. The rectum should be empty and a
general sponge-bath or tub-bath and a vaginal douche
given, the latter consisting usually of a l per cent, car-
bolic-acid solution. A fresh night-gown, stockings, and
a wrapper are to be put on unless the examination or ap-
plication is to be made in bed, when the wrapper is not
necessary. For a digital examination all that is required,
if the patient is in bed, is to have her moved over to
that side of the bed which the surgeon prefers, where
she is made to tie on her back with the knees drawn
up. The covering should not be too heavy. A chair
is placed at the bedside for the doctor, and a towel and
some vaseline must be ready. A basin containing water
should be placed on the washstand.

For applications the patient is to assume the most
convenient position.

The several positions necessary to know are the left
lateral, the dorsal, the knee-chest, and the upright posi-
tion. In the lateral, usually called the " Sims position,"
the patient lies on her left side and chest, with the left
arm drawn behind her and her head and right arm rather
toward the right corner of the table, the buttocks rest-
ing well over toward the left lower corner; the legs
should be flexed and the right knee drawn up above
ihe left. This is the position usually ordered for
applications requiring the use of the speculum, as the
uterus and anterior wall of the vagina are well forward
and a better view is obtained.

CYJV.-F.COLOC/CAL POHITIO.KS.

255 '

The dorsal position is the one Kciiurdlly adopted for
t^xaminationand in operations.whether capital or minor.
The patient lies flat on her back, and the knees are
flexed or the legs otherwise arranged according to the
nature of the operation.

In the knee-chest position the patient must lie upon
the side of her face, with her arms outstretched and her
hands grasping the upper end of the table. She lies flat
on the chest, with the hips elevated, the back being bent
in opposite the lumbar region, and the weight of the body
resting chiefly on the knees. This position is usually
chosen for replacing a retroflexed uterus and for making
applications to the uterine cavity or to the vault of the
vagina. The Sims speculum is the one generally used.

For the upright position, the clothes of the patient
are adjusted by folding the skirts about the waist, then
wrapping a sheet about the waist and lower extremities,
allowing an op.n'nj at the side. Th; patient stand.s
with the right foot resting on the rung of a chair or
on a low stool. In this position pessaries are some-
times inserted and examinations made.

Sheets or blankets, in addition to the patient's own
clothing, are generally used as coverings, and should
be arranged so that the patient is quite covered until
everything is ready, when only the part to be operated
upon should be exposed. For vaginal operations two
or three thicknesses of gauze of sufficient size to ex-
tend from above the pubes to below the perineum may
be wrung out of a disinfectant solution and spread over
the parts : the operator works through a slit in this,
the ofjening being made sufficiently large so as not
to interfere with his movements. Although this plan

I
i

3^f NURSTNL.

has not yet been tjcnerally adopted, the idea seems
to be a good one. Long canton -flannel stockings
reacliing to the thighs should be worn under the
sheets that are used to throw over the legs. For
examination under anaesthesia it is necessary in addi-
tion to have plenty of towels, a good supply of hot
water and vaseline, ether or cliloroform with inhaler,
basins, specula, uterine dressing- forceps, cotton, and
disinfectant solutions.

Frequently the nurse is required to hold the Sims
speculum : she should stand on the left side of the
patient, allow the left arm to rest lightly on the pa-
tient's hip, and with the hand separate the buttocks
near the vaginal opening; with the right hand she
grasps the speculum, holding it steadily and firmly as
directed by the operator. The speculum should be
placed in some warm solution or in warmed vaseline
before being introduced.

The local dressings generally in use consist of pack-
ing.s of gauze and tampons of various kinds. The
gauze is made in strips about sixteen inches long and
two inches wide. The plain sterilized gauze may be all
that is needed for this purpose ; at times iodoformizcd
gauze or gauze prepared with certain other chemicals
may be desirable. Such packings are usually left in
from twenty-four to thirty-six hours, and are then re-
moved with forceps, care being taken to make sure
that every piece has been taken away by ending the
procedure with a digital examination, as any gauze left
in will decompose and may set up an inflammation.

Tampons are made of absorbent cotton or of lamb's
wool. The cotton is cut into strips about eight inches

long, four inches wide, and half an inch thick : each strip
IS then doubled, the ends are rounded off" with the scis-
:, and the whole is tied securely in the middle, where
it is folded, with a piece of stout linen thread, leaving
a length of thread of about six inches, with the ends
knotted together, by which the tampon may be re-
moved. Tampons are used as supports to take the
place of pessaries, and for applying local antiseptics,
powders and soothing drugs in inflammatory conditions.
Lamb's-wool tampons are used when the walls of the
vagina are to be kept apart, as they are non-absorbent
and do not become sodden like absorbent cotton.
They are made by twisting around three fingers a
piece of wool 30 cm. long and 3 cm. wide, so as to
form a loop; a piece of linen thread is tied around the
centre of the loop, leaving long ends to the threads as
described above. The wool is then spread out flat.
Usually an order is given to remove a tampon after
twenty-four hours, and to follow its removal with a
warm -water douche.

If a Hodge pessary, or one of a similar type, is to
be removed, two fingers of the left hand are introduced
into the vagina, and the index finger, being hooked
over the anterior bar of the pessary, which rests
against the upper portion of the symphysis pubis,
gives it a half turn : this frees it from the cervix, and
it only remains to remove it from the vagina. The
pessary should be placed, after removal, in a i : 40 car-
bolic-acid solution for five minutes, then well washed
off and dried.

For making the general dressings in a gyn .ecological
ward, the necessary instruments to have ready are a

25S NURSING.

Sims speculum, uterine and ordinary dressing forceps,
a uterine sound, probe, tenacula, curettes both sharp
and dull, bullet forct;ps, applicators, cotton-holders, and
a pair of straight sci'ssors. These should be sterilized
ready for use, and in addition there should be a dress-
ing-basket or carriage containing a roll of sterilized
gauze and absorbent cotton, also the various disin-
fectant powders, such as iodoform, and boracic acid,
and astringents. Rubber strapping wound in strips on
glass rods, perineal and the modified Scultetus band-
ages (Fig, 13), should be ready to hand, and plenty

of basins, warm solutions, and towels are among the
things required.

Fnr minor operations the preparation of the patient,
with a ffw niodificatiuns, is practically the s;ime as foi

PREPARATION Oh PATIENT.

259

an abdominal section. Twelve hours before the opera-
tion, the physician usually orders a tub-bath or a sponge-
bath and the administration of a cathartic; on the next
morning the patient must take no breakfast : she should
receive a simple soapsuds enema, which should be re^
peated until effectual. The parts must then be shaved .
it may be necessary to go over the surface with the
razor two or three times, in order that the finest hairs
may be removed. When this has been done, the parts
must be thoroughly scrubbed with green soap and
water, washed off with alcohol and afterward with
ether, and finally sponged with a i : 5000 bichloride
solution. A compress of sterilized gauze wrung out
of warm bichloride i : 5000 is next put on, and held
in place with a sterilized abdominal binder to which
are attached perineal straps, to keep it from sliding out
of place.

The After-care of an Abdominal Section Case.
*In the care of a patient after an abdominal section,
.or the first twenty-four hours, very little can be done
except keeping her quiet, watching the pulse, looking
out for hemorrhage, and allaying the excessive thirst,
as much as possible, by rinsing out the mouth with soda-
water or plain water and moistening the lips from time
to time. As a rule, the patient is not allowed to drink
water, a.s it induces and prolongs nausea, which would
defeat our main object, which is to keep her in every
way as quiet as possible. Nourishment by the mouth
may not be ordered until next day, and then probably
only in very graduallj- increasing quantities. Stimu-
lants should be kept near at hand, and if the patient

^4« AppcDdix, Nulc IT,

NUXS/NG.

is in an exhausted condition, a nutritive enema may be
ordered at once, so that the necessary articles for giv-
ing one should be ready for use at a moment's notice.
Unless the patient voids urine within eight hours after
the operation, the retention should be reported and a
catheter prepared. If urine is voided, the quantity
should be carefully noted. The bowels will nearly
always need attention by the morning of the second
day, and it is important that the nurse should record
and report accurately the result of the enema which is
generally ordered. If there be no result after several
repetitions, she should be particular to report the fact
immediately, as failure on the part of the bowels to
move m.iy indicate an obstruction, and the surgeon
may wish to institute further treatment at once. For
the first week or ten days a record sheet should be
neatly and accurately kept by the nurse. For uneasi-
ness and pain in the back, small flat pillows and the
knee-pad must be adjusted and changed whenever
necessary.

Unless otherwise specified by the doctor, the diet
should consist of liquids until after the sixth day or
until the stitches are removed, when soft food may
gradually be added.

Tlie After-care of a Case of Perineorrhaphy.
For the first twenty-four hours the treatment is
practically the same as for cases of abdominal section,
but .soft food is generally ordered on the second day,
and the bowels should move freely at least once daily:
an enema sliould be given previous to the movement, to
soften it and to prevent straining. When a patient is

CARE AFTER OPERATION.

having a movement of the bowels, great care must be
taken that the stitches arc not torn apart, and if there
be any straining whatever, the nurse should hold the
parts together: this is a good plan to follow, at any
rate for the first few days. Usually catheterization is
ordered during the first forty-eight hours. Antiseptic
precautions must be carefully followed, the parts should
be bathed before using the catheter, and the greatest
care employed <o prevent any drops of urine from
falling upon the stitches ; the wound should be washed
off with a little sterilized cotton held with forceps and
dipped in a 1 per cent, solution of carbolic acid or a
10 per cent, solution of boric acid. It should then
be wiped quite dry with bits of cotton held in the s
way, and powdered boric acid or other powder, or the
dry dressing ordered reapplied. The hands should
be scrubbed clean and disinfected before beginning the
work. These precautions should be taken each time
the urine is voided and after every movement of the
bowels. Usually a little gauze packing is put just with-
in the vagina at the time of the operation to absorb any
oozing from the stitches, and this should be removed
the next morning. A douche should never be given
after a perineorrhaphy without an order from the sur-
geon, and then the greatest care should be taken to
see that no water is left lying against the stitches
within the vagina, as is likely to happen unless one
swabs it out and makes it quite dry, which may be
done with the aid of forceps covered with cotton.
For the first forty-eight hours, if the patient is very
restless, the knees should be bound together to pre-
vent any sudden movement, which is apt to tear the
switches.

Hicmorrhage is liable to occur after operations upon
the cervix or after a perineorrhaphy, and the nurse
should be able to control it until the doctor arrive:
For bleeding from tlie cervi:- a hot alum douche is
generally all that is necessary, but if this does not
answer, then the vagina should be cleaned out with
cotton applied by means of the forceps, and tightly
packed with plain sterilized gauze or ^auze medi-
cated with some such astringent as tannic acid in
powder or solution. For h.-cmorrhage from the peri-
neum, the parts may be elevated and pressure made
with a pad of cotton or gauze against the bleeding
surface.

Lavage of the bladder, or bladder- washing, in gyne-
cological cases is usually ordered for a cystitis which
may be cither acute or chronic. Boric-acid solu-
tion is most frequently used. This is sometimes
mixed with an equal quantity of salt solution.
Three pints should be put into a fountain syringe,
and the end of the rubber tubing attached to a
glass catheter which is introduced into the blad-
der ; the urine is first drawn off" and then a pint of the
boric solution allowed to run gently in ; (he tubing
is then slipped off the catheter, half the water is drawn
off. the tube replaced, and the other pint, if necessary, in-
troduced. The third time this is done the water should
be clear when empded from the bladder.* If a double
catheter can be obtained, there will be no necessit>- for
removing the tubing, as the fluid will run out as quickly
as it is introduced. If no tubing can be procured and
we have no fountain syringe, a rubber catheter may be
introduced to which a small sjla'^s funnel is attachet!,

GYN^COIOGICAL TERMS.

and the solution be poured slowly and gently througli
this, a pint at a time. Some patients cannot bear so
great a distension of the bladder, and as soon as any
complaint is made one should allow the fluid to escape.
The vessels and catheter used must be surgically clean,
and all precautions taken as in an ordinary catheter-
ization.

As nurses are constantly hearing difficult and un-
familiar words used in connection with gynEccological
work, and as it is important that they shouSd in many
cases undt;rstand something of the nature of the ope-
ration performed, a synopsis of gynacological opera-
tions and the terms applied to them will be introduced
here :

Metritis. From the Greek metra, uterus, and the ter-
mination ilis. signifying inflammation. Inflammation
of the uterus. This condition may be due to any in-
flamm^itory condition existing in the pelvis ; more com-
monly it comes on as a consequence of post-partum
infection (after labor), and is known as septic metritis.

Endometritis. From the Greek eiuion {or eiido), mean-
ing within, and mdritis. inflammation of the uterus.
Inflammation of the lining membrane of the uterus.
For this the operation of cnrcttcmcnt or curetting is
performed, which means the removal of the inflamma-
tory products by means of a dull or sharp curette.

Stenosis of the Os Uteri or Ccn'ical Canal {sten-
osis, a. narrowing; o.!, mouth). A contraction or nar-
rowing of the cervical canal. For this the operation
of dilatation is performed, which means the stretch-
ing or dilating of the cervical canal by the use of in-
struments called dilators, or by sponge tents.

LaeeralioH of llie Cen>ix Uteri. A tear of the neck

of ihe womb. The tear may be unilateral — ' f. con-
fined to one side, bilateral — taking in both sides;
or stellate — *. e. irregular or star-shaped. This con-
dition is generally caused by childbcaring. For this
lesion the operation of trachelorrhaphy {from the Greek
trachilus. neck, and rhaphia. a sewing) is performed, in
which the torn lips of the womb are brought together
by sutures. When this is done immediately following
childbirth, it is called the "immediate operation;"
when performed after the first week, it is called the
"secondary operation."

Relaxed Vaginal Outlet. The relaxation of the tis-
sues that form the entrance to the vagina. This is .
caused by over-distension of the parts during child-
birth. The operation performed for this is known as
perineorrhaphy {pfrincum. and rltaphta, a sewing or
suturing), and has for its object the bringing together
of the relaxed tissues by dissecting away a portion of
the mucous membrane of the vagina, and then uniting
the denuded parts by sutures.

Laceration of the Perineum. A tearing of the tis-
.sues forming the perineum. There are several grades.
When the laceration extends through the .sphincter
ani, it is known as a complete laceration ; when it does
not extend .so deep, it is known as an incomplete or
partial laceration. The operation performed for rem-
edying this condition is also known as perineorrhaphy,
and, as the name impliL-s, means the bringing together
of the parts by sutures. In cases of complete lace-
ration spL'cial care must be used in giving enemata,for
some time after the operation, to do it in such a way
as to avoid disturbing those sutures which are passed
through the fibres of the sphincter anj.

GYNjECO LOGICAL TERMS.

Excision of a Bartholinian Cyst. The cutting out
of a cyst formed by dilation of the duct coming from
one of the glands of Bartholini. The gland becomes
swollen as the result of the accumulation of its secre-
tions due to the closure of some portion of the duct

Uterine and Cervical Polypi. These are tumors which
occur in the mucous membrane, and are made up of the
same kind of tissues as the membrane from which they
grow. They are generally attachL-d to some portion
of the cervical canal or fundus of the uterus by a long
pedicle or root. They arc removed by being twisted
off with forceps, by incision, by ligature and incision,
by means of the cautery (Paquelin's), or by the

Carcinoma of the Cervix Uteri. Cancer of the neck
of the womb. Its most prominent symptom in the
majority of cases is ha-'morrhage. The treatment of this
condition is either palliative or radical, ^y palliative
treatment is understood the removal of as much as pos-
sible of the cancerous mass by means of the finger and
curette, and the destruction of the tissue, which it is im-
possible to remove by this procedure, with the thermo-
cautery (I'aquelin's). By the ran'/V-ij/ treatment is meant
the total extirpation of the cancerous tissues. This is
performed either by amputating the diseased portion
or by completely removing the cervix and uterus by
performing a vaginal hy.sterectomy (from the Greek
hyslera, the uterus, and ectoniia, cutting out).

Cystocelc (from the Greek cystis, bladder, and cele,
a tumor). A prolapse of the anterior vaginal wall,
which brings down with it the bladder.

Colpocflc. Or. colpos, vagina, and cele, tumor. De-
scent of the vaginal wall. Ever>- cystocele is a coIqq-

266 NUKS/NG.

cele. The condition is frequently a consequence of 1
labor. The operation performed for its relief is known j
as anterior colporrhaphy {colpos, vagina, and rhaphia,
suturing), winch means the bringing together of the re-
laxed vaginal tissues by sutures.

Reclocde. A mixed word from the Latin rectum |
and the Greek ceii\ tumor. A prolapsus or relaxation |
of the posterior wall of the vagina, which brings with
it the rectum. This occurs in most instances as a
consequence of childbirth.

Amputation of the Ccn-ix Uteri. The removal of
the cervix. This is performed for prolapsus of the
uterus; also, for hypertrophic elongation of the cervix,
or for cancer of the cervix.

Pelvic and Abdominal Operations and Diseases.

Ceeliotomy or Laparotomy (the latter from the Greek
lapara, lit. the flank, and lomia, a cutting), and Abdom-
inal Section are synonymous terms employed to de-
scribe the incision through the abdominal walls.

Ceeliotomy is the proper scientific term, ciclia being
the Greek for the abdomen, and tontia, meaning " cut-
ling."

Ovaritis. Ovarium, ovary, itis. inflammation of. In-
flammation of the ovary.

Salpingitis. Salpinx, the tube, and itis, inflammation
of Inflammation of the Fallopian tube.

Salpingitis and Ovaritis. Inflammation of the Fal-
lopian tube and ovary.

Abscess of the Oi-ary. A purulent collection (pus)
m the ovary.

Pyosalpinx. Greek fyon, pus, salpinx, the Fal-

GY.V^.COLOCJCAL TERMS. 267

lopian tube. A collection of pus in the Fallopian
tube.

Hydrosalpinx. Hydrops. Jropsy, salpinx. Fallopian '
tube. A collection of watery fluid in the Fallopian
tube; dropsy of the Fallopian tube.

HiEmatosalpinx. H<nna (gen. hamatos), blood, sal-
pinx, Fallopian tube. A collection of blood in the
Fallopian tube (most frequently due to extra-uterine
pregnancy).

Ovarian Cystoma. A cyst of the ovary.

HtEmatoma of the Ovary. A blood-tumor of the
ovary.

Dermoid Cyst of the Ovary. A cystic tumor con- ]
taining skin, teeth, hair, etc. Dermoid cysts are ci
genital tumors.

Ovariotomy. Ovarium, ovary, tomia, section. Re- j
moval of an ovary.

Oophorectomy. Oophorum, ovary, ectomia, excision. ,
A ftetter term to signify an operation for the removal J
of an ovary.

Salpingo-oophorectomy. Salpinx, the Fallopian tube,
oophorum, ovary, ectomia, excision. Removal of the '
Fallopian tube and ovary (as for myoma of the ute-
rus). When the tubes and ovaries on both sides are
removed, the operation is called a double salpingo-
oophorectomy.

Myotnectomy. Myoma, lit. a thing made of muscle,
a muscular tumor; ectomia, excision. The removal
of a myoma from the uterus. Such a growth is com-
monly spoken of as a fibroid tumor, but myoma is the
more correct term.

Hysterectomy. Hystcra, the uterus, ectomia, excision.

368

XUftSlNG.

The complete removal or extirpation of the uterus.
This may be done cither throu<jh the vagina {vaginal
hysterectomy) or through an incision in the abdomen
(abdominal hysterectomy). It is generally performed
for carcinoma (cancer) of the cervix or uterus,

Hystero-myoiiiectomy. The removal or extiipatioa
of the uterus for myoma.

HysUrorrhaphy or Suspensio Uttri, Hystera, the
uterus, rhaphia, a suturing. The suspension of the
uterus to the anterior abdominal wall by sutures.

Parovarian Cyst. A cyst developing from the par-
ovarium of the broad ligament (between the ovary and
Fallopian tube).

Extra-uhritie Pregnancy. A pregnancy going on
outside the uterus, generally in some portion of the
Fallopian tube, in which case it is called "tubal preg-
nancy." It may also occur in the ovary or even in the
abdominal cavity.

Casarcan Section. The removal of the fcelus from
the uterus by means of an incision through the abdom-
inal and uterine walls of the mother. It is resorted to
only when the pelvis is deformed, or when the foetus is
still living after the death of the mother.

CHAPTER XVII.

As the technique of the operating-room has come
to have such an important bearing on surgical opera-
tions, and as the nurse is frequently depended upoa
to prepare everything required, and to see that every-
thing in the room is in a condition of cleanliness and
order, her duties in this special work will be dwelt
upon in detail. To ensure thoroughness in the anti-
septic preparations, one nurse should be given the
responsibility of the care of the operating-room — a
task which is usually sufficient to occupy her whole
time. Any further assistance, which is needed, should
be rendered by the pupil nurses of the school, who
receive their operating-room training in this way.
The pupil nurse thus works under the direction, ob-
servance, and criticism of the nurse in charge, upon
whom devolves the responsibility of rendering surgi-
cally clean everything in the operating-room that is
likely in any way to come in contact with a wound.
This duty includes the care and sterilization of instru-
ments, the preparation of solutions, ligatures, dressings,
and operating-room linen (including surgeons' opera-
ting suits and nurses' dresses), the antiseptic care of
the room, and involves a thorough knowledge of the
details of the preparation for any kind of operation.

270 NURSWG.

For sterilizing purposes an Arnold steam sterilizer
is all-sufficient, as it is qiiiti; large enough to hold
bottles of salt solution, dressings, or instruments; in
a general operating-room not k-ss than two and some-
times three or four of these sterilizers are needed, each
supplied with a Bunsen burner and gas tubing. The
dishes neeckd for ijpeialions var\- in size and shape.
They arc used to hold the various solutions for the
disinfection of hands and instruments, and some should
be reserved for the reception of specimens : they should,
where it i.s possible, be of glass, but if glass ones are
not obtainable, those of white porcelain or porcelain-
lined ware are the next best. When the porcelain be-
gins to chip off a basin, the latter should be replaced
by a new one, as it is impossible to be sure that a
chippeit dish is surgically c]ean. All such dishes, after
an operation, should be washed in hot soapsuds, then in
clear hot water, and allowed to drain instead of being
wiped off, as bits of lint from the linen would be apt to
cling to the surface. The instruments are placed in
dishes filled with a I : 40 carbolic-acid solution, or,
what is still better, the dishes are filled an hour before
the operation with a I : looo bichloride solution, and
just before the operation are emptied, rinsed out with
sterilized water, and again filled with sterilized water,
m which the instruments are received.

An operating-room nurse should familiarize herself
with tlie names of the instruments ordinarily used in
surgical operations, and be able to select the sets used
for the different cases. To prepare instruments for use,
i"hey may be wrapped in a towel or put into a bag, which
is placed in an Arnold sterilizer and steamed for half an

SURGICAL 0P!:f!ATI.VG-A-0OMS. 2yt <

hour: just before they are needed, they arc lifted out ]
(after tlie hands have been disinfected) and placed at
once in the basins of solution prepared for them. The
objection to .'sterilization by steam is that the instruments
must be nickel- plated, otherwise they will rust, and even I
if but a small portion of the plating has worn off and
Ihey are left standing for any time at all, this is like-
ly to happen. A second method is to place the instru-
ments in a porcelain-lined kettle filled with a I per cent '
solution of carbonate of soda, which is allowed to boil |
for five minutes, after which they are lifted out and e
once transferred to the dish containing the solution.
This is a very convenient method of preparing in-
struments quickly for a second operation.* After an
operation, to prevent rust, the instruments should be
cleaned at once. They are first wa.shed and scrubbed
very carefully in warm soapsuds; finally, after being
rinsed off in clear warm water, they are carefully dried.

In adilition to the regular disinfectant solutions (ci
bolic acid and bichloride of mercury) other cleansing ]
agents are now used in operating-rooms for various ;
purposes, particularly salt solution and distilled water.

Normal salt solution — so called since it contains
approximately the same proportion of salt as is found
in the blood-serum, i. c. -^^ of i per cent. — is made
according to the following formula:

^, Sodium chloride, gram, v) (circa 3iss);
Distilled water, litre j (circa Oij).

Mix thoroughly with a glass rod and filter through
filter-paper into a sterilized flask or bottle of a capa-

272 /fUXSIATG.

city of about two litres ; stopper the bottle with steril-
ized common or absorbent cotton, keeping the plug in
place with a few turns of gauze bandage, which also
prevents any accumulation of dust upon the lips of
the bottle. The flask is then heated over a gas flame

and the solution allowed to boil, after which it is placed
in the sterilizer to be steamed for half an hour. This
process is repeated three times at intervals of twenty-
four hours, the solution in the mean time being kept
in a room at a temperature of about 30° C. The
solution is sterilized in this way because it has been
foun4 by experiment that after the first sterilization

LIGATURES.

the spores are not destroyed ; the intervening twenty-
four hours allow for the development of any spores
which may have been present, so that they can be
destroyed by the second sterilization; the steaming on
the third day kills any which may possibly still r
and the solution is thus rendered com-
pletely sterile. Before the operation it
is reheated and used at whatever tem-
perature is desired.

Salt solution is used for irrigation or
for sponging exposed tissues, to keep
ready for use rubber tissues, which are
to be used for covering skin-grafts, and
to wa.sh out the abdominal cavity after ab-
dominal operations. Besides its cleans- •
ing properties, it has been proved to act
as a stimulant to the tissues, and the red
corpuscles arc preserved in it, whereas
they are destroyed by plain water.

Distilled water, when used in large
quantities, can be most readily obtained
from a boiler-room, a'^ it is easily made
by turning on the steam in the boiler
and allowing it to condense. It is fre-
quently used now instead of disinfectants
for covering instruments, for sponging,
and, instead of boiled plain water, for
preparing salt solution.

Suture Materials and Ligatures.— TimBCDrn^AiNiNn
Ligatures are of various kinds and sizes. Gl^rmls."
They are made of silk, silkworm gut, catgut, and
silver wire.

To clean the glass reels or spools (see Fig. 15) upon

274 NURSING.

which ligatures are wound, a good scrubbing with green
soap and water and placing in a i : 500 bichloride solu-
tion for twelve hours is effectual.

Silk Ligatures. — The heavy silk ligatures are cut
into lengths of ICX) cm., the intermediate size into
lengths of 4,0 cm., and the " carriers," or those of fine
quality, into lengths of 50 cm. Four strands of the
heavy silk are wound together on one reel, ten of the
intermediate on a second, and eight of the fine on a
third reel. For sterilizing these, a test-tube lai^e
enough to hold four reels is used, and a httle cotton
placed in the bottom of it. The tube is then plugged
with cotton and steamed in the sterilizer for three suc-
cessive days — for one hour on the first, and half an
hour on each of the two following days. They are to
be kept dry, and the plug must never be removed until
the ligatures are required for use.

Catgut Ligatures. — Half a bunch, or six strands are
wound on a long glass reel and immersed in a bottle
of 95 per cent, alcohol, making sure that the alcohol
more than covers the reel, to allow for evaporation;
the bottle is then plugged with cotton and placed in a
water-bath until the alcohol boils, when it is removed.
The boiling must be repeated on two successive days,
great care being taken, since the alcohol is very in-
flammable. To prevent evaporation the jar is sealed
by being covered over with protective and then paraf-
fined. When required for use, the gut is cut in lengths
of 40 cm., wound on reels, and placed in 95 per cent,
alcohol, which is boiled in a water-bath just before
the operation.*

Silkworm gut is cut into lengths of 30 cm., doubled,

DRAINAGE.

27S

placed in tubes, and sterilized in the same manner as
silk ligatures. SilvLT wire is treated in the same way.

When working with any of these prepared ligatures,
thorough antiseptic precautions must be observed: the
hands must be carefully prepared, as if for an operation,
before touching them, and nothing which is not sterile
should be allowed to come in contact with them. This
is one of the instances where the nurse must be de-
pended upon to be absolutely accurate in the observ-
ance of the most minute details.

For drainage, rubber tubing of various sizes is used,
as are also strips of gauze and glass tubes. The gauze
should be cut " by drawn thread" into strips of about
a yard long and an inch wide, each of which is made
into a little roll : four or more of such rolls should be
enclosed in a glass tube and sterilized in the same way
and for the same length of time as silk ligatures. For
the same purpose strips of iodoform gauze should be
kept ready cut in proper widths. When using tubes
or gauze drainage at a dressing, all handling of them
should be avoided. They should always be handed
to the surgeon by means of a pair of sterilized for-
ceps. Rubber drainage-tubes are prepared by scrub-
bing them well with soap and water and rinsing
them in boiled water. They are then soaked in a
1 : lOOO bichloride solution for twenty-four hours, after
which they are placed in a carbolic-acid solution 1 : 30
for twenty-four hours, and finally kept in a 3 per cent,
carbolic-acid solution, which is to be changed weekly
or at least every ten days. Just before they are needed
they are boiled in soda solution. Glass tube.s are

2;6 .\UFS/NC.

boiled and kept in i : 20 carbolic-acid solution, and-l
washed off in alcohol before using.

Dressings are now-a-days chiefly furnished in the 1
form of rolls of gauze, common or absorbent cotton,
or pads. The gauze is probably used [iiost and should 1
always be kept ready, rolled in six-yard lengths, and
folded so as to have a width of about nine inches; |
pieces of any size required can then be readily cut
off Pads are made of various substances, such as J
pine-fibre, Virginia moss, or wood-wool, and may be |
of any size or shape according to the special require-
ments of each case. All forms of dressings must be |
sterilized for half an hour before being used.

Sometimes gauze is used as a medium for holding I
chemical sub.stances, such as iodoform or perman-
ganate of potassium. To make iodoformized gauze,

Take of

Salt-solution soapsuds, 6 ounces;

Iodoform powder. 10 drachms;

Sterilized gauze, 3 yards.

Mix thoroughly. Fold the gauze lengthwise with a
width of nine inches and dip into the mixture. Rub
the solution well into the meshes. When the gauze
is thoroughly impregnated, place it on a clean rubber
cloth and roll it up loosely. Keep in colored glass
jars.

Permanganate Gan~i\ — Plain gauze is cut into suit-
able lengths and sterilized for an hour, then dipped
into a .solution made with

Permanganate of potassium. lo grammes (grs. cl);
Hot water, i litre (Oij).

It is then rolled like the iodoform gauze, and kept in

a porcelain or dark jar. In preparing gauze the hands
should be sterilized as for operations.

Sponges are to be made of gauze, small squares
being cut and the corners folded in, so as to form
small round puffs.

Sea-sponges, when used, should be prepared by first
pounding them well to remove the sand, and then wash-
ing several times in water. Afterward they are soaked
in a saturated solution of permanganate of potassium,
decolorized in oxalic acid (sat. sol.) or dilute sulphuric
acid, and ag.iin washed thoroughly in warm water and
placed in a weak solution of hydrochloric acid (acid, hy-
drochloric, dil. .^ij, aqux ad Oj) for twenty-four hours.
They are then to be washed in water until the washings
are clear, placed in a bichloride solution i : looo for
twelve hours, and finally washed in hot water and kept
in a 3 per cent, solution of carbolic acid.

Besides these, a nurse may be expected to prepare
iodoformized glycerine or oil, and celloidin solution.
The two former are generally mixed in the proportion
of 5 parts of iodoform in lOO parts of glycerine or oil :

Iodoformized Glycerine.
Iodoform, 5 grammes (grs. Ixxv);

Glycerine. 100 cc. (Siij circa).

Mix and pl.irc in a wide-mouthed, thin glass flask, and
sterilize for one hour in the Arnold .steam sterilizer.

2; 8

plugging the flask afterward with sterilized <
When glycerine is used alone it is sterilized in the sani
manner. These solutions are used for injections intc
tuberculous joints and in preparing gauze packings.

Cdloidin Solution (bichloride i : 16,000).
Ether ( Squibb 's),

Absolute alcohol, HA. 200 cc.

Of a solution of bichloride of mercury (grm. I

dissolved in absolute alcohol 40 cc), t cc.

Mi.v, and add of Anthony's "snowy cotton" sufficient:!
to make the consistency that of simple syrup.

It is used chiefly for sealing wounds after abdominal J
sections.

For iodoform celloidin, the bichloride is omitted I
and 25 grammes of iodoform powder used instead;
the powder and alcohol are first mixed together, the
ether is then added, and finally the cotton.

The operating-room linen list calls for sheets, small
pillow-cases, towels for general purposes, small crash
towels for the ether cone, linen half-sheets, blankets ,
and rubber sheets. Some towels should always 1
kepi in a 1 : 1000 solution of bichloride of mercury. A
number of linen half-sheets are to be prepared in the
same way for spreading over the rubber which pro- j
tects the blanket covering the patient; for this
pose they are much more convenient than a number '
of towels. In addition, the nurse should see that the
white cotton suits worn by the surgeon are kept in re-
pair, and that clean ones arc ready on each operating
day. Her own dress should be of the same material.

THE OPERATING-ROOM. 279

made with plain waist, skirt and belt, and with the
sietvcs cut off just above the elbow.

The walls of the room, as well as the woodwork.
are to be brushed down once a week and washed fre-
quently ; the floor, if not tiled, may be paraffined, and
wiped up with a damp cloth and freshly rubbed after
the work on each operating day, Kverything should
be kept in perfect order and quite clean. The methods
here outlined are largely those used in the Johns Hop-
kins Hospital : every surgeon, however, has his own
preferences, and the nurse must of course carry out his
directions. Those given here are useful and may be
followed when no others are ordered.

In large general hospitals it is, as a rule, found neces-
sary to have two operating-rooms — one for genera! sur-
gery and another for gynaecology. When this is the
case, the technique of the two rooms may vary some-
what. In the latter, for instance, the supply of dress-
ings is confined to those required for this special work.
There should be a full supply of perineal and abdom-
inal bandages, other kinds being but rarely called for;
long stockings made of canton flannel should be made
to put on the patient during minor operations. For
nbdominal operations, the half linen sheet should be
made with an opening; down the middle long and wide
enough to allow of the exposure of the surface where
the incision is to be made. Sometimes squares of
sterilized gauze slit in the centre are used for this
purpose and thrown away after one operation, but the
sheet can be washed, and is tlicrcfore more economical,
and it also stays better in place ; besides, it covers a
larger area, and so fewer towels are required.

NL'XSING.

As an abdominal section may be done in either ope-
rating-room, we shall use it as an example of the steps
to be taken in actually preparing for an operation.

Preparations should be begun ^ good while befon;
the operation, so that everything may be in readiness
at the hour appointed. The temperature of the room
must be regulated either by means of the steam coil
or an open fire, so that it may be 80° F. at the time
of the operation. On the table should be placed a felt
pad sufficiently large to cover it; next to the pad (for
which, il necessary, a folded blanket may be substi-
tuted) comes some rubber sheeting, and over this,
again, a white sheet is spread. A small air-pillow or
one stuffed with hair is put where the head will rest.

The operating-room dress js first put on, then the
hands and arms are vigorously scrubbed with soap and
hot water, and after this the regular preparations are
begun. The instruments, ligatures, and dressings are
put in the sterilizer 1 the various basins for the solu-
tions and instruments are conveniently arranged on
extra tables round the operating table; the salt solu-
tion is heated in its flask over a Bunsen burner; large
granite-ware vessels of distilled water are put on to
heat; and then the hands arc again prepared, so that
the nurse may be ready to sponge a wound or assist
the surgeon in other ways in his manipulations. This
preparation is important, and consists in first scrub-
bing the hands and forearms for ten minutes with
warm water and borax soap or green soap, paying
particular attention to the finger-nails ; they are then
iiiiniersed in a saturated solution of permanganate of
potassium for one minute, subsequently decolorized

orized by ^H

PRIVATE OPERATIONS.

26T

b^ing soaked in a saturated solution of oxalic acid,
rinsed off in distilled water, and finally immersed in a
solution of I : lOOO bichloride of mercury for five min-
utes. Constant vigilance should afccr this be exercised
that nothing whatever is touched that is not sterile;
the assistant nurse or the orderly must be called upon
to do any lifting or carrying.

Just before the operation, the instruments are lifted
from the sterilizer into basins containing the solutions.
After the patient has been arranged on the table,
properly protected with blankets and rubber sheets,
only the parts to be operated upon being exposed, the
articles for final preparation should be handeii to the
surgeon by the assistant nurse. These consist of a
basin of warm water, green soap, and hand scrubbing-
brush, together with the permanganate-of-potassium
and oxalic-acid solutions: after the parts have been
treated with these, ether or 95 per cent, alcohol is
poured over the field of operation, which is finally
washed off with a 1 : 1000 bichloride solution. Plenty
of dry sterilized towels must be at hand, and basins
filled with towels previously sterilized and then soaked
in a 3 per cent, carbolic-acid solution will be required
to replace those in the proximity of the woimd, which
have become soiled during the operation.

To Prepare for an Operation in a Private House.
Of course difficulties will be met with in carrying
out antiseptic preparations for an operation in a pri-
vate house, which are never met with in a hospital, but
a well-trained nurse should be able to overcome the
majority of them with a little tact and ingenuity. A

f Z82

KUKSINC,

nurse should have at least a Si:m boim' ootkc. so that
sfae may have sufficient time to make ber prepaia-
tioos : she should select the room, if the surgeon has
not already (k>f>c -^o, n-ith a %-ieir to securing pn^icr
light for the operation. It must be coovenieot to Ibc
patient's bed-room, and caipets. bunging^, and all utK
neccssaiy furniture should be cleared out of it, the
walU brushed down, and the floor washed. If house-
bold vessels must be depended ujion. then all pitcbeis.
basins, and towels should be boiled for an hour in a 2
per cent solution of carbonate of soda or a 1 : 40 car-
bolic-acid solution. The table is usually the pine one
from the kilchtn, and must be scrubbed off with green
soap and hot water. Two or three smaller tables for
basins are needed, and if they must be protected they
may be covered with sterilized towels. These, together
with two or three plain chairs, are all the furniture
necessary. There .should be plenty of hot and cold
water, soap, and toweh. The cold water must first
have been boiled and then kept in a thoroughly
clean vessel. There should be plentj- of jars or paiLa
to receive the water that has been used. The surgeon
usually brings his own dressings and instruments, and
other details should be carried out according to his
dircction.s.

CHAPTER XVIII.

H/BMORRHAGES,

HEMORRHAGES might properly be classed under the 1
head of emergencies, as they very frequently occur
when least expected, and their treatment requires
prompt action coupled with presence of mind and
calmness. By word, sign, or look, a nurse should
never inform her patient that anything unusual or
dangerous has occurred : her manner should be quiet
and reassuring, though she should fully realize that
the bleeding must be controlled as quickly as possible.
and adapt her procedures to the necessities of each i

Hjemorrhage may be defined as the "escape of
blood from any part of the vascular system, with or
without rupture of the coats of the vessel." Haemor-
rhages are arterial, venous, or capillary, but in severe
cases the bleeding may be from all three sources at
once. When a ha;morrhage occurs in connection with
wounds, it is called traumatic (relating to a wound or
injury); when, however, it occurs as the result of a
diseased condition, and is not directly attributable to
violence, it is said to be spontaneous. The loss of
blood may present more or less danger according to
the size of the injured vessel and its distance from the
heart. Hemorrhages may be external or internal, and

284 NURSING.

are to be combated by local or constitutional treat-
ment, or by the two combined.

The nican^ by which the arrest of hemorrhage is
brought about are of two kinds: (1) natural and (2)
artificial.

Haemorrhage from any of the large arteries is always
serious, and, unless checked promptly, sometimes re-
sults fatally in a very short time. Arterial blood is
to be recognized by its bright red color and by the
fact that it comes out in spurts or jets corre'ipondine
in time to the contractions of the left ventricle, which
force the blood through the arteries.

A venous haimorrhagf differs from one which comes
from an artery, in that the blood is of a dark and pur-
plish color, and flows in a steady, slow stream ; it is
more easily controlled and les.s dangerous than an arte-
rial haemorrhage, unless a large vein has been severed.

In a capillar}' haimorrhage the bleeding comes from
the capillaries, which intcrvcnt between the end of the
arterioles on the one hand and the beginning of the
veins on the other. In this case there is no spurting
of the blood, but rather an oozing, which, however, at
times may be very troublesome to control.

The constitutional symptoms of a severe haemor-
rhage are well marked, and, where the bleeding is in-
ternal or comes from a wound covered by a large dress-
ing, they may be the first signs to apipear, and should
therefore be carefully watched for. The pulse, which
varies in frequency and tension according to the
amount of blood lo.st. will give us valuable information
as to the condition of the heart, and enable us to form
some idea of the imminence of the danger. Where

lf/EMOKRJ!AUE. 285

the hiemorrlinge has been severe, the h'ps have a pale,
drawn look, and the whole face is pallid and wears an
anxious expression ; the pupils are dilated ; there arc
signs of restlessness ; the body is bathed in a cold per-
spiration and the extremities are cold and clammy; tiie
nails and finger-tips look blue, and the respirations
gradually become weaker and shallower, until finally
they are sighing; the patient complains of dizziness;
the speech becomes thick and unintelligible, or may
even be entirely lost. These symptoms are followed
by unconsciousness, from which, if the loss of blood
has been very great, the patient is never aroused, but
dies in a state of collapse. Syncope is a desirable
condition if it comes on early enough, as the bleeding
ceases with it, and an opportunity is thus aflbrded for
the blood to coagulate, by which means the mouths of
the bleeding vessels are closed before the heart's action
regain'; its normal strength, Thf coagulum which
forms when the blood-current is slow and the bleed-
ing surface is exposed to the air, acts as a natural plug
at the ends of the ruptured vessels. In the case of a
vein, where there is no such propelling force to dis-
lodge the clot, the vessel, as a rule, quickly closes, but
in arterial hjEniorrhage the plug formed is liable to be
dislodged from the end of the artery with the next
heart-beat. Fortunately, however. Nature has pro-
vided for this, since the arterial walls have the power
to contract and retract, thus lessening the size of the
outlet and preventing the displacement of the clot.

In the arrest of hsemorrhage by natural mcan.s the
following factors are concerned:

J. Clotting of the blood ;

licart, sometimes showD ^^H

^m selves. ^^M

e is arrested by — ^^M

limb or part) ; ^H

bove the vessel, includ- ^^M

jptured vessel ; ^^H

r cold ^H

ir styptics, besides heat'^^f

2. A weakened action of tin

by fainting ;

3. Changes in the vessels themselves.
By artificial means hsemorrhage is arrested by-

1. Position (elevation of the limb or part)

2. Pressure directly on or above the vessel,

ing acuprcssun

3. Forcible flexion ;

4. Ligaturing or tying the ruptured vessel

5. The application of heal or cold

6. Cauterization;

7. The use of astringents or styptics, besides
and cold;

8. Torsion or twisting.

Pressure is of two kinds — provisional and perma-
nent. In provisional compression, tlii; finger is placed
on th:; bleeding point, or, if it is an artery that has
bten ruptured, just above it, and kept tbere until aid
comes. Permanent compression may be made by
mean.i of compresses and bandages fastened tightly
over the wound, or by the Esmarch rubber bandage,
or the tourniquet applied at any point in the line of
the artery between the wound and the heart tight
enough to stop, or at least to much impede, the cir-
culation.

Acupressure is now but rarely employed. This meth-
od is carried out by passing a pir. or needle through
the tissues over the artery, and again through the tis-
sues on the other side, thus making pressure on the
vessel. The pin is kept firmly in place by twisting
silk or a fine wire over the point and head of the pin
in the form of the figure 8. The pin is usually re-

HMMORRHAGE. 287

moved in six or ciyhl hours, aftur the clot has become
firm.

Ligatures are sometimes used in cases of accidental
haimorrhage, as well as for tying the ends of vessels
which havu been severed during operations. The
nurse should, therefore, have ready for the surgeoa,
when he arrives, artery forceps, scissors, sponges, lig-
atures, and so forth.

Cold is frequently employed, as it causes the arterial
walls to contract. Ice is the most convenient form in
which to apply it: sometimes douches of ice-water are
used, or cloths wrung out of ice-water and placed over
the bleeding part are sufficient where the hsmorrhage
is slight. An ice-bag half filled with pounded ice, laid
over the parts in the neighborhood of the bleeding
vessel, will sometimes serve the same purpose. Heat
is seldom applied except in the form of a very hot
douche for uterine hemorrhage, the temperature of
the water being from 115° to 120° F. The actual
cautery is, however, sometimes used during operations
to check oozing, especially in abdominal surgery.

Besides heat and cold, there are other styptics or
agents for the arrest of hemorrhage, which are ap-
plied either in powder or liquid form. Monsel's solu-
tion of iron is very efficient: it can be applied with
a camel's-hair brush or on a pledget of cotton or
gauze. Sometimes the powdered pcrchloride of iron
is thickly sprinkled over the bleeding point. Alum
and tannic acid are also well-known styptics, and in
an emergency vinegar or common salt often does good
service.

Torsion is performed by catching the end of the

783 JVU/fSWC.

vessel with the forceps and twisting it two or three
times.

Position, flexion, and rest are material aids in stop-
pin|^ bleeding, and where the haemorrhage is not very
extensive, elevation and perfect rest may be sufficient.
By elevating the limb or the part, the force of the
blood-current toward that point will be lessened, and
the amount of blood lost will be thus reduced. Thi.s
is something a nurse can always do at once. If the
bleeding be from the abdomen, the foot of the bed is
lifted on to a low table or placed on two chairs, stools,
or bricks according to the height desired. If it be
from the leg, this should also be supported in an ele-
vated position by pillows or by some other device. If
it be from the forearm or hand, the part is to be raised
above the head, or flexion of the forearm on the arm
will often answer. A firm pad is put in the hollow of
the elbow, and the forearm is bent tightly against the
arm and held in place by a stout bandage. If the haem-
orrhage comes from the leg or foot, the thigh is flexed
upon the abdomen and the leg upon the thigh, and
held finnly in this position as long as is necessar\-.

Rest during and after hsemorrliage should be main-
tained, as any movement will increa.se the heart's
action and thus augment the flow of blood, or where
the bleeding has stopped it may bring it on again by
displacing the blood-clot which is forming or has
already formed at the mouth of the vessel.

Traumatic ha.-morrhages are classed as (i) primary,
and (2) secondary. Primary hemorrhage is that
which occurs at the time of the iojury or operation.
Secondary hemorrhage may occur at any time from

HAEMORRHAGE.

twelve hours up to ten days or two weeks afler the
operation or injury. It may be due to the slipping of
a ligature or to the separation of stoughs. After aq
amputation or a serious operation of any kind, where J
many large arteries have been severed, a constant watch
should be kept for haemorrhage during the first forty-
eight hours. A little oozing does not necessarily mean
a serious ha;morrhage, but if the stain on the dressing
continues to grow larger and is of a bright-red color,
instead of becoming paler, then haemorrhage is taking
place, and the nurse must decide for herself whether
or not the surgeon should be summoned at once. If
she is doubtful, it is alway.s better to be on the safe
side. The pulse is probably the best guide, and in a
case of severe haemorrhage the dressings may have to
be removed and the vessel tied. The nurse herself
should never leave a patient who is having a hemor-
rhage, but should send some one else at once for the
surgeon, and in the mean time she should do what she
can to control the bleeding by first making pressure
over the bleeding point or in the line of tlie main
artery leading to it. The part should be kept elevated,
and. later on, permanent compression can be applied by
means of an improvised tourniquet. This is made by
placing a firm pad, such as a roller bandage, over the
wound or just above it in the course of the arterj', and
then tying a bandage or a handkerchief, folded diag-
onally, loosely around the limb; a short stick is next
slipped under the knot above the compress, by the help
of which the bandage can be twisted as tightly as we

Afier tiic li.Kinurrhai^e has ceased, it is sometimes

-r "■

we ^H

ago /fUJiSif/G.

oecessaiy in order to keep up the required blood-supply
to the brain and respiratory cenires, to lessen the
amount in the extremities by banda^ng them either
with F.smarch's rubber bandage or by ordinary band-
ages tightly apphed,*

Whiskt-y or brandy is given, and heat apphed exter
nally after the ha;niorrhage has ceased. The patient
should be kept quite free from excitement and in
ignorance of the amount of the bleeding or the degree
of the danger to which he has been exposed. The re-
sponsibility of giving the patient information on either
of these points rests entirely with the doctor, not with
the nurse.

Haanaturia, or blood in the urine, may have its
origin in the kidneys, ureters, bladder, or urethra.
If the blood be from the kidneys, it will be diffused
throughout the urine, giving to the whole amount a
uniform reddish color. Hiemorrhage from the ureters
most frequently results from the passage of a renal
calculus which has torn the mucous membrane. When
the bladder is the source of the bleeding, most of the
blood comes away at the end of micturition in small
clots, and one does not see the intimate admixture of
blood and urine which occurs in renal haemorrhage.
When the haemorrhage is from the urethra, the blood
precedes the flow of urine. These conditions should
be noted by the nurse and reported, and it may be laid
down as a general rule that when an evacuation of an
unusual nature comes from any internal organ, it .should
be kept for the inspection of the physician.

li[>htaxis , or nose-bleed, is a very frt^qucnt form of
hemorrhage which is rarely dan^LTo'!^ ; it may. Ii

•SKAppcnlii, NdKh.

HMMOHRHAGE. 29I

ever, be difficult to check. The onset is not infre-
quently preceded by a sense of fulness in the head,
accompanied by more or less vertigo. The chin
should be kept elevated and the head not allowed
to drop forward, as it is so often allowed to do.
If the bleeding is from only one nostril, the arm on
that side ts to be elevated and ice-water or ice
applied to the back of the neck and forehead. Ice-
water or strong salt solution {i drachm of salt to 4
ounces of water) may be injected; finally, where all
other methods fail, the nares must be plugged. A
small soft rubber catheter, a piece of linen thread, or
cord, and a small roll of lint or a sponge are needed.
The thread if passed through the eye of the catheter,
and the catheter introduced through the nostril into
the throat : the string is then caught with forceps and
drawn out of the mouth, so that the plug or sponge
can be attached ; the catheter is then withdrawn from
the nose and the pledget pulled into position. The
two ends which come from the nostril are tied over a
second plug which fills the opening. It is usual to
have the string long enough, so that after tying around
the sponge we can leave an end to come out through
the mouth on to the cheek, where it may be fastened
with a bit of adhesive plaster. This facilitates the re-
moval of the plug. The nurse is seldom called upon
to adopt these measures, as the procedure is at times
quite a difficult one, requiring the experience of the
sui^eon. and the foregoing description has been in-
serted here chiefly that everything, which may possi-
bly be required 111. ly be ready in case of necessity.
Bcckymoscs arc due to extravasations of blood from

^'URSING.

a small vessel into the surrounding cellular tissue, and
chiefly follow blows and contusions.

To pack the rectum for h=emorrhage a piece of
gauze or lint is inserted, pressure being applied at the
centre, so as to make a sort of bag which is packed
with cotton, strips of gauze, or compressed sponges,
the ends of the bag being allowed to project from the
anal orifice. Within the sphincter the rectum forms
quite a large natural pouch, which requires a consider-
able mass to fill it. This arrangement of the pack-
ing makes its removal easy when it is no longer
needed.

Uterine haemorrhage may occur from many causes —
C. g. during pregnancy or after delivery, in various
pelvic diseases, or as a consequence of operations.
Those occurring previous to labor are called ante-
partum haemorrhages. The patient should be at once
put to bed. kept perfectly quiet, and the physician sent
for. Post-partum hiemorrhage will be considered in
the chapter on Obstetrics.

Hfemorrhage from the genital tract after gyneco-
logical operations may usually be controlled at once
by packing the vagina. Strips of gauze are prepared,
the necessary instruments are sterilized, and the pack-
ing is done by the surgeon : until his arrival the nurse
may give hot douches, as hot as 1 1 5 ° to 1 20° F. ; the
foot of the bed is to be elevated, and the patient kept
quiet. If the bleeding be profuse and the ser\'ices of
a physician cannot be obtained, no valuable time should
be lost, and the nurse mu.st undertake the packing her-
self

When a patient has fainted after a profuse hxnior-

HMMORRHACE.

rhagc. the head is to be lowered, but no stimulants or
hypodermics are to be given without a direct order
from the surgeon, since they increase the force and
frequency of the heart's beat and tend to dislodge the
clots, which may be forming at the mouth of the
bleeding vessels. In rare instances, and where there
is danger of collapse, the surgeon may think it best to
order stimulants as being the lesser of two evils.

Arterial harmorrhage, as we said, is best arrested
by pressure or by ligature. If the artery is imbedded
deeply in the tissues and cannot be reached with the
fingers, a graduated compress of gauze or lint is packed
firmly into the wound and held in place by a bandage.
The amount of haemorrhage from an artery will depend
upon its size and the manner in which it has been cut.
An incised wound or one caused by a sharp instru-
ment bleeds more than one made with a blunt instru-
ment, where we have a contused or lacerated wound,
because the ragged edges of the torn artery and sur-
rounding tissues retard the escape of the blood, so
that clots tend to form more quickly.

To be able to control harmorrhatre from arteries by
pressure it is necessary to know the location of the
principal arteries and how to reach them. The student
nurse is expected to familiarize herself with the larger
arteries during her study of anatomy, and with the
manner of compressing them: the latter can only be
learned by practising the methods after they have
been demonstrated.

Venous hremorrhage is arrested by pressure below
the wound — that is, on the side distant from the heart.
Lai^ veins, like the jugular, should be compressed

NURSING.

both above and below the wound. This is necessary
for two reasons: first, because the vein may bleed (rom
both ends; and secondly, because | what is held by many
to be even more dangerous) air niay enter at the prox-
imal end and cause sudden death. Unless it be a
large vessel which has been ruptured, the danger from
a bleeding vein is not so alarming as that from the
rupture of an artery of the same size, and compres-
sion will usually suffice to check the hemorrhage.
When varicose veins of the leg rupture, the limb
should be elevated in addition to making compres-
sion.

To control bleeding from the capillaries the wound
should be exposed to the air, the part, if possible, ele-
vated, and compression made. This is not a danger-
ous form of bleeding, but is sometimes troublesome to
control.

A hjemorrhagic diathesis is a predisposition to
ha;morrhage caused by an abnormality in the struc-
ture of the walls of the vessels: in persons who have
inherited this abnormality, the slightest wound may
result in fatal bleeding. Sometimes one will
whole families of these " bleeders."

Nur-ses may meet with bleeding from the umbilicus
in new-born infants: powdered perchloride of iron or
alum may be applied.

Internal haimorrhages may result from various
causes : the most common ones are those from the
lungs, stomach, intestines, and pelvic organs.

The blood in hemoptysis, or bleeding from the
lungs, is characterised by its bright-red color and the
frothy appearance which it has from being mixed with

I
I

H.-EMORKIIAGE. 295

air-bubbles ; a >pasm of coutjhiiig usually precedes it.
If the bleeding is slight, there may be some doubt
whether it is from the lungs or not. since it may
have come from the mouth or throat. This symptom
is always more or less grave, but unless large blood-
vessels are involved it is not necessarily dangerous.
The patient should at once be placed in the recum-
bent position and kept perfectly quiet and free from
excitement. Small pieces of cracked ice maybe swal-
lowed whole or allowed to dissolve in the mouth, and
a light ice-bag should be laid over the chest. The
patient must be warned not to speak or to attempt
to swallow food, since even these movements may
increase the hsemorrhage. The physician should be
called at once, and he will probably, if the haemor-
rhage be marked, order a dose of morphine.

Hamalfincds means the vomiting of blood. The
blood is generally dark red in color, often resembling
coffee-grounds, and is mixed with particles of food.
The patient should lie down and keep quiet; if the
bleeding continue, bits of ice may be given, and ice-
water compresses or an ice-bag applied over the
stomach. The nurse should try and make sure that
the blood has not originally come from the nose and
been swallowed and afterward vomited.

Haemorrhage from the intestines, or enterorrhagia,
may come from various causes, frequently from ul-
ceration of the coats of the intestine, as in typhoid
fever, in dysentery, acute or chronic, from internal
haemorrhoids, or from carcinoma of the intestine.
Cold in the form of cold-water injections or a piece
of ice introduced into the recturt), ice-cloths tjr an_

296 NURSING.

ice-bag applied to the abdomen, are sometimes or-
dered, with elevation of the foot of the bed and per-
fect rest. Ergot is of no value, but the physician may
order opium, not only to control the peristaltic action
of the intestines, but to allay the pain (if any be pres-
ent), and also quiet ti : patient.

CHAPTER XIX.

Bandages. — Surgical Emergknciks, — Shock. — Fractukes. —
SUKcicAL Appliances. — Dislocations. — Sprains. — Contus-
ions.— Burks and Scalds. — Frost-bite. — Forkign Bonos IM
THE Eyes, Nose, Ears and Larynx.

The principles of bandaging, the variety of bandages,
and indications for applying any particular form may
be taught theoretically, but only a great deal of prac-
tice will enable a nurse to become expert in bandaging,
A beginner must not set out with the idea that the first
essential in applying a bandage is to have it look well.
The chief points to be taken into consideration in band-
aging are—

!. The object of the bandage ;

2. The kind of bandage and the materia! of which it

is made ;

3. The part of tlie body to which it is to be applied;

4. The best method of applying it.

Bandages are used in surgery to Weep dressings and
applications in place, to make compression, to prevent
motion, and to act as a support and protection. They
are made of different materials according to the use
to which they arc put. For hospitals, the substances
chiefly in use are surgical gauze, bleached or un-
bleached muslin, flannel, and rubber. For private
practice it may be sometimes more convenient to use
old linen or muslin. These bandages vary greatly in

I
I

V 398

AUXS/A-G.

the matter of pliability: the unbleached mushn, for'i
instance, is not so adjust^iblc and does not he
snugly as j;auze or flannel, and therefore more skill is
required to apply a muslin bandagu. so that it will stay
in place, and while being comfortable may also look
well, than \* h(.n gau7.e is employed. When we have a
bandage to put on, we must always take into consid-
L-ration the part of the body to be covered This is
portant. not only because it will influence us in our
choice of the bandage, but because we must always
have some idea of the degree of pressure that will be
comfortable, since some parts are more elastic than
others. Any excessive tightness should be avoided,
though allowance must be made for some loosening
of tile bandage later, caused by the moving about of
the patient. The maintenance of an even pressure,
sufficient firmness, and comfort should always be kept
in mind. We shall stand convicted of a disregard of
this rule if when a bandage is removed from an arm,
fcfr instance, the flesh of the arm lies here and there in
little ridges separated by distances which just corre-
spond to the width of the bandage ; for the presence of
these show that the compression has not been made
evenly, and that the bandage has been in some places
perhaps uncomfortably tight and in others too loose.

Bandages are classified as simple and compound, the
former being made of one piece, the latter of two or
more pieces. The roller bandage is made in six, eight,
and twelve-yard lengths and of various widths. As
gauze stretches more and is less bulky, bandages of
this material should be made both wider and longer
than the muslin bandages used for the same purpose.

BANDAGES.

299

The average widths of muslin bandages arc about
as follows ;

For a finger, i inch ;

For the arm or head, 2j^ inches ;

For the leg. 3 to 4 inches;

For the body. 6 to 8 inches.

Gauzi; bandages for the head, arm, or leg are made
3j/ inches wide;

For the fingers, i ^/i inches ;

For the body or for large dressings, 6, 8, or 9 inches.

Muslin bandages arc to be torn, and, the ravellings
from the sides having been removed, are to be wound
tightly and evenly either by hand or on a bandage
roller. The end of a piece of muslin with the stamp
of the maker in blue letters should never be used,
unless it has been first washed, and a bandage should
not be handed to the surgeon with ravellings of
thread hanging from it. Some gauzes can be torn
when wet, and rolled after they have been allowed to
dry. but. as a rule, gauze bandages have to be cut.
Usually a thread is drawn out as a guide to follow
in cutting out each bandage, which is then rolled by
itself; but where very many are used this procedure
takes too long, and, although bandages made in this
way do not look quite so neat, a broad piece of gauze
may be rolled on a large roller and then cut with a
.sharp knife into the requisite widths. For the wider
bandages, such as the 7-inch and 8-inch widths, and
for those which must be wetted, and for plaster-of-
Paris bandages, it has been found very convenient
to roll them on small round hard-wood sticks about
three-eighths of an inch in diameter: this prevents

XL'PS/.VG.

them from doubling up and makes them
to apply.

Flannel bandages when used to reduce swelling
cedcnia are best cut on the bias, as made in this way
they will be more elastic and it will be
possible to make firmer pressure. The
rubber bandage is used to control hscm
orrhage. for varicose veins, or for re-
ducing swelling. For holding dress-
ings or applications in place on a limb
the simple roller is used, and should
be put on firmly enough to prevent
the dressing from slipping: the ten-
sion should be uniform throughout
the course of the bandage. The spiral
:\n6 Jigiire-ofS 3i.n: the forms used for
bandaging the limbs. The bandage
should always be put on from the ex-
tremity of the limb toward the trunk.
It should be held firmly in one hand,
HBBL-Rmjo- Baku- _^|,j applied with the outer surface
next to the skin, and as it is unwound
the roller should be held close to the part. The band-
aging of the leg of a patient who is sitting is much facil-
itated by using a heel-rest (Fig. l6).

The single and double recurrent bandage (or cape-
hnc) and the fgurc-o/S atc used for the head. The
Barton bandage is employed to keep the jaw in place.
A recurrent bandage is also the one generally used
for the stump after an amputation. For the axilla,
shoulder, or groin the spica (either double or single)
is used. For a fractured clavicle the Velpeau or

re easy^^^l

BANDAGES.

30t

Desaults is employed. T^ic fiffure-ofS is particularly
adapted for applying to the breasts, and for the abdo-
men some modified form of the bandage of Scultetus
is largely used. The T-bandage keeps dressings in
place on the perineum. Bandages intended to pre-
vent all motion are usually made of plaster of Paris,
starch, or crinoline, and of these the plaster-of- Paris
bandage is the most frequently used. To make plas-
ter-ol-Paris bandages it is necessary to have the plas-
ter of an extra fine quality, without any lumps in it.
and to select either crinoline or gauze, since the
meshes of these substances are large, retain the plas-
ter well, and are readily moistened. The dry plaster
IS to be spread evenly on the gauze with a knife and
smoothed over it by means of a tightly-rolled Flannel
bandage, and as the plaster is rubbed in, the banda<;e
IS rolled loosely on a small round stick. When fin-
ished they are wrapped in paper, and kept in a tin box
away from the air and moisture, though at best they
are apt to deteriorate soon. Such bandages are much
used in fracture cases. When they are to be applied,
the limb is first bathed and powdered, then wrapped
in folds of gauze, or, better still, covered with rolls of
sheet cotton of a sufficient thickness to protect the
skin from the plaster. In.-^tead of gauze or sheet cot-
ton cut into strips, a flannel bandage is sometimes
used, but it is liable to be unpleasantly warm and may
cause irritation. A basin of warm water, a can of plas-
ter, salt, and large rubber sheets to protect the bed
and floor, are required. The plaster bandages are put
into the water and allowed to remain till the little bub-
bles of air cease to rise. This is a sign that they are

302 NURSING.

thoroughly soaked, and they should now be wrung out
moderately tightly. For the foot and leg the surgeons
usually begin by putting on two 4-inch bandages, and
then for the thicker parts of the leg and thigh two 6
inches and one 7 inches wide. After the bandages nave
been applied some plaster is stirred into the basin of
water until the consistency is that of thick cream, and
this is rubbed smoothly over the whole dressing. The
addition of salt to the water in the proportion of about
two drachms of salt to a quart of water will materially
hasten the hardening of the plaster ; but this is not
always used, for frequently the difficulty is to keep the
plaster from hardening; too rapidly. When it is neces-
sary to remove a plaster bandage it should be cut ofi"
with a stout sharp knife or scissors, and the process
will be found less difficult if the line of incision from
time to time be moi.stened with dilute hydrochloric
acid from a medicine-dropper.

Crinoline bandages are used to keep dressings im-
movable; they should be rolled on sticks, wetted in
warm water, and not too tightly wrung out, just before
being used. To make them even stiffer, .starch is
sometimes incorporated into the crinoline. The starch
should be boiled as for laundry use, the crinoline band-
age dipped into it, wrung out, and applied. Such a
bandage should be exposed to the air until dry: hot
cans placed about it will hasten the process.

In addition to the spiral and figiire-ofS bandages
and their various modifications, we must speak of the
triangular bandage, which is rarely employed in hos-
pital practice except as a sling, but is very serviceable
in surgical emergencies, as it can be more readily

imprc

BANDAGING.

tiiX than any other kind. Two opposite c
of a large square of strong muslin measuring a yard
or 40 inches each way are brought together, and the
square cut into two equal triangular pieces. These
bandages are u.sL-d for the same purposes as the roller
bandage — namely, to keep dressings in place, to fix
splints, and for protection and support. A large un-
cut handkerchief can be made to answer as well.
The various methods of applying the triangular
bandage are fully demonstrated in the ordinary
books on bandaging.

Where small dressings are to be put on or e
cations are to be held in place, and a bandage would
be too large or cumbersome, strips of rubber adhesive
plaster are used. Splints on arms or legs are some-
times held in place by thi.s means, and in cases of
fractured ribs, where the movements of the injured
side are to be restricted, straps of rubber plaster are
applied halfway round the chest, thus dispensing with
the necessity of having a bandage. The rubber adhe-
sive plaster is very convenient, as it is always ready,
and needs no special preparation beyond being torn
into the required widths and lengths and then rolled
on glass rods. When rubber plaster is to be removed,
it should first be soaked with alcohol, which loosens it
somewhat and renders the process less painful, Any
remains of the rubber adhering to the skin can be
easily washed off with alcohol or ether.

For practising bandaging the best opportunities arc
afforded by minor surgery cases in dispensary work, to
which the nurses are usually detailed in turns as assist-
ants. In connection with this, a good book on band-

304 NUJfS/A'C.

aging, in which the various steps arc all carefully
demonstrated, should be obtained, and the methods
studied out and practised on fellow-nurses and patients
until the requisite skill is acquired ; but it must be re-
membered that it is not so necessary to keep to a pre-
scribed figure as to have the bandage put on smoothly,
firmly, and evenly.

Next to that of the physician, the presence of a
trained nurse should be most valuable at the time of
an emergency. While others are standing shocked
and helpless, her presence of mind will not desert her,
and she will at once suggest the right thing to do, and
will proceed to do it in a cool and collected manner.
The example she sets, in keeping her own nerves well
under control, will go far toward steadying those about
her and making them of .some help to her. An emer-
gency may be of greater or less importance: if it be
only a minor accident, a nurse may be able to do alt
that is necessary for the time being, but in any case,
except it be veiy trivial, medical aid should be sum-
moned at once, and if possible this should be done in
writing, so that the surgeon may know what to expect
and may be enabled to save time by bringing with him
whatever is neces.sary. So much will depend upon the
nature of the emergency that only general rules can be
given, and a nurse must be guided by these, together
with the result of her own experience. If a haemor-
rhage should be the worst symptom of an injury, it
should be controlled at once before anything else is
done, and if the patient is in a condition of shock,
steps should be taken to revive him.

By " shock " we mean a gener^ depression of the

SHOCK. 305

whole system produced in some obscure way which
IS at present imperfectly understood. This condition
occurs after severe frights, accidents, and operations,
or may be brought about by some strong emotion.
"Collapse" and "prostration" are used to express
similar conditions. Symptoms of shock should always
be watched for after slight as well as after grave
injuries. It is always the safest plan to keep a patient
quiet for a time after any kind of injury, and the pulse
should be taken at intervals, because sometimes changes
in it may be recugnized when no other symptoms are
apparent. Tiie symptoms to be looked for in shock
.ire a weak, rapid pulse, a subnormal temperature, a
cold skin, pallor, a pinched look of the face and about
the lips, feeble or sighing respiration, and sometimes
nausea. The patient must be placed with his head
low. and stimulated by being enveloped in blankets,
while hot-water bags, bottles, or cans are placed along
his sides, between the legs, and to his feet, the effects
of these being supplemented by friction and by the
use of whiskey or brandy internally. If the patient is
uncon.-^cidus, these may be given hypodermicalh'.
When they can be administered by the mouth, a tea-
spoonful may be given in half an ounce of hot water
every ten or fifteen minutes. Strong hot tea or coffee
are also valuable stimulants. An electric battery
.should be ready for use, as a surgeon sometimes asks
for it; and ether and a solution of strychnine may also
be required.*

If the injury be to the head, alcoholic stimulants are
generally contraindicated, and should never be given
without a special order.

Fractures, — Fractures are very frequent
gencies, but when unaccompanied by a wound they
do not, as a rule, require the same degree of haste as
cases of haemorrhage. The first thing to be done is
to place the fractured part in as comfortable a position
as possible for the time being; then the clothing is
gently removed, the seams being ripped rather than
cut, beginning with the uninjured side first. A frac-
tured limb must be handled as little as possible, as
there is always danger of injuring the surrounding
tissues or of lacerating blood-vessels with the sharp
points or fragments of the broken ends. In raising a
fractured limb one should never take hold of it from
above, but should slip the hands underneath, and.
taking firm but gentle hold at two points a short
distance from the fracture on each side, and all the
while making slight extension with the hand on
the distal side, so as to keep the ends from rubbing
together, should lift: with both hand,'; at the same time
slowly and evenly until the limb is in the position re-
quired.

Fractures maybe recognized by the following signs,
some of which, however, belong to dislocations as well :

1. Pain;

2. Inability of the patient to move the limb naturally ;

3. Deformity or displacement, either seen or felt by

passing the fingers over the seat of pain ;

4. Crepitus, the grating sensation felt on rubbing the

broken ends together ;

5. Abnormal mobility in the course of a bone;

6. Swelling and discoloration.

Fractures are classified according to the nature and

FRACTURES.

extent of the break and of the accompanying injuries.
A fracture is said to be simple or compUk where the
entire continuity of the bone is severed with but httle
injurj' to the surrounding parts; it is called a com-
pound fracture if not only the bone is broken, but a
wound is made which extends from the scat of frac-
ture to the outside. Such wounds may be caused by
the injurj' itself or may occur secondarily from the
protrusion of pieces of bone through the skin.

A coniminntcd fracture is one in which the bone is
shattered into a number of fragments. The term
impacted fracture signifies that the broken ends have
been forcibly driven into one another, and arc thus
fixed.

Fractures may be miiltipli: — i. £. where the bone is I
fractured at two or more different points or where dif-
ferent bones are broken.

A complicated fracture is one associated with a seri-
ous injury to some important adjacent part — e. g. a
large vessel.

A green-stick or incomplete fracture occurs where
the bone is soft and bends, and is only partially frac-
tured; it is most frequent in children.

Fractures ai-e also described as transverse, oblique, or
longitudinal according to the direction of the break.

The process of repair of fractured bones, while not
coming directly into a nurse's work, is one of very
great interest. At the time of the fracture and for a
little while after, much blood is poured out in close
proximity to the injury; this subsequently coagulates,
and forms a framework upon which new tissue-cells
may grow and divide. New blood-vessels enter, lime

[

Son

NURSING.

salts are dqjosited, and in a few days the so-called
callus is formed. The quieter the ends of the bones
are kept, the less will be the amount of callus. This
first callus has for its chief function the keeping of the
ends of the bones at perfect rest until they become
firmly united. The union of bone requires from four
to six weeks, and then the provisional callus becomes
in part absorbed. Still, the injured part is somewhat
weak, and is not to be depended upon too much, and
care should be exercised for another month, while for
the process to be thoroughly complete from six months
to a year are needed.

In considering the treatment of fractures, we shall
first speak of the care of the patient when he has to be
moved some distance before tile part can be properly
attended to. The principal point to bear in mind is to
keep the fractured part immovable, and in such a posi-
tion that it may give as little pain to the patient as pos-
sible ; and if this be done, there need be no hurry about
having the fracture set at once. The limb should be
supported with something stiff and smooth, such as
thin, narrow pieces of board or shingles, stout paste-
board, or the bark of trees, padded with something
soft, such as cotton, wool, hay, straw, or leaves, which
can be held in place by triangular bandages made
of handkerchiefs or by strips of linen, muslin, ribbon,
or whatever is at hand. For the forearm two padded
splints, long enough to take in the hand also, should
be applied, one to the front and the other to the back
of the limb, slight extension being made by pulling
gently on the patient's hand. The splints should be
tied on in two or three places, and the whole forearm

brcarm ^^|

FAACTURES.

309

suspended in a sUng which should reach from the
finger-tips to beyond the elbow. If it be the upper
arm that is broken, it may be bound tightly to the
side. For a fractured leg slight extension should be
made from the foot, and the leg lifted ou to a pillow
which is tied firmly about it, or broad strips of wood .
may be padded and placed oni: on either side of the
leg and tied securely. If tlie thigh is fractured, the
splint should extend from under the arm to the
ankle, being bound to the body and to the leg by
means of long towels or pieces of sheeting applied
at intervals.

For a fractured clavicle or collar-bone the patient is
to be placed flat on the back, and when moving him a
firm pad should be introduced into thi.' axilla, and the
arm bound to the side, with the forearm flexed across
the chest; this will prevent the broken ends of the
clavicle from rubbing together.

For fractured ribs a broad body bandage applied
tightly, so as to prevent motion and deep breathing,
is all that can be done besides keeping the patient
quiet. The chief danger in the case of a fractured
rib is that one of the sharp ends of the bone may
pierce the pleura or the lung.

For a fractured jaw the teeth should be closed upon
one another and a Barton bandage applied. Food
should be given with a spoon or through a tube
placed behind the last molar tooth.

Pott's and Colles' fractures are named after the sur-
geons who first described them. The Colics' fracture
is a fracture of the lower end of the radius within
about an inch of the wrist-Joint. A Pott's fracture is

|(0 NURSIfiG.

on? in which the fibula is broken about an inch
rt liiiif iibdvo the malleolus. It is accompanied by
liirnlllu nf the foot outward, owing either to ruptui
III lln- inlrrnal lateral ligament or to the breaking
III llii' Up of tho internal malleolus.

I'nu'tiin^n of the skull are dangerous in proportion
tti Ihf injury to the brain resulting fron' them, and
I'tiFrliri)! aytnptoms .should be watched for. Little can
|iii ilutui l>y the tuirsc except to keep the patient in a
i|nlnl. iliirk rnoni, with cold applications to the head:
nil ainunUDK are to be administered, but the surgcoo
nliHlilil III' Ncnl for at once.

ill" Wound of a compound fracture must be treated
iillll'o^plii idly. If there be much swelling about a frac-
llll^, III ivducc it lead-and-opium lotion or fomenta-
llnH* t\rv "ometimes ordered. After the swelling has
ntltinliti'il, \\ ]y.'rmnnent dressing is usually put on. Be-
liih' Hpl'lyin); this dressing the bones are placed ia
|||i' iiiitnMl position by manipulation, and displace-
nii'lll It prevented by renduriiig the parts immov-
rihk'

To he able properly to assist the surgeon in the
pullini: up of fractures, the nurse must be familiar
with tile ncccs.sary appliances, including splints and
Ihii ilifTcrcnt kinds of apparatus for making extension.
^pIlnlH arc made of many different materials. Wood
Mlul plaster arc considered the best and are most gen-
bT'llly UHcd, although for certain cases leather, wire,
iir splintii made of hard rubber are better.

W'li'di'n splints are madeof varying thicknesses and
il^i - , white pine, pojilar, and willow are best adapted
flit ihin purpose. Before being used, the splint should

SPL/NTS 311

be well padded with cotton-wool, or layers of gauze
may be strapped to it in two or three places with
strips of adhesive plaster. The splints should be
long enough to include the joints above and below
the fracture, and are held in place with bandages,
which in turn are frequently covered by one made
of crinoline. Splints are spoken of as anterior, pos-
terior, and lateral; we have also straight, angular,
and curved splints.

Whalebone or strips of gutta-percha ol varioua
widths are sometimes padded and placed in dressings
to give them additional firmness and strength.

For fractures of the leg between the knee and ankle
the plaster-of Paris splint is used very often as a per-
manent dressing. For fractures of the femur it
generally necessary to employ some means by which
constant traction upon the leg can be kept up, in order
to overcome the contraction of the muscles, which tends
to displace the two ends of the fractured bone. One
means of applying this is by the use of Buck's e:
tension app.u'atus, of which several modifications have
been introduced. The materials required for this ex-
tension are moleskin adhesive straps, bandages,
modified Volkmann slide, the combined bed-cradle
with pulleys, weights, and blocks for elevating the
foot of the bed, so as to obtain counter-extension by
utilizing the body-weight. These appliances the nurse
should have ready when the surgeon comes to put
up the fracture. The straps should be cut as in
Fig. 17, and slipped through the small cross-bar of
wood ; each strap should be two inches wide, and long
enough to extend up the side of the leg and to incluo;:

mjltSING.

at least the lower third of the thigh. The entire
should also be prepared by being shaved and
bathed. The straps may be heated for application by
holding them over an alcohol flame or by pressing the

'c limb ^^H

freshly ^H

non-adhesive side of the strapping against a hot-water
can just before they are to be used.

Where the movement of a limb is to be restricted,
sand-bags are used: they are made of ticking of dif-
ferent Jenpths and covered with rubber sheeting.

Dislocations. — A dislocation is the displacement
of one or more of the bones of a Joint. A disloca-
tion may be simple, complete, compound, or compli-
cated.

A simple dislocation is one in which displacement
has taken place, with a minimum of injury to the
surrounding tissues.

It is complete where the bones which enter into the
formation of the joint are entirely separated from each
other.

In a compound dislocation the tissues and skin are
torn apart, as in compound fractures. Besides these,
the terms recent and old arc used ; in the lattt-T. inflam-
matory changes have, as a rule, taken place, which

DISLOCATIONS. 3r3 '

interfere with reduction, A dislocated joint will pre-
sent a deformed appearance, and the displaced bone
will form a projection near by. Dislocations are
very painful accidents, and in most cases there is lit-
tle that a nurse can do beyond supporting the part
and applying cold applications to keep the inflam-
mation in check until the surgeon arrives. Simple
dislocations arc usually reduced by manipulation or by
extension ; where there is much muscular resistance,
chloroform or ether is given to complete anesthesia.*
When a dislocation has been reduced, the part should
be supported with bandages until the relaxed or torn
ligaments become firm and strong again. A dislo-
cated jaw may be reduced by protecting the thumbs
well, and then placing them in the mouth on the lower
molar teeth on each side, and pressing firmly down-
ward and backward, when the bones will slip into
place.

Sprains or wrenches of joints are caused by a twist
or by a blow which may be direct or indirect; the
injury consists in the rupture of a greater or less
number of the fibres of the ligaments. The symp-
toms are severe pain, inability to use the joint, dis-
coloration from effusion of blood, swelling and heat.

For nimor sprains the treatment consists in giving
rest to prevent increase of the inflammation, elevat-
ing the limb to lessen the blood supply, and in
the use of hot applications, or cold evaporating
lotions to the swollen part, massage and support
with a pad and a firm bandage between times.
Where there is not much swelling a plaster-of-Paris
bandage is sometimes applied in order to secure abso-
lute rest Lead -and -opium lotion is frequently ordered.

314 NURSING.

Gauze may be soaked in it and applied to the part
being covered wilh oiled silk to prevent evaporation.

Strictly speaking, a scald is an injury to the tissues
produced by contact with moist heat, whereas a bum
is caused by dry heat. Bums are classified as of the
first, second, and third degree respectively, according
to the depth to which the tissues are involved. This
classification, however, does not teach us much, as a
bum of any degree may prove fatal through shock if
a lai^e surface of the body has been injured. A super-
ficial burn, for instance, involving a third of the body,
more especially if the patient be a young child, will
almost certainly prove fatal, while a very deep bum.
provided it be localized, may not be so serious, un-
less important -nerves or vessels have been destroyed.
Where symptoms of shock are present, constitutional
treatment should at once be instituted, as the danger
to life is great.

A burn of the first degree is one in which only the
superficial layer of the skin is reddened with slight
vesication; bums of the second degree extend through
the true skin; while in those of the third degree the
injury goes beyond the subcutaneous and involves
the deeper tissues.

After treatment of the shock, the next important
thing to remember is to exclude the air, as this will
tend much to allay the pain. In superficial burn.';,
where the akin is not broken, bicarbonate of soda in
powder should be sprinkled thickly over the burn,
the part wrapped in moist gauze, lint, or linen, over
which a layer of common cotton is applied and held
in place with a bandage. Flour may be used instead
of the bicarbonate of soda. These two remedies are

BURNS. 315

ea.fily obtaini?d, nnd arc efficient. The objection to
powder of any kind where tlie skin is broken is that
it fiirms into hard cakes and is difficult to remove.
Applications in liquid form are therefore better, or
gutta-percha tissue, perforated here and there, may
first be laid over the burn, and then over this a layer
of cotton, which can be kept in place by a bandage
or by a coating of celloidin or collodion. If there are
vesicles, they should be snipped open with sharp scis-
sors or knife at the lower edge, and the fluid absorbed
with gauze or cotton sponges; gau/.e or lint pads may
then be wrung out of a saturated solution of bicar-
bonate of soda or boracic acid and applied. The
various oily dressings most frequently used are Car-
ton oil, ointments of zinc oxide, bismuth, or boric
acid, and simple or carbolized sweet oil. The oi
menls are best spread on sheets of lint or protective,
and changed before the odor becomes offensive. Car-
ron oil, which is made of equal parts of lime-water and
linseed oil, becomes exceedingly disagreeable, and the
oil in it stains the bed-linen. It is not so much in
vogue as formerly. To prevent deformities from con-
traction, splints and bandages are used. Where the
burn heals by granulation, if the granulations become
exuberant and we have the so-called "proud flesh,"
thev may be touched with a stick of nitrate of silver.
The system should be supported by a liberal light
diet, particularly where there is much discharge. In
connection with burns there may be brain disturbances.
as delirium or a meningitis; pneumonia and bronchitis
are also complications to be watched for. and inflam-
mation or ulceration of the intestines, particularly of
the duodenum, is not uncommon. The f^ces should

316 NVRSINC.

be examined, especially if there be any pain in the
abdomen. When the air-passages have been scalded
by steam or hot liquids, the result is generally serious ;
the steam from lime-water, not too hot, may be inhaled
*o soothe the injured tissues.

In Germany continuous warm-water baths are now
being used with very good results where the deep
tissues are involved and sloughs and charred material
are to be removed. Where convenient, we may begin
with a warm tub-bath, with boric powder added to
the water, which is excellent for its stimulating effects,
for relieving the pain, and for cleansing the surfaces
before applying dressings.

For burns from acids, plenty of water is poured over
the surface to dilute the acid and thus render its action
less harmful. Alkaline .solutions are apphed, and the
main treatment is like that of other bums.

The nurse may meet with cases of severe exhaus-
tion due to exposure to intense cold. The symp-
toms are something like those of the later stages of
intoxication from stimulants. An intense drowsiness
may result in coma, from which the patient never
awakens. In a case of frost-bite the vitality may be
only partially destroyed. The patient should be kept in
a cold atmosphere or put into a cold bath, and the part
rubbed with snow or ice until sensation is felt and the
color returns : the rubbing is then discontinued and ice-
water compresses are applied. Stimulants, brandy, cof-
fee, and hot drinks, are given, but external heat is only
gradually permitted, since the restoration of the circu-
lation can only come about very slowly in the frost-
bitten parts, and in trying to hasten it too much we

317

FOREIGN BODIES.

run the risk of producing, or at any rate increasing
the tendency to, gangrene of the tissues.

Foreign bodies in the nose are seldom found except
in cliildren. and consist of buttons, stones, or anything
small and round that they can push in : they arc not
generally dangerous, although they are apt to produce
inflammation if not removed at once. Peas or beans
become enlarged after a short time by imbibition of
water, and cau-se pain by pressure. It will probably
be necessary to call in a surgeon, but simple means
Jiiay first be resorted to, such as making the child
sneeze, or by telling it to take a breath and then to
close the empty nostril and mouth tightly and force
the air out through the obstructed nostril. If these
means do not dislodge the object, a small piece of
wire may be looped around it or it may be syringed
out.

Foreign bodies between the eyeball and one of the
lids will cause a great deal of irritation, and in fact
will soon set up inflammation. If the particle be
sharp, like a sliver of glass or steel, it may become
lodged upon the surface of the eyeball, and can only
be extracted by a surgeon ; but when it moves loosely
under the upper lid, as a rule, it may be removed by
taking the upper lid between the thumb and index
finger and drawing it well down over the lower iid,
pressing it there for a moment, and then letting It
slide back: the particle will generally be left on the
cheek. If not succe.ssfu! the first time, the procedure
may be repeated, or the upper lid may be everted by
turning it up over a pencil or any small rod and ex-
posing the inner surface, when the object may be

seen and wiped off with soft linen or a camelVhair
pencil. Any irritation may be allayed by dropping
in a few drops of a solution of boracic acid ; with chil-
dren a few drops of a i per cent, solution of cocaine
arc used to prevent them from shrinking during the
process of extraction.

Another place into which foreign bodies find their
way is the external ear. They should be removed at
once, as they are liable to cause inflammation. If a
physician cannot be found at once, the nurse may at-
tempt the removal by syringing out the ear, but un-
less she has had a great deal of experience she should
never use a probe or forceps, since special skill is re-
quired in these manipulations lest the tympanum be
injured or tlie object be pushed in still farther. If an
insect should become lodged in the ear, a piece of cot-
ton-wool should be saturated in a strong solution of salt
or vinegar and the opening completely filled with it.
The patient should then lie on the car with the cotton
in it, at the same time pressing the hand firmly over
it: the plug may be withdrawn after a short time,
when the insect will probably be found on the cotton.
Another way is to place the patient on the other side,
with the affected side upward : the tip of the ear is
drawn up to straighten the tube, and then warmed oil
is poured in, when the insect will probably float on the
surface of the oil. To syringe out the ear the patient
holds the ear downward and the water is allowed to
run in very gently, being directed toward the upper
and posterior part of the canal.

Just here earache may be mentioned, as it is of fre-
quent occurrence in children, and is an ailment that

FOREIGN BODIES. 319

may be met with among adults. IIc;tt will usually re-
lieve the pain, and may be apphed in the form of hot
hops or salt-bags or hot flannels, or by means of a lit-
tle device called a "Japanese hot-box."

An obstruction in the throat is not very easily re-
moved. The first efforts usually made are to try to
dislodge the object by striking the patient forcibly be-
tween the shoulders with the palm of the hand, or the
patient may be inverted, head downward, and the slap-
ping repeated. If the object is in the cesophagus or
gullet, a drink of water or a swallow of bread may
push it down. If not too far down in the throat, an
attempt to remove it with finger, forceps, or umbrella
probang will probably be made. Anything in the air-
passages may be coughed up. Fish-bones, if imbedded
in the mucous membrane, must be removed with instru-
ments by the surgeon. Even when a pin or bone has
been swallowi'd, it may have scratched the mucous
membrane on its way down, and may leave the patient
with a sensation which makes him believe that the
foreign body is still pre.sent in the throat, so that even
after a careful laryngoscopic examination has proved
its absence he may still decline to be convinced that
it has been gotten rid of.

If any hard foreign substance has been swallowed,
it i.s best to let it alone, as it will be carried through
the alimentary canal. For anything sharp, such as a
pin or a piece of glass, purgatives should not be given,
but, instead, the patient should be made to cat solid
foods, in which the object may become imbedded and
be carried off without injuring or perforating the coats
of the intestines.

-J

CHAPTER XX.

Medjlal EMtBCENciEs.— Amii'iaAL K f:si'iR *Ti ON.— Drowning—
Poisons. — Mbdical Ai-i-liancks. — Medicai. Rounds.

Under the head of medical emergencies may be
classed conditions of unconsciousness, such as syn-
cope, hysterical, epileptic, and apoplectic attacks, acute
alcoholism, sun-stroke, drowning, and poisoning.

Syncope, or unconsciousness, is often seen in a
mild form, in what is commonly called a " fainting fit."
The condition is generally due to some disturbance in
the circulation, and often follows a transient anaemia
of the brain. It comes on suddenly as a rule, and is
not a serious condition unless the attacks are often re-
peated, in which case one would suspect the existence
of some disease of the heart or blood-vessels. The
patient should be put in the recumbent position, with
the head lower than the rest of the bodj-. so that the
blood may flow more quickly to the brain : this, in
addition to loosening the clothes about the neck and
upper part of the body and allowing the free access
of pure air. is usually sufficient. The respiratory
movements may be stimulated to action by holding
for a few .seconds aqua ammonia or some smeUing
salts near the nose, although here we must warn against
the danger of holding strong ammonia too close to the
nostrils of an unconscious patient. If recovery does

MEDICAL EMERGENCIES. 321

not almost immediately take place, external warmth
should be applied and medical aid sent for.

Care should be taken not to confuse fainting with
that form of hysteria in which the patient lies appar-
ently unconscious: the latter may be recognized in
that the pulse-rate will be normal, and if an attempt
is made to raise the eyelid the patient will resist and
close it again ; the body will feel warm, and there will
be little if any change in the color of the face. For
hysterical patients it is best to remain with them while
the attacks last, but to leave them undisturbed until
they recover.

Epilepsy is another form of unconsciousness which
may be mistaken for hysteria. Epilepsy should prop-
erly be discussed under nervous diseases, as it has itp
origin in the brain. Since it is of such frequent occur-
rence, and may come on at any time or place, one may
be almost certain of somewhere being confronted with
a case, and it is very necessary to know what to do
and what not to do for the sufferer. The attack is
.characterized by well-defined symptoms: the patient,
sometimes after uttering a peculiar cry. but often with-
out giving the slightest indication to the bystanders
that anything is wrong, suddenly falls to the ground,
where he lies unconscious. The muscles become
rigid {tonic spasm), the eyes are fixed, and the pupils
often dilated. In some but not in all cases there is
frothing at the mouth. After a few seconds the mus-
cles become relaxed, and the tonic spasm is followed
by twitchings and jerkings of the whole body (clonic
spasm). The attack l.xsts only three or four minutes.
after whicli the patient cither becomes completely con-

322 NURSING.

scious, or on coming to seems drowsy and goes off
into a deep sleep. The onlj' relief that an on-Iooker
can give is to place the patient on his back with the
head slightly raised, loosen any tight clothes, and sec
that he does not hurt himself: he should be allowed a
free supply of air. and something should be placed be-
tween the teeth to keep him from biting his tongue,
A piece of lead pencil or wood wrapped in a hand-
kerchief can always be obtained, and will serve every
purpose. No attempt should be made to stop the
movements.

The so-called apopUctxe fit is usually caused by
haemorrhage into the brain-substance. A person sud-
denly or after some slight premonition falls and be-
comes unconscious, the face takes on 3 deep purplish
flush or grayish-pale color, the pulse is full and slow,
and the breathing stertorous. The patient should be
put in a semi-recumbent position, all tight clothing
should be loosened, especially about the neck, and cold
applications should be made to the head, while dry heat
in some form is applit-d to the trunk and extremities.
Stimulants must not be given, and the room should be
kept cool, dark, and quiet.

Owing to the flushed face and unconscious condition
which occur in both, apoplexy and the stupor of alco-
holic intoxkalion may easily be confounded. In in-
toxication, however, the alcoholic odor of the breath
may be a guide; the pupils are more often dilated
evenly, and the patient can often be partially aroused
from the condition of stupor, although he may sink
again into it at once. In acutL- alcoholism an emetic
may be given, and after he has vomited freely the pa-

MEDICAL EMESGENCIBS. 323

tiont may be turned on his side and left to sleep off
llie effects. A nurse must never take the responsibility
of these cases upon herself, as a condition of coma not
unfrequently simLiktes so closely that of alcoholism
that even physicians of widu experience may be unable
to decide at first as to the correct diagnosis. This is
more particularly true in cases in which no history of
the onset of the attack is obtainable. Many of the
cases which die suddenly, and for years back have
been classified as instances of sudden death from heart
disease or apoplexy, have now been shown to be due
to diseases of the coronary arteries of the heart.

By coma is meant a condition of deep unconscious-
ness. It may be due to any one of many various
causes ; thus we may have a ura;mic, a diabetic, and a
post-epileptic coma.

Sunstroke, or insolation, as the name indicates, some-
times results from prolonged exposure to the sun's
rays, but it more often comes on not from any direct
exposure, but from staying too long in a continuously
high temperature. There are two forms — one in which
the temperature is high, and the other in which it is
subnormal. C;ise.s in which there is no elevation of
temperature are classified under the head of " heat
exhaustion."

In sunstroke, or thermic fever, the patient has an
extremely high temperature, from 106° to 1 10° F., or
even higher. He is unconscious, the face is deeply
flushed, and the breathing deep and labored. The
first tiling to do is to reduce the excessive temper-
alure, which should be done in hospitals by immersing
the patient at once in ;i cold tub-bath at 70° F., while

324 NU/tS/NG.

iced compresses are applied to the head; or he may be
stretched on a bed covered with a long rubber sheet
and freely sponged with ice-water and rubbed over
with ice. If in a tent, the patient may be placed on
the ground and water from a hose or pails poured
over him, care being always taken to make sure that
the head is kept quite cool and wet.

In heat exhaustion the symptoms may be quite the
oppo.site, and resemble more those seen in a condition
of shock: the temperature is subnormal, the pulse
small and rapid, the extremities cold, and conscious-
ness may be entirely lost. Stimulants are given until
the pulse improves, the patient being kept quiet and
in a dark room.

Artificial respiration is resorted to when a patient
has ceased to breathe, and the employment of mechan-
ical means promises a restoration of the act of respi-
ration. In asphyxia from chloroform, in narcotic
poisonings, and suffocation from gases, with the new-
bom infant, and in cases of drowning, it is often
necessary.

Sylvester's method is considered the best. The pa-
tient is placed on his back with a pad just under the
shoulders to assist in the expansion of the chest walls;
the tongue must be caught with forceps and drawn
out, the forceps being left on to prevent it from slip-
ping back, or after being drawn out it may be held in
place by a dry handkerchief or strip of cloth tied to it,
the ends of which are crossed at the back of the neck,
brought around, and fastened under the chin. The
operator stands or kneels at the head, and. grasping
the forea^nl^; at a point about halfw.iy between the

ARTIFICIAL RESPIRATION. 325

etbow and the wrist, carries the arms steadily over the
patient's head until the hands touch behind. By these
means the chest-cavity is expanded. After being held
there for two seconds, until sufficient air has entered the
lungs, the arms are carried back and pressed against
the sides of the chest in order to expel the air; after
an interval of a few seconds the process is repeated.
This is continued, the movements being made steadily
and slowly .it the rale of sixteen to the minute, corre-
sponding to the number of normal respirations. Much
perseverance is necessary, as we may often have to
work for two hours or more before any signs of life or
breathing become visible. It i.s to be remembered that
there is always a tcndencj' to perform the movements
altogether too rapidly.

Marshall Halls method is to roll the patient over
on his face and make gentle pressure on the back in
order to expel the air from the lungs. In order that
it may enter them, he is rolled over on his .side and
ihese movements repeated at the same rate a.s in Syl-
vester's method.

To restore a person who is apparently drowned, one
mu.st lose no lime, but begin at once by removing the
clothes as far as the waist. The mouth is pres.sed
open, wiped out, and the back of the throat cleared of
any mucus that may have collected there. The patient
is next turned with his face downward, the abdomen
being allowed to rest on a folded coat or shawl or
over tlie knee of the operator, and pressure is made
on both sides of the thorax, so that any water which
may have entered the air-passages may be forced out.
When this has been accomplished, the patient is again

386 NURSING.

turned on his back and artificial respiration
In the mean time some one should have been
stimulants and blankets. Hot and cold water alter-
nately dashed on the chest may assist in exciting the
respiratory movements. As soon as possible the pa-
tient should be enveloped in blankets and surrounded
with hot cans, and even after he has begun to breathe
fairly well he must still be watched until there is no
further danger of the respiration again ceasing.

started ^^1
for ^^1

Poisons, as the term is popularly understood, are
substances which when taken into the body in small
quantities endanger or terminate life. They may be
taken accidentally or with suicidal intent, and it i.s
usually under such circumstances that a nurse is called
upon to act with promptness in order to counteract or
check the action of the poison. If a poison have been
administered by accident in the presence of a nurse,
she should relieve her patient, as far as possible, from
anxiety or nervous shock by making any neces.sary
statement as little alarming as possible, and by taking
prompt steps to remedy the evil. A physician should
at once be sent for, and in the mean time, according to
the nature of the poison, remedies may be administered
which act either by removing the substance or by
preventing or counteracting the action of the poison.
Such remedies arc termed antidotes. An antidote may
act in one of three ways : mechanically. b\' preventing
absorption or by emptying the stomach ; chemically,
where one substance, combining with another, pro-
duces a comparatively harmless third substance; or

POISONS. 327

physiologkally, where the substance administered coun-
teracts the effects of the poison upon the system.
When one has to act upon general principles without
knowing what the poison is, an emetic is perhaps the
best thing to give first. An emetic which can nearly
always be obtained in a moment is mustard and warm
water. For an adult half an ounce, and for a child two
drachms, of mustard to a cup of water may be given,
and the draught repeated every ten or fifteen minutes
until free vomiting is produced. Salt and warm water
may be used in the same way. or vomiting may be
produced reflexly by tickling the pharynx with the
index finger.

The other common emetics ordered are — sulphate
of zinc {10 to 30 grs.) in a cup of water, repeated even.
fifteen minutes; powdered ipecacuanha (15 to 30 grs)
or fi. ext. ipecac (15 to 30 mins.).

The washing out of the stomach may sometimes be
the quickest and best thing to do if the patient is no'
insensible or if the mucous membranes have not been
too much injured by the action of the poison.

Poisons may be divided, according to their action,
into corrosives, irritants, narcotics, and narcotico-irri
tants.

A corrosh'e poison is one that is likely to eat or
burn through oi^anic tissue instantly, while an irritam
poison is one which acts more slowly upon the tissues,
producing inflammation which may re.sult in suppura
tion and perforation.

For these violent poisons the antidote should be
one which will act chemically upon the poi.son, either
rendering it harmless or at least reducing the violence

3^8 NURSING.

of its action. An emetic is, as a rule, not indicated, I
the action of sulphuric acid, for instance, being usually ]
so rapid that the tissues would be injured long before I
an emetic could be given, so that the latter would only
add to the irritation. The stomach-pump should not ,
be used, as itn introduction may assist in the destruc-
tion of the mucous membrane and produce perforation.
Demulcent drinks (mucilage) may be given, and if
possible some chemical antidote.

In the after-care of patients suffering from poisoning
from irritants, great care should be taken with regard
to the diet; only the soft, non-irritating foods should
be given, such as finely-strained gruels, milk-porridge,
egg albumen, etc.

In narcotic or narcotico-irritant poisoning the action
is systemic, and the antidote may be a combination of
all three forms.

Below we have tabulated some of the more import-
ant poisons, together with the treatment to be followed
when they have been taken into the stomach :

Carrosivt Paunv : fsimtJiale Trtalmmt.

(uve msEimii mixed with
milk ot wuer, chalk-nw-
iler, cji an alkali, such u
sodi. ililulcd. roliowed lijr
mucilagi[ious drinks.

Nilric.
Ol»lic.
fiulphurii

e lime-water ani] milk or
,-rup of lime. No oil, ac |
nirl abscnptions.
For any alkali ^veamild add,
such as vinegar gr lemon-
juice, carlxilic acid miicil
with wUcr.souiddcT. With
lixed oils. sQch as sweet oil
ot cas]ur«il,tlie alkalies rural
emulsions. ~

^^^^1

^^3^

H H

^^^^^^^^^1

^^I^^^H

POISON

S. 329

Irritants :

■

Antimony .

Tanar emetic.
Wine of antimony.
.Synip of squills.

Produce emtsi-. Give m. anii-
(lole tannic acid or very
strong tea. I'ollow with
demulcent drinks.

Arsenic . .

Fowler'^ sululion.
Paris green.
Rough on Rals,

Give an emetic of mustard and
water. The antidote is llie

made freshly by adding a
suflicienl quantity of aqua
ammonia or of a mlulioii of
carbonate of soda to the linc-

red precipitate. Strain and
wash the precipitate and slir
it in milk or water, and give
freely and frciiuently.

Bichloride of mer-

Albumen (white nf egg) is a
chemical antidote, one e^

Mercury (hy.
drargiTiim).

limalel.
Calomel.
Blue mass.

to 4 gr. of the mercury.
Milk may also be given and
then flour paste. Vomiting
is to be induced after the
antidote has been given.

Iodine . . .

Tincture of iodine.

Starch or flour, mixed into a
paste with water, sbould be
given, and lie followed later

Iran ... .

Tincture.

Syrup of the iodide.

MonseVs solution of

■he subsuiphnte.

Antidote, magnesia. Plenty
of water to drink. Pro-
duce emesis.

Lcid . . .

Acm.ile of lead (sugar
oflea.l|.

Antidote, sulphate of soda or
orwhiteofeggormilk. Use

Phosphorus

Mutches,

Phosphide of zinc.
I-.II.

V:irous kinds ofhv|»j
phospliilcs.

Wash out the stomach in re-
sulphate of co|:per answers
well. Oil mu.st never be
given, as il dissolvea phos-
phorus and hasten; its ab-
sorption.

- ■■

Coihonic otide gns '
(i!!uminiUing gis).

Fresh air. Anilicial respira-
tion. Stimulants.

^Q^^^^B

^^^^^H

Nan^i and Nar- ^^^^^H

I 1 "«'"'■ j ,loni«„pin,„digi,di.. ^B

f B».,l, 1 SUnmcb-lulj, ckl .pplic- ^H

llcllBilcnna .

Tinclure.
Fluid extract.
AlropiDC (alkaloid!.

S3™.,

Emetics or stomacli-tube, tan- ^^^^
. nicacid.andmorphine. At-

Digitalis . .

tinciai icspiruioD, ncsi.
Enielics, tannic acid in luee
. quanlilies. Hot external ^>-
plications.

CbloT*! . - .

Chloral hydiBle.
Crotou chloral.

Wuh out the stomach with
lea or cofTce. Alcoholic
.slimulsnH. Sliydininc. Ar-
tificial re^pnUion Eitet-
nal heat, mustard |<laUen.
mustard fv«i.biuh, etc.

Hyoscyamus.

Tiiiclure.
Filrncl.
Sulpliale of hyoscyn-

Same irealiticnt a< for bdU-
doniia-poisoninE. Fitsh air-
Cold-water affiisiuns.

Chlorofonii

lanu. Strychnine hypodw
mically. Counter-irritanth.

Nicotine . . I Alkaloid of tobacco.

Prompt emetics. Tannic acid.

Artificial rcspration.

N„,.™»:

Fluid exttttd.
Strychnine.

Emetics, Tannic acid ur tinc-
ture of iodine. Morpliinecc

Opium , . .

Lauiianum.

McMumi's elixir.
Morphiue (alkaloid).

Emetics, such as sulphate of
zinc or mustard. The »tt.m-
ach-tube. Cold-water afTu-
sious. SlroDK black coffee
by mouth and rectum. Al^
lificial respiration. Keepihe

Poisoning may also follinv the use of certain kinds ^^|
of mushrooms, tainted nieat.s. fish, cheese, milk, and ^^|

ice-cream. In such case prompt emetics, followed by ^^H

MEDICAL APPLIANCES. 331

purgatives and stimulants, internal and external, should
be employed.

Except in the case of mushrooms the poisonous
properties of these substances are often the result of

bacterial growth.

For medical nursing but few appliances are needed
in proportion to those required in surgery; still, there
arc certain things which are necessary and which
should be kept on hand ready for use.

The same conveniences for applying heat externally,
such as hot cans and bags, with their canton-fl^innel
covers, are required. Pneumonia cotton-jackets, flan-
nels with oiled-silk covers for stupes, should be kept
made up, since they may be needed at any moment

An ausciillation tmi.>et should be a yard square, and
made of cambric or Victoria lawn or of some other
thin white material : it is used by the physician during
the examination of the heart or lungs when he wishes
to listen with his ear directly against the patient's
body. It should be thrown by the nurse over the
patient's face and chest. When laundried no starch is
u.sed. as it must be soft and noiseless.

Cupping-glasses, an aspirator, one or more stomach-
tubes, and catheters should be included among the per-
manent ward supplies.

The aspirator is an instrument used to withdraw
serous or other fluids from the pleural or abdominal
cavity; by means of it suction is possible without the
introduction of air.

In preparing for aspiration the needle should be
sterilized in the same way as that of a hypoder
syringe, and the part of the body where the needle is
to be introduced washed off first with soap and water,
then with bichloride solution, and afterward with
absolute alcohol. Besides these, there must be a
basin of carbolic-acid solution, towels and sponges, a
hypodermic syringe, a solution of cocaine, stimulants,
and, if the amount to be drawn off is very large, an
extra receiving vessel should be ready. A small
dressing of absorbent cotton and celloidin will be
necessary for application after the operation.

If a patient is to be tapped for ascites, a rubber sheet
and an abdominal bandage will also be needed.

For venesection the same antiseptic precautions
are taken as in aspiration, and in addition to the things
mentioned above, artery forceps, dressing forceps, scal-
pel, scissors, needles, and ligatures (all sterilized) must
be ready. The dressing necessary for a minor ope-
ration will also be required.

In some diseases hmage of the stomach is ordered ;
a long rubber stomach-tube is used and the stomach
washed out with lukewarm sterilized water or a warm
boric-acid solution. For this procedure there should
be in readiness a rubber sheet, soft bath towels, a good
sized basin, a gallon of sterilized water at about
loo^F., and a two-quart pitcher. The patient may
sit in a chair or, if in bed, he may be supported by a
head rest. The head should be inclined slightly
but not too far backward. The tube is inserted as
far as the back of the pharynx, and, the patient
being told to swallow, is passed down the cesoph-

STOMACH WASHING. 3 = 3

agus, its extremity having been previously dipped in

water or oil. The mouth of the tube is slightly
elevated, and half a pint of the irrigating fluid
poured gently in through a funnel. The outer end
of the tube is to be lowered before all the fluid has
run into the stomach, and in this way the gastric
contents may be siphoned off into a basin. The
process is repeated until the washings become clear.
After the stomach has been thoroughly cleansed,
nourishing food is sometimes introduced through
the stomach -tube. This latter procedure is known
as gavage.

On medical morning rounds the head nurse should
always have with her the book containing the night
report, an auscultation towel, a tongue-depressor, a
measuring- tape, and a thermometer. She should an-
ticipate as far as possible anything that may be asked
for, and be prepared to answer questions regarding
any of the patients under her chaise.

CHAPTER XXI.

Diet.

The importance of diet and its application to the
needs of the system, whether in health or disease, can
hardly be overrated, and to properly appreciate it one
should have at least a general idea o( the constituents
of the different varieties of food. The doctor orders
what food a patient shall have, but the nurse has
much to do with its preparation and administration.
It is unfortunate that so few nurses understand any-
thing about food-composition and the principles under-
lying food preparation, since for invalids these are of
paramount importance. In hospitals it not infrequently
obtains in the nurse's mind that if any one part of her
dutie.s may be neglected, it is the attention given at
meal-time. It is pretty well understood among nurses
that medicines are to be given promptly at the time
they are ordered, and any neglect of this duty is con-
sidered a grave mi.sdemeanor; but it has not yet be-
come clear to all women who nurse in hospitals that it
is equally important that the patient's food sliould be
given at stated intervals, in correct proportions, and in
an inviting form. Fresh air, pleasant surroundings,
and good food will do much toward restoring health
or improving a patient's condition; and with these a
nurse has much to do. In the free wards of hospitals

THE PREFARATJOK' OF FOOD.

it is not an uncommon thing to leave tlie distribution
of the food to the ward maid, with but a very hasty
or superficial supervision on the part of the nurse: the
result is that an overloaded plate of food of various
kinds may be carried to a patient who has not even
the appetite or inclination for the daintiest morsel ;
the plate is put down and left during the time pre-
scribed for the meal, and then carried off again by the
maid; and it may only be quite by accident that the
nurse learns afterward that the patient has eaten noth-
ing. Nor can it always be expected that women com-
ing into hospitals, new to the work and to illness, should
realize the importance of this part of their duties unless
the fact has been thoroughly impressed upon them. Skill
and intelligence in this, as in the other departments of
nursing, require that the theory and practice should go
hand in hand: theory alone will not do, nor will it an-
swer to depend upon chance opportunities to put theo-
retical teaching into practice. Lectures and demon-
strations are better than nothing, but being talked to
and seeing the demonstrations of some other person
will help the nurse but very little toward performing
the work skilfully herself, nor will the principles upon
which they are based appeal to her then so forcibly as
when she can actually see certain results follow in her
own experience. But, if she once undersbmds the
principles, her attention to the nourishment of the '
patients under her care is less likely to be a mere per-
functory duty, and, knowing the results which she
wishes to obtain, she will be interested in watching for
the success of her efforts. Fortunately, the increased
attention given to domestic science in its various

336 J^URSMG.

branches inakt:s it now possible for training-schools to
secure conipetL-nt instructors in cookery for invalids —
a fine art worthy of being studied not only in theory,
but in practice as well. This study calls for a know-
ledge of elementary chemistry as far as it applies to the
effects of heat, cold, air, and water on food, the classi-
fication and composition of the principal food-sub-
stances, and the process of selecting and preparing
such foods in simple palatable forms for invalids. Of
the preparations there should be a good number to
choose from, and the pupil should go over the tests
and actually prepare each dish at least three times.

1. She should assist the teacher in making it, and
be taught the principles to be observed in preparing
such a dish;

2. She should prepare it under the ob-servation and
criticism of the teacher ;

3. She should prt-pare it, as a test of her ability,
quite alone.

As the primary idea is to instruct, the time allowed for
such a course should be devoted exclusively to teach-
ing, and since the preparation of large quantities would
take too long, and thus hinder systematic instruction.
it cannot be expected that all the delicacies for daily
use in the hospital can be prepared in the cooking-
school. Most of the beef-tea, however, and of the
broths needed for the hospital inay be made daily, and
in addition the dishes prepared during the instruction
of the day may be contributed as extra dishes to the
wards. The time required for such a course is at least
one month: the class may consist of two, or probably
the school might spare from the regular ward work

THE PREPARATION OF FOOD. HJ

even more than two pupils at a time. A course of-*
this kind gives a nurse an intelligent comprehension
of the value of certain kinds of food in disi;ase, and
of the best and most wholesome methods of preparing
them, so that she will afterward be able to expl.iin to
others how the work should be done when she has
not time to do it herself She will have at her com-
mand a varied and extensive list to select from. ;
will be taught the correct manner of serving. If she '
becomes a district nurse, she will be able to advise the
housekeepers or mothers how they may spend sm^l
sums of money for food in the most profitable way, a
give valuable instructions how to prepare it

As a preparation for the position of head nurse in a
hospital, such instruction gives lier a practical regard
for economy, and teaches something about household
arrangements — qualities very desirable in a woman
who is responsible for the careful ordering of a ward.
In the ward a nurse should be detailed in turn for a
certain length of time to have charge of the nourish-
ment of the patients : in this way she knows just what
each one is getting. :md, after serving each patient's
food herself, she should then go round to all the bed-
patients, encouraging some to eat, finding out their
likes and dislikes, feeding the helpless ones, and then
making an accurate report to the head nurse of those
who have no appetite and do not eat well.

The cleanliness of the refrigerator where the butter,
milk, and extra food for the patients are kept should
be under the supervision of the nurse in charge of the
meals; the work must be done thoroughly to ensure
keeping things sweet and free from fermentative bac-

338 ffVSSING.

tcria The milk-jugs and cans require to be daily
washed out carefully, and left standing full of boiling
water for an hour. The greater the pains taken to in-
struct the nurse as to the reasons why such continuous
and strict attention to these details is neccssaiy, the
greater the responsibility on her part to see that the
proper conditions are maintained.

All dishes used for diphtheria patients or, in fact,
for those with any infectious disease, should be kept
apart from others, and not put into common use again
until they have been boiled in a 2 per cent, solution of
carbonate of soda for one hour.

Sometimes, when a patient is not inclined to cat. a
little judicious management on the part of the nurse
will result in a fairly good meal being taken : she may
do this by as.sisting the patient to take it, encouraging
him to try a little more, or by diverting his mind with
conversation that will be of interest, and keeping his
attention off" what he is doing, so that sometimes he
will unconsciously eat a great deal more than if left to
himself. Considerable skill is required in administer-
ing (bod to helpless patients. If it has to be given
with an ordinary cup or glass, the vessel should never
be more than half full, and the head should be slightly
rai.sed and supported firmly ; care should be taken not
to throw the head so far forward as to make swallow-
ing difllicutt. A napkin is to be folded under the chin
and the fluid given gradually; an occasional stop
should be made, so that the patient may not have to
swallow during inspiration. If feeding-cups are used,
glass ones arc preferable, as the amount given at one
time can be more easily measured. For patients who

FEEDING PA TIENTS. 339

niust !ie fiat on their backs, a favorite way to give fluids

is tiirough a glass tube : an ordinary pipette may be
bent at any angle desired by heating it in an alcohol
flame, and through it the patient may suck his nour-
ishment without having to be niised. The fluid may
be taken in this way as slowly or as rapidly as he
wishes, and there is no danger of any running down
the outside of the cup on to the clothing; if a glass
tube cannot be procured, a small piece of clean rub-
ber tubing will answer, but it should be washed thor-
oughly after use and kept in fresh water Where the
lavorabie termination of a disease depends upon keep-
ing up the patient's general strength, it is important to
give nourishment as regularly at night as during the
day unless orders are given not to waken him. Fre-
quently a patient will awaken just enough to take what
is held to his lips, and at once drop off to sleep again.
Patients are apt to lie awake toward morning, when a
cup of hot milk, cocoa, or broth should be ready to
be given, as this often sends them to sleep again for
two or three hours. It is also good practice to give
a glass of milk or some light form of nourishment
the last thing before a patient is settled down for the
night.

Food given to patients in small quantities and at
short and regular intervals will digest better than
when the same daily quantity is taken in heartier
meals at longer intervals, as the function of the di-
gestive organs is weakened, and sympathizes, so to
speak, with the condition of the general system, Food
of any kind sh uild never be left in a sick-room after
a p.tiieiu has finished with it, nor should it be al-

540 NUSS/NG.

lowed to remain on the bedside stand tn the hope
that a little may be taken later. This applies to milk
particularly, which is so much used, for it perhaps
more readily than any other kind of food absorbs ir
purities from the air. The drinking-water is not i
frequently a source of disease, and intestinal irritation
has often been traced to this source, although the
water itself may be apparently clear and may look
perfectly pure. Where intestinal disturbances cannot
be traced to any direct cause, one suspected agent
may be excluded by boiling all water used for drink-
ing purposes, and keeping it in clean vessels. The
same dangers arise from the use of impure ice.
Where there are epidemics of fevers, intestinal dis-
eases, or cholera, drinking-water should never b«
taken unless it has previously been boiled. It i)
safer, where one suspects the water, to use some of
the well known table-waters — e. g. Apollinaris or Selt-
zer water.

In private nursing the nurse usually has to make
arrangements for keeping small quantities of food or
milk for night use near at hand and fresh. Where a
small refrigerator is not obtainable, a large di.sh-pan is
a good substitute : the ice used may be kept for a long
time if wrapped in a piece of flannel and not allowed
to come in contact with the water that drips from it
This can be arranged by turning a smaller basin upside
down in the pan and putting the ice on it ; then the
milk, fruit, etc. may be arranged about it. the whole
being covered over iVith a fresh napkin and kept near
an open window.

Food -constituents may be grouped as albuminoids

FOODS. 34 (

or proteids, fats, carbohydrates, inorganic constituents,
and water. A diet to be perfect must contain all these
in certain definite proportions. The diet in illness will
depend largely upon the nature of the disease, the
amount of waste of the tissues, and the forms of food
best suited to repair as much of the waste as possible.

The patient's strength is to be kept up, so that he
may utilize food to the greatest extent possible to
repair or prevent ti.ssue-waste ; no food should be
given that cannot be readily assimilated.

In diseases accompanied by fever, wasting of the
albuminous tissues takes place, while at the same time
there is a disturbance of the processes by which food-
substances are digested and absorbed. Albumen is
often found in the urine, and the amount of water
in the body is diminished. In the weakened state
of the powers of digestion which accompanies fevers,
the food which contains those substances which
are most readily assimilated, and leave a minimum
amount of residue, is desirable, and it should be in
liquid form.

Milk is considered the perfect food in these cases,
as it contains albumen, fat, sugar, and water, besides
inorganic salts of lime and potash. If it disagree with
the patient, and curds appear in the stools or vomiting
ensue, it may be given boiled, or may be diluted with
plain or effervescent water in the proportion of 3 parts
of milk to I of water, and given in smaller quantities
and more frequently. If it still disagree, it may be
ililuted one-half, or lime-water or bicarbonate of soda
(10 grains to the pint) maybe added to it. Where
these fail, peptonized milk may be given. When milk

342 ATUXS/NG.

i the exclusive diet, the amount usually ordered is
from 3 to 5 pints in the twenty-four hours; this should
be divided up into equal parts, and given ont;e every
two or three hours. Occasionally milk cannot be
taken at all, and where there is much depression
the albumen of egg in increasing quantities may be
ordered. To prepare this, only the white of the egg
is taken, beaten to a froth, strained, and, a few drops'
of lemon-juice being added, it can be given with
equal parts of water.

Other substitutes for milk are kumyss, whey, butter-
milk or meat broths, soups, and meat extracts; these
do not contain the same amount of nutriment as milk.
Unless the process of preserving the albuminoids in the
broth is understood and carried out, it is of little value
as a food. The broths commonly in use in hospitals
serve more as a warm, slightly stimulating drink than
as a form of nourishment ; the extracts are more stim-
ulating, but are only nourishing to a small extent.
Meat-jellies may also be used for administering albu-
minous foods in an easily -digested form. Farinaceous
foods are not usually ordered in fevers, as they read-
ily ferment, and no starchy food is suitable in fever,
such as typhoid, where the lesions are in the small
intestines, since the stomach, upon which we have
mainly to rely in this disease, does not digest starch.
The importance of giving plenty of water in febrile
diseases is now generally insisted upon by medical au-
thorities. If a patient does not ask for it himself, it
should be offered to him, and he should be induced to
take it frequently : some advocate giving it as often as
every hour during the day if it does not interfere with

I
I

FOODS. 343

digestion. Frequent draughts of cold water will lower
the temperature somewhat, flush out the kidneys, and
assist in carrj'ing off waste products from the alimentary
canal. It may be alternated with effervescing waters,
lemonade, rice-water, or barley-water, •

Tea and coffee are sometimes ordered in fever as
slight stimulants. Alcoholic stimulants are ordered
when it is necessary to assist in checking tissue-waste;
when the pulse becomes dicrotic, rapid, and irregular,
the tongue dry and parched, and the nervous symp-
toms marked, alcohol may be the only thing which
will bring the patient through.

A convalescent fever patient is allowed to return to
solid food by degrees, beginning with so-called light
diet, under which head we include baked custards,
jellies, soft-boiled eggs, and milk-toast ; then extra
diet is allowed, when fowl, chops, baked potatoes,
etc. may be cautiously given. The above course of
diet is that usually prescribed in typhoid fever. In
some forms of febrile disease, as pneumonia and tuber-
culosis, where no part of the alimentary tract is in-
volved, the "light" form of solid diet may be given
even when there is pyrexia; in tuberculosis, in fact,
any food that is nourishing and easily digested is
usually allowed.

In di.seases where fever is not a prominent symptom,
and where the efltcts of certain foods upon the disease
must be taken into account, special forms of diet are
prescribed.

In acute gastritis the giving of food by the mouth
may be stopped entirely, so that complete rest is
afforded to the stomach, while the nourishment is

•St> Appcndii, N11104.

NUJiSWG.

administered by nutritive eneniata. In the milder ]
forms peptonized milk is often ordered or egg-albu-
men diluted with water, and the wa)' is paved to solid 1
food by the use of scraped raw beef in small quanti-
ties. Fats, starchy foods, highly-seasoned foods, and J
stimulants are to be avoided, and may only be given |
with the physician's orders.

In dyspepsia easily assimilated foods are ordered in |
small amounts and at fixed intervals: hence the im-
portance of giving them promptly and in the precise ]
quantities directed.

In diseases of the kidney a diet consisting of milk 1
and vegetables, together with plenty of water, is pre- j
scribed as a rule. In diabetes, sugar and starchy 1
foods, fruits, and sweet wines are not allowed. Gluten 1
bread is ordered instead of white bread, as, if properly 1
made, it contains a minimum of starch.

It need hardly be added that we have always to ]
take into consideration the exigencies of the particular
case with which we are dealing, and, while following
general principles, be prepared for such modifications
in details as may be indicated. The patient's physical
comfort should be looked after before giving food,
the mouth washed out, the face and hands bathed,
the bed cover and pillows arranged, and everything
disagreeable, as, for example, the sputum cup, put
out of sight.

CHAPTER XXII.
The Administration of Anaesthetics.

A NURSE is often called upon in private practice to
administer an ana;stlietLC, as it is not possible at every
operation to have sufficient medical assistance. She
can never feel herself competent to do this unless she
has taken advantage of her opportunities in the hos-
pital for watching and herself practising the adminis-
tration, and for informing herself thoroughly of the
principles and methods involved, of the dangers to be
watched for. and of the proper way to guard against
them. Every time she is present when a patient is
being anesthetized gives her another opportunity for
following each step in the process, and when a fitting
occasion for a.sking questions regarding any point pre-
sents itself, she should not neglect to do so.

Anesthesia means a condition in which there is an
absence of sensation. The agents used to produce
this condition arc called anesthetics, and may be
either local or general in their effects. The general
effect is produced by inhaling the ana:sthetic in the
form of vapor or gas into the lungs, whence it is car-
ried by tlie blood to the nerve-centres, upon which it
acts.

Local anaesthesia is produced either by the injection
of the proper agents in liquid form into the subcutan-
eous tissues or by applying them externally.

NURsmc.

Anii;slhelic.s arc largely employed in surgery, their
principal uses being to do away with pain during ope-
rations and to produce insensibiliu- and a relaxed con-
dition of the muscles when a thorough examination is
necessary. In obstetrics the inhalation of chloroform
or ether is a great boon, and in medical treatment an-
.-t^^thetics are sometimes given to control convulsions.
Tile genera! effect of an ana[:sthetic may be either par-
tial or complete. The two substances most frequently
used for inhalation are ether and chloroform ; in dent-
istry nitrcus oxide or laughing gas is used, as Its
effects pass off rapidly and the patient need not be
put in the recumbent posture.

To Prepare a Patient for Anaslhesia. — No solids
should be allowed for six hours previous to the ad-
ministration of an anesthetic, but light, easily- digested
food, such as a cup of coffee, beef-tea, or a very little
bread and milk, may be taken three hours before. If
an anaesthetic is given very soon after a hearty meal,
vomiting almo.st invariably follows, and may delay the
operation; moreover, there is danger of solid portions
of food being drawn into the trachea and producing
suffocation, or the throat and pharynx may become
filled up and the obstruction only with difficulty be
removed.

If the patient be very weak and delicate, the phy-
sician may order stimulants, usually half an ounce of
either brandy or whiskey half an hour before the ad-
ministration of the anesthetic : this should not be given
without orders.

The forenoon is the best time to select for giving an
anesthetic, as the vital powers are in better conditio

ANJESTHESIA. 347

if the patient has had a good night and has not been

exhausted by nervous strain, pain, or worl<. The cloth-
ing should be light and warm, but loose about the neck
and chest, and no corset or tight waist should be per-
mitted, because the respiratory organs must have free-
dom of movement. The urine should be voided or
the catheter passed. If there are false teeth, they
should be removed. If the patient be a child, c;
should be taken to see that the mouth is quite empty,
as there may be coins, buttons, or other articles stowed
away in the mouth. The patient is placed in a recum-
bent position, with the head low or resting on a small
air-pillow, and should be covered with warm blankets,
the hands being left free, so that the pulse may be easily
reached ; a towel is to be laid across the chest under
the chin. An extra towel and basin should be ready.
The nurse must also have at hand a hypodermic
syringe (sterilized and in good order), whiskey or
brandy, tincture of digitalis, a solution of strychnine,
morphine, atropine, and aqua ammonia, as any of
them may be called for. There should be, besides, a
liberal supply of both chloroform and ether, towels,
inhalers, and vaseline; the latter is applied about the
lips and nose to prevent irritation from the vapor.
The pulse .should be taken before starting. The an-
aesthetic may be given to the patient either in bed.
after which she will have to be carried to the ope-
rating-room, or in a room near the latter where there
will be nothing suggestive of the operation. The
room should be quiet, and no talking is to be done
beyond what is absolutely necessary, and that in a
low tone ; otherwise it takes longer to get the patient

348 AX'J!S/.\'C,

under the influence of the ansesthetic. Besides I
anicsthetizer, if the patient is a woman the nun
should always be present to give any necessary assist
uncc, but a second or even third person may be neededj
if there be much struggling. Ether is probably given*
in this country oftener than any other anaesthetic, as
thciv w-cms to be little danger to life under ordinary
liicuni^tiinccs when it is carefully administered. The
I'ontraimlicdtions to the use of ether arc chronic dis-
cstsci of the brtwchi and of the kidneys. Speaking
Kvn«^rall\', chloroform is preferable for very young <
vvt)' old piitients.

If lights are used near ether, they should be ke]
rtUivx the neighborhood of the can or inhaler, as etha
vtn>ov i^i heavier than air and vcrj- inflammable.

'Iherr are various styles of ether-inhalers, but one J
thut is easily made and can always be had fresh am
CJDHn is the so-called "ether cone." It is prepared hyM
folding two or three layers of paper {not too stifF— a
newspaper an.swers the purpose) together to make a '
thin pad about 16 inches long and 9 wide, and stitch-
ing to this a small. loosely-made crash towel or a ])iece
of linen large enough to cover it entirely; the whole
IN then twisted into the shape of a cone and held in
place with pins, a small opening being left at the top.
A small sea-sponge or some absorbent cotton is put
innide upon which to pour the ether.

About half an ounce of ether is poured upon the
Hponge at first, and the cone held at a short distance
from the patient's face, or for a few moments he may
be permitted to hold it himself if inclined to be nerv-
ous or to think that he is going to be suflbcated.

ANESTHESIA. 349

After these first few moments, however, when the
feeling of irritation has passed, the cone should be

held closely over the mouth and nose, and the patient
encouraged to take deep breaths or to blow out. The
first stage is the most disagreeable, owing to the irri-
tation produced on the mucous membrane of the
mouth, throat, and bronchi, which may give rise to
coughing and a sensation of suffocation. When the
patient struggles, talks, or cries out, the pulse and
respiration are quickened and the face flushes. The
L'ther is kept up steadily, a few drachms being added
from time to time, until finally the patient quiets down,
the muscles become relaxed, and sen.sation is lost ; this
stage is called that of primary anaesthesia. This, how-
ever, is only transient, and may in its turn be followed
by struggling and excitement, after which there ensues
a condition of complete anaesthesia in which there is
absolute relaxation of the muscular system, the con-
junctival reflex is abolished, the face and skin are
moist, and the patient lies as if in a deep sleep. The
pulse is full and qui. kencd and the respirations are
.slow and regular; these, as well as the reflexes, should
be watched constantly. The reflex to light should re-
m:iin active; that is, when the eyelid is opened the
pupil should contract. A rapidly-dilating pupil is a
sign of imminent danger. The time required to pro-
duce complete anesthesia, differs with different indi-
viduals, and may vary from five to twenty minutes.
It is also modified by sex and age, women and chil-
dren being influenced more readily than men. Patients
who have been alcohol habitues usually struggle vio-
lently; during the struggling the anaesthetic must be

pushed, but great care must be taken when the strug-
gling begins to cease, as they then pass with great
rapidity into the stage of complete anjesthesia.

In the early stage of the administration of ether the
patient may suddenly stop breathing and the face be-
come cyanosed ; the cone should be at once removed,
and pressure made upon the chest and sides once or
twice, when the breathing will recommence. After the
patient is readj- for operation, the etherizer continues
to keep a constant watch upon the pulse, respira-
tion, reflexes, and general condition, and a few drops
of ether in the cone from time to time will suf-
fice to maintain the unconsciousness. To prevent the
tongue from falling back into the throat and thus
obstructing the air-passages, the lower jaw should be
pushed forward and upward. It may be held in this
position by two or three fingers placed behind the
angle of the jaw, while the others keep the cone in
place. Any accumulation of mucus in the mouth
should from time to time be wiped out with a towel.
If we are warned by contractions of the abdominal
muscles (retching) that vomiting is threatened, it may
be averted by pushing the ether; if the patient does
vomit, the head is to be quickly turned to one side,
and the mouth cleaned out before an inspiration can
be taken, otherwise some of the solid particles vomited
may be drawn into the larynx. If the breathing ceases,
the head and chest should be lowered to send more
blood to the brain, and artificial respiration should be
begun at once and maintained until breathing is re-
established ; aqua ammonia may be held at a little
distance from the nostrils. The pulse may be conveni-

ANMSTHESJA. 35 1

ently counted in the temporal or in the facial artery,
and if it grows weak and fluttering, the attention ot
the surgeon should be at once called to the condi-
tion. Ether is very irritating to the kidneys, and the
amount of urine should be accurately measured for
some days before and after the administration.

A patient should be watched until consciousness is
restored, which usually takes place within half an hour
or an hour : with some ihe cfTccts are slept olTl while
others may be very excitable and hysterical. Nausea
nfld vomiting frequently follow ether narcosis, and
basins and towels should be kept at hand, so that the
clothing may be protected. The head must be low,
no pillow being used. If the vomiting is persistent,
frequent drinks of water only aggravate it; Seltzer
water in sips or a little cracked ice is better. The '
extreme thirst may be somewhat relieved by hot tea
or hot water, a teaspoonful at a time. If there be pain
from accumulation of gas, a drop of the tincture of
capsicum in a little hot water will often give relief.
For headache an ice-cap or ice-clnths may be applied
and the patient kept quiet; no visitors should be
allowed.

Chloroform ranks next to ether as a systemic anes-
thetic. It has some advantages over ether, as it is
more pleasant to take, its vapor is not so irritating to
the mucous membranes of the mouth and throat, and
its action is much more rapid, while its after effects
are less disagreeable. The danger to life where the
administrator has not had a wide experience is much
greater than with ether. Children and old people bear
it better than the middle-aged. To prepare a patient

//UJlSfNG.

to inhale chloroform the same points are observed as
with ether: anointing fhe lips and nose with vaseline
or ointment is here even more essential, as chloroform
vapor is very irritating, and if applied to the skin for
any length of time may produce vesication.

Chloroform-inhalers are of many kinds; the small
wire frame covered with flannel is perhaps among the
simple'itandbest,but in the absence of any special appa-
ratus a towel or napkin may be used. Half a drachm of
chloroform is pourtd upon the towel, which at first is
held some little distance from the face, and gradually
brought nearer until it is within two or three inches
of the nose and mouth ; this allows for free dilution
with air — an absolute necessity. The patient should
be induced to breathe quietly and gently, in order to
avoid any Irritation or sense of suffocation; the time
required to produce in.sen.'^ibility is about five minutes,
and when this is complete there will be no contraction
of the eyelids when the conjunctiva is touched. The
pulse, respiratidn. pupil, and color of the face should
be constantly watched, as, while the patient is in ap-
parently good condition, the breathing or the pulse
may suddenly cease and the face take on a livid hue or
become gha.-itly pale. The.'ic are indications of danger.
Artificial respiration is at once resorted to if the respi-
ration ceases. If it be the pulse that stops, no time
must be lost, and the patient must be partially sus-
pended, with the head lowered, and artificial re.'ipiration
at once instituted. A nurse will probably seldom, if
ever, be entrusted with the administration of chloro-
form.

Chloroform is almost exclusively used instead of

ANAiSniESIA. JJS (

ether with obstetrical patients : it is administered gener- I
ally durjn{^ labor in the second stage when the pain is '
very severe or when forceps are applied.

The agents used as local anaesthetics are the hydro- ]
chlorate of cocaine, carbolic acid, ether, alcohol, nitrous |
oxide, methyl chloride, and ice.

Cocaine is a powerful local anaesthetic; it is used 1
in solution in strengths from i to 20 per cent. For I
the surface of mucous membranes a piece of cotton [
saturated with the solution is held to the surface for I
a few moments until insensibility is produced. To I
produce anaesthesia of the skin it is used hypodermic- j
ally. Before injections are given the skin and syringe ]
should be antiseptically prepared. Cocaine is particu- j
larly valuable in operations upon the eye, ear, throat, |
and nose, and also in making examinations of these \
organs; it should never be used, however, except by j
a physician's order, as individual susceptibility to the
toxic influence of the drug is sometimes marked, and j
death has more than once followed its use even ;
weak solutions. Some surgeons prefer using a weak j
solution of cocaine, combined with carbolic acid;
it is well to have both drugs in readiness.

To produce insensibility of a part by means of car-
bolic acid, the pure acid (liquefied) is painted over the I
skin; this first causes some pain, but is followed by I
numbness, when an incision may be made without its 1
being felt. It is little employed, owing to its caustic
action upon the tissues.

To produce local insensibility by means of alcohol,
a vessel containing the alcohol is placed in a larger
one which is filled with ice and salt, and when in-

354 NURSING.

tensely cold the part (a finger or hand) is either placed
in it or compresses kept very cold with the alcohol
are laid over the part until insensibility is brought
about. Ice and salt held in contact w'tn the tissues
into which the incision is to be made wul also render
them less sensitive to "-■""

The ether spray din le surface for a few

seconds will also bring iition of local anaes

thesia.

CHAPTER XXIII.
How TO Observe, Report, and Record Symptoms.
It is essential for a nurse from the beginning of her
hospital work to cultivate the faculty of observation,
and this quality should extend not only to the par
ticular symptoms of her patients, but to every detail
of the work pertaining to their welfare. In her first
month in a hospital the beginner will probably only
succeed in becoming familiar with her surroundings, a '
few nursing appliances, and some of the minor steps
in nursing; and with the multitude of new duties
which press upon her it is unlikely that she will be
able to get any very clear ideas about the individual
patients and their diseases. In her second and third
months a clearer conception of her duties to the pa-
tients will gradually open up to her, and any general
symptoms or conditions common to all sick people
will one by one present themselves to her notice, to
be followed gradually by symptoms or conditions
peculiar only to individuals or to particular diseases.
Not al! the observations concerning patients that a
nurse must necessarily be conversant with can be
grasped immediately; they are only acquired through
constant contact with illness, much practice, and the
application of the principles which have been taught
to her with reference to diseases and their phenomena.
To some, who are endowed with quick instincts and

356 NURSING.

keenness of perception, this knowledge comes much I

more readily than to others, who can acquire habits 1
of observation and accuracy of statement only by pa-
tience and perseverance. In the observation of symp-
toms there are three rules that a nurse should never
lose sight of:

1. She should always observe mmutely and accu- I

rateiy the condition of her patient ;

2. Tiiese observations should be made according to

a regular system and method ;

3. She must learn to express the results of such ob- ,

servations in a clear and concise form, both 1
orally and in writing. ,

It is very important that these three principles
should be daily carried out in practice, as it is upon
the nurse that the physician must for the most part
depend for accurate statements regarding the condi-
tion of the patient during his absence. Frequently
such observations will assist him materially in mak-
ing a correct diagnosis and in the treatment of the
disease. As we said before, the reports should be
i^iven in a systematic, clear, and concise form ; they
should contain a simple statement of facts as they
present themselves, without an attempt at offering
-iny opinion or sugge.-itiop A well-trained nurse
is never guilty of attempting the diagnosis of a dis-
ease, even when inviteJ to do so. Her manner should
be quiet and matter-of-fact, and she should not be too
ready to take unto herself any undue credit for doing ,
only that which it is her duty to dn. Her own work •
will also be made easier for ln;r in proportion to her I
ability to distinguish grave symptoms from unim*

OBSERVATION OF SYMPTOMS. 357

portant ones, since she will frequently be placed in a
position where she must decide whether the symptoms
arc sufficiently serious to require the calling in of a
physician at an inconvenient time, or whether the in-
structions already given are sufficient to meet the
requirements of the case.

Symptoms are either objcclwe, those outward indi-
cations observed independently by the physician, nurse,
or any one under whose notice the patient comes;
or subjective, those complained of by the patient or
elicited by inquiry from him. Both subjective and
objective symptoms must be remembered, but the pa-
tient's statements cannot always be fully relied upon,
as ill people sometimes imagine their condition to be
worse than it really is, and exaggerate their ailments,
while clever malingerers, who are only feigning illness,
are never at a loss for a pain or an ache. These state-
menbi, however, must be reported just as they are given
by the patient, as it is for the physician to decide which
of the symptoms are real and which are simulated.

In a hospital the observation of a case should begin
immediately after a patient comes under the nurse's
care, and be conlinued during all the time he remains
under it. The time may be divided into three periods :
(1) that immediately following his admission ; (2) that
during which he is confined to bed ; and (3) that of
convalescence.

The first thin<; to be noted is the general appearance,
whether the patient seems very ill and in great suffer-
ing, or whether the indisposition is ,apparently only
slight and not alarming. Besides this, attention is
given tu the sex, color, and approximate age, then to

the manner or disposition, whether the patient !
to be quiet and orderly or rough and inclined to 1
troublesome ; any indications of weakness, such as i
ability to walk, awkwardness, or peculiarity of gait,
should be noted, as well as any signs of deficient
power in the trunk or in the arms. In examining ,
into the condition of the mind u-e note whether th<
patient is conscious or unconscious, rational or irra.-]
tional. depressed or hilarious, or whether he show anjrfl
signs of intoxication or delirium. The speech, tooJ
should be observed: it may be "thick" or "clear."
or there may be hoarseness ; again, the patient may
mutter or give vent to loud screams, according to
the form of the delirium. The face and special senses
are also very interesting ; thus the color of the skin
may be bluish (cyanosis), pale, or jaundiced ; the ex-
pression may be one of pain ; and the eyes are to he
looked at particularly to ace whether the pupils are
dilated or contracted, and whether they arc equal orl
unequal in size.

The pulse and temperature maybe taken while these
symptoms are being observed, and it should be remem-
bered that all the.se points are to be noted in a quiet.
unobtrusive manner, and as far as possible without the
patient's knowledge. When the patient first enters the
hospital any peculiarities of manner arc apt to be ex-
aggerated, and. as we said before, the registered pulse i
and temperature may not, owing to excitement and
fear or to the unusual exertion necessitated by travel-
ling, give us entirely reliable information. A nurse ]
should do everything in her power by gentleness and J
attention to put a new patient at his ease, and in doing j

OBSERVATW.\ OF SYMPTOMS,

359

so she may very soon gain his confidence and learn
important facts about his previous history that might
not otherwise be ieamed either by herself or the phy-
sician. These first observations occupy only a few
minutes, as a nurse familiar with her duties can pass
from one detail to another with rapidity.

Further observations are made during the patient's
bath, whether given in the tub or in bed, but before he
is put to bed his weight should be taken. When in
bed the general condition of the body is ascertained,
and the existence or extent of any deformity of obesity,
emaciation, or cedema is noted ; the condition of the
skin is next observed, whether it be hot and dry or
cold and clammy, etc., or whether there are signs of
any eruption, of bed-sores, ulcers, or of old or recent
scar.-i. Where such an examination is possible wc
should not fail to look for any peculiarities relating
to the thorax or abdominal organs. The position the
patient as.sumes, the extent and seat of any pain com-
plained of, nausea or vomiting, cough, expectoration
(its nature and amount), are all important. Some in-
formation on these points must be ready for the phy-
sician on his first visit if he asks for them. In an hour
or so after a patient has been put to bed and is quiet
and composed, the pulse, temperature, and respiration
should again be taken, as they are now likely to nfford
more reliable information than on admission.

The daily symptoms of a bed patient that must
necessarily be noted may be best observed in connec-
tion with the different .systems of the body, particular
attention being paid to those which are more especially
involved, but all incidental symptoms must also be

he patiem^^l
ness coni-^^^

360 NUKSmC.

taken into account. The position which the [
assumes, the expression of his face, restlessness, coi
plaints of pain, the occurrence of hjemorrhage, rigors,
any elevation of temperature, the condition of the pulse
and respiration, as well as signs involving any of the
special senses, — all must be recorded. It may not be
necessary, of course, to mention all these symptoms in
connection with a disease, but it is necessary that a
nurse should understand something of the signiiic^ncc
of each when unusual symptoms make themselves
manifest.

The position in bed is of importance, as often by it
our attention is drawn to the organ affected, ^i^ce the
patient usually chooses, sometimes involuntarily, the
position which causes the least pain and discomfortJ
In diseases of the heart or respiratory organs, wherel
there is difficulty in breathing, a sitting posture will be 1
preferred, or if one lung is affected the patient will
sometimes lie on that side in order to give the normal
lung as much freedom as possible, so that it may be
better able to meet the increased work it is called
upon to f>crform.

Dyspncea, or shortness of breath, occurs in various
conditions, particularly in diseases of the lungs and
bronchia! tubes, and almo'it always in diseases ol the
heart, when the circulation in the lungs is impeded;
shortness of breath is often a prominent symptom in
certain stages of Bright's disease, and relieved breath-
ing is usually indicated by the patient's ability to lie
down without a sense of discomfort or distress.

In abdominal diseases the patient may lie on the sidi
with the knees drawn up to relax the abdominal muscle^^

OBSERVATION OF SYMPTOMS. 36I

and thus relieve pressure ; for this reason where there is
severe pain from peritonitis the patient will generally
prefer to lie on his back with the knees drawn up.
keeping as still as possible, since every motion causes
intense pain; in colic the patient is restless and turns
frequently, preferring, however, for the most part, to lie
on the abdomen, since he finds that pressure relieves
the pain. Usually in fevers, as in typhoid fever, the
patient if not delirious lies quietly on his back, and
is passive when turned from side to side ; any attempt
to move himself of his own accord is to be regarded
as a favorable symptom. Where there is very great
pain the patient is apt to be quiet, fearing the slightest
movement, and in conditions of great weakness no
effort is made to change the position. In some ner-
vous diseases there may be continued restlessness, and
no position is comfortable for any length of time. As
the fatal termination of disease approaches, there is
also very often extreme restlessness, shown more espe-
cially by movements of the head, hands, and feet; but
this is quite different from the ordinary restlessness of
illness, and is accompanied by other more important
symptoms.

Pain. — Where there is a complaint of pain, it should
be inquired into, and as far as possible its nature and
seat should be determined. Pain may be general or
strictly localized; it may be continuous or come on
in paroxysms. It may be dull and boring or sharp,
shooting, and throbbing. At the same time, as we have
said, the condition of the pulse, the expression of the
face, the position of the patient in bed, should be noted
and any further symptoms recorded.

NURSING.

The appearance or expression of the face, to which 1
we have more than once referred, should become a I
study to the nurse, for, coming as she does in contact j
with so many different people, she will find it of great I
use to be able to interpret correctly the different ex-
pressions of the countenance both in health and dis-
ease. Palenes-s of the face in an invalid, coming on
suddenly, may be associated with faintness from hem-
orrhage or some other cause, while a more or les
gradually increasing bluish appearance about the nos-
trils, lips, and cheeks is indicative of imperfect oxy-
genation, depending on some interference with the
respiration or circulation. Its duration and degree
should be noted. A " drawn " appearance about the lips
and mouth accompanies nausea, and excess of blood in
the head is shown by a deeply-flushed, almost purplish-
red color of the face. In pulmonary diseases there
may be a characteristic flush or red spot on one cheek,
not infrequently on the same side as the affected lung.
Besides these, there are tints peculiar to certain dis-
eases; so we have often a wa.\y-white hue in Bright's
disease, the yellow skin in jaundice, the sallow com-
plexion of opium hoMtues, and the dry, flushed face
in fevers. The rash of some eruptive fevers appears
first on the face, and its general appearance, extent,
and color should be observed.

The expression may be indicative of marked changes
in the course of disease. A pinched, anxious expres-
sion is often associated with a grave prognosis, and a
dull, apathetic, expressionless countenance, like that so
often seen in typhoid fever, is often significant of a
serious illness. On the other hand, after the crisis

OBSERVATION OF SYMPTOMS. 363

of the disease is passed the patient will often show
by his calm and placid look tlidt a marked improve-
ment has taken place. Where there are any signs of
paralysis or impairment of the mental faculties, it should
also be noticed whether both sides of the face are alike,
or if the mobility is confined to one side or if one cor-
ner of the month is puffed out during expiration.

Rigors or chills arc sometimes the first indications
of an oncoming illness, and are important symptoms.
The duration and intensity of the chill may vary greatly,
from a slight subjective feeling of cold, lasting only a
Tl-w minutes, to a pronounced fit of involuntary shiv-
ering, which may last for half an hour or more, and
during which, in spite of all efforts to keep his body
still, the patient is shaken, sometimes so violently as
to move the bed on which he Is lying. During this
time the body may be externally cold and the face,
lips, and finger-tips blue. The temperature should
always be taken during a chill, when it will usually
be found above norma!, and again after the chill has
ceased; during a severe chill there will probably be
hyperpyrexia. These paroxysms occur in malarial
fever (when they may be severe and recurrent), at
the beginning of other fevers, and in acute inflam-
mations. When they occur in the course of any ill-
ness except malaria, they are of importance, as they
indicate the probable existence of some complicating
suppurative process. Notice should be taken when
tiiey occur, how long they last, and if they are re-
peated, the degree of their severity, and the tempera-
ture of the body during and after the chill.

In a case of hemorrhage the source of the bleeding

364 Xt/KSWO.

should be investigated, as well as the appearance of
the blood, its color, whether it is fluid or coagulated
or mixed with other substances, such as food, and the
quantity of blood lost should be estimated.

The number of hours a patient sleeps should be re-
corded in the written report, as the administration of
narcotics will depend upon the amount of siccp ob-
served by the nurse; a patient's own statements are
often very unreliable on this point. One should de-
scribe whether the sleep is quiet or disturbed and
restless, whether the patient sleeps lightly and is
ea,sily wakened, or whether he is only aroused with
difRcultj-.

The temperature, pulse, and respiration arc always
the chief guides, however, and ihcy have been consid-
ered by them.selves elsewhere.

The condition of the tongue is an important symp-
tom, as almost all diseased conditions have some action
direct or indirect upon it. It may be pale and flabby.
having marks of the teeth upon it.orbright red. or. again,
it may present the appearance which is described as the
"strawberry tongue" of scarlet fever. If the longuc
is coated with fur, the color may be whitish or of vary-
ing shades of brown or black. Tlie darker shades of fur
are often present in the continued fevers. The tongue
usually cleans first al the edges, the process gradually
advancing toward the centre. When it cleans in patches,
this is held to be no good indication. We should notice
whether it be dr)' or moist : the dry tongue occurs most
frequently in fevers and in mouth-breathers; any swell-
ing or soreness is also to be watched for. In observ-
ing the tongue the teelh and gums should not be for-

OBSEKVAr/ON OF sy^^PTOMS. 365

gotten; if there be any accumulation of sordes about
the teeth, or if they be loose, or the gums are sore and
tender and bleed easily, a report should be made at
once, especially if mercurials are being given.

Special Senses. — Tastf. — When the tongue is out
of order the sense of taste is often impaired. Cer-
tain diseases or the administration of certain drugs
may give rise to a characteristic taste in the mouth ;
thus the patient sometimes becomes aware of a per-
sistent metallic flavor while taking mercurials or
arsenic ; a bitter taste is complained of in certain dis-
orders of the digestion, and a salty taste in phthisis.

The Ears. — In disease the sense of hearing may be
abnormally acute, especially in nervous troubles; some
drugs, particularly quinine, may produce temporary
deafness. The occurrence of pain in the ear or any
diiicharge from it, with the amount and character
of such discharge, should be carefully recorded.

T/u Eyes. — In observing the eyes we should note the
condition of the pupils. They may be dilated or con-
tracted; they may react readily to light or their size
may remain unchanged. The eyeball itself may be
roiled from side to side or remain motionless. In
some diseases we have protrusion of the eyeball, in
others it may be sunken. The conjunctival reflex
may be active, while in cases of complete uncon-
sciousness it is lost.

Any departure from the normal in the condition of
the skin should be watched for; it may be too dry or
too moist. Perspiration maybe caused in illness either
by weakness or it may accompany a fall of tempera-
ture. A high temperature with a damp skin indicates

366 Nl/RS/NC.

great weakness and is fl grave symptom. Any pecu-
liarity in the odor of the perspiration should be noted.
Localized sweating is not uncommon in certain forms
of nervous di.seases.

In diseases of the respiratory organs the chief points
to notice are the cough, expectoration, rate of breath-
ing, pain, ami dyspnoea.

Cough is the result of irritation in some part of the re-
spiratory tract, and is caused very often by some accu-
mulation or occurs as the result of reflex irritation. The
main points to notice about a cough are its frequency
and duration, whether it comes on in paroxysms or is
short, hacking, and difficult to control; at what times
of the day or night it seems to be worst, and whether
it is brought on by lying down or moving about; the
amount and gross appearance of any accompanying
expectoration and the location of any pain associated
with it should also be noted. Coughs may be described
either as sharp and barking, as in some forms of hys-
teria, or deep and hollow, as in lung diseases; then
there is the ringing, brassy cough which accompanies
aneurisms of the aorta, and the peculiar laryngeal cough,
which is high-pitched and superficial : besides these
must be mentioned the characteristic croupy cough in
children — a crowing sound produced by the spasmodic
contraction of the glottis. The typical convulsive par-
oxysm of whooping cough, in which the sound is loud
and barking and accompanied by a whoop heard .soon
after a long inspiration, will hardly be mistaken after it
has once been witnessed. If there is any expectora-
tion, it may be mucoid — that is, clear and tenacious,
somewhat like the white of egg; mu co-purulent, a

OBSERVATION OF SYMPTOMS. 367

combination of mucus and pus; or completely puru-
lent, as in abscess of the lung. It may be ropy and
tenacious, or frothy, and may be streaked with blood.
No sputum can be said to be characteristic of phthisis:
the nummular or coin-shaped sputum occurs perhaps
most commonly in chronic tuberculous disease of the
lungs. Now-a-days, by means of special staining
methods and microscopical examination, physicians
are able in three or four minutes to examine the
sputum for tubercle bacilli, and if these are found,
there can be no doubt of the existence of a tuber-
culous process. The bacilli are found in greatest
numbers in the minute, whitish, cheesy-like particles,
about the size of a pin's head, so often seen in the
sputum of phthisical patients. When the lung is gan-
grenous the sputum consists, as a rule, entirely of
greenish pus, and has a very offensive odor. The
sputum of pneumonia is scanty as a rule, sometimes
very tenacious, and at certain stages is intimately
mixed with blood, which gives it a rusty color. The
amount of blood may be great, producing the so-
called prune-juice expectoration; in the pneumonia
of drunkards or where the constitution has been
much impaired, the measurements of quantity should
be accurately reported and recorded: and if at any
time the nature of the sputum appears to be changed,
a specimen should be preserved for the inspection of
the physician.

Dyspncea, palpitation of the heart, variation in the
quality and frequency of the pulse, syncope, and
cedema may all be present as symptoms of disease of
the heart; anyone of them may occur in other diseases.

I
I

36S ATXS/.VG.

Pilpinrtioa is freqocol not oviy in or^mc but in fuoc-
ttooa) di<tc«<ics of tbc beait. and in dy^iepsia, hysteria.
Mid oenvus prastntion.

ReUftUf infermitioo as to the condition of the ap-
petite and die aittouat of food taken by a patient can
only be obtained 6wn the nurse's observations ; the ex-
ttd amounts. whed>er of solid or liquid foods, which
are taken should be noted, and al$o the houn: at which
Xhey were pvem. It should be noticed whether the
(ood is eaten with a nJish or only with an elTort ; some
patients are inclined to be ravenous, white in others the
appetite is capricious, and can be tempted only by par-
ticular (arms of fix>d. Any inclination to nausea or
\-oni)t)ng should be irconkd.

When food is not rcuiocd tbc fact should be recorded
and trported, with the antount and characier of the
vomitus. In some instances this may have peculiar
characteristics; if so, it should be covered over and
saved to show to the ph>-5ician. The color and odor
. of the rejected material are of importance, especially
where there is any suspicion of intestinal obstruction ;
for where this is at all serious tbc contents of the in-
testine, not being able lo pass by it, are forced back
into the stomach, producing vomiting of fxcal matter.
Small quantities of blood may be changed in the
stomach from a red to a dark-brown color by the
action of the gastric juice, so that the vomited ma-
terial has been described as "coffee-ground" vomit.
The position and nature of any pain associaied with
vomiting, and any other symptoms occurring with it,
should be inquired into.

Flatulence is the result of fermentation of the con-

OBSERVATION OF SYMPTOMS. 369

tents of the alimentary canat, with the production of
gas; if these gases are not liberated in some way
iliey accumulate until there is tympanites or distension
of the abdomen ; this condition is recognized by the
liard, unyielding, resonant, distended abdomen, and for
its relief the passing of a rectal tube is frequently ordered.
In a general description of evacuations from the bowt;U
should be mentioned the color, consistency, whether
farmed or liquid, the admixture or non-admixture uf
blood, mucus, or pus, the quantity, odor, and frequency.
The evacuations characteristic of certain diseases will
be found described elsewhere. The urine should also
be kept imder daily observation.

The implication of the nervous system may be first
shown by one or more of many various symptoms.
Thus we may have incoherency of speech, rigidity,
contortions of the face and body, twitchings, delirium,
paralysi.s, coma, most of which conditions may best be
treated of in the general description of nervous diseases.

Delirium may be present as a complication in a great
many diseases : delirious patients should be kept under
constant surveillance, as they frequently get out of bed,
and are liable to do themselves harm. When least ex-
pected, a delirium which has before taken on a low
i|uiet muttering form may become loud and noisy or
even maniacal. On the other hand, there may be
merely a wandering of the mind, without any at^
tempt to move — a symptom which sometimes occurs
only during sleep.

Coma is also associated with many diseases, partic-
ularly those of the kidneys and heart. It is a state of
complete insensibility. In coma-vigil the patient lies

witli the eyes wide open, but in a ddirions, unooascioas
state ; both are very grave 5)'niptofBs. In connection
with diseases in women the catamenia should be
fully watched as to regulant\', amount, color, and pain.

Even s>-mptoms which may appear trivial should be
considered of sufScimt importance to report, for uhen
takenin coanection with others they may be of value.

In hospitals, regular report-books for the night re-
ports should be kept. The day report can be given to
the physician when he makes his daily visit, but the
Dight nurse should make a brief and accurately written
statement of each patient's condition during the night.
In the case of patients who are seriously ill a special
written record for the twenty-four hours should be
kept. The night report should be headed with the
date, and each patient's name is to be written on the
margin, a space of one or more lines being left be-
tween each. No remarks ^should be allowed in this
report beyond a clear statement of facts founded upon
observations such as wc have spoken of in this chap-
ter, and at the end should be appended the nurse's
signature.

scions ^^^1
ection ^^|

care- ^^\

CHAPTER XXIV.

Obstetrics. — Pregnancy. — Symptoms and Physical Signs. — De-
velopment OF THE FiETUs.— Abortion,— Miscarriage.— Prb- I
MATURE Labor.— Care of the Patient before, niritiNG. awd .
AFTER Labor,— Care of the Breasts.— Care of the Child.—
The Puerperal State.

The impregnation of the ovum, which is to result
finally in the formation of a new being, constitutes
what is called conception. The ovum lodges in the
uterus, and, remaining there, gradually develops until
the fcetus matures, when it is expelled, under normal
conditions, in the shape of a well-formed infant. In
the beginning the new organism is called the embryo,
after the fourth month the fcetus. The symptoms and
signs of pregnancy are numerous. The first to appeai'
after cessation of the menses are nausea and vomiting
(morning sickness), which, however, generally occur
only in the early months of pregnancy. In some cases
there may be slight nausea on rising, which does not
result in actual vomiting, and as a rule the nau.sea and
vomiting of pregnancy amount to nothing more than
an inconvenience, but occasionally this symptom is ag-
gravated, and may become of grave import. A few
weeks after conception there can be noticed some
enlargement of the breasts and a darkening of the
arcols ; the breasts become fuller, the veins are dis-

Tbe dBoges Di Ae sue of Aeabdomeaare Aftmd-
cat of cuiuse apm tbe prog^cssne cab^genicat of the
aterm. The aterostf frst is knr is the pefaris; somk-
time dorn^tbc fooftb moDtfa tbe fiadas b oaa levd
wjtfa the bdm of tbe pelvis; by tbe end of the fifth
RKXilli it has riiea halfiv^totbc ambtlicas; aodattfae
end of the sixth U oo a level with the BadxBcm. At
the end of tbe seventh oioath the fandus is uudmay
between the ambiltcos and the l^ of the stemom;
at the end of the eighth inonth it reaches to the
xiphoid aulHiee; and finalty during tbe ninth tnoodi
the uicnia again sinks a linlc in tbe abdomcrL Be-
tween the eighteenth and the twentieth week quicken-
ing is fir^t felt ; that is. the mother first ^Is the move-
ments of the child From the fifth month on. the
(cctal heart may be distinctly heard on listening with
the Htethoscope ; the sound resembles the ticking of
a watch under a pillow. The rate of pulsation of the
flctal heart varies from 130 to 160 beats per minute.
Attempts have been made to determine the sex of ihc
child before brrth by the frequency of the heart-beats,
the pulse being generally a little slower in larger
children, who arc more commonly males, but no
trustworthy diagnosis can be made by this method.
Changes aUo take place throughout the whole body
of the pregnant woman ; the heart, having more work
to do, enlarges a little, and there is a general increase
in tension in the .'irterial system. Sometimes there is
HWclling of the thyroid gland.

The obstetrician is often able to diagnose pregnancy

PREGNANCY. 373

very early by a vaginal examination. The vagina as
early as the third week assumes a bluish tint, owing to
the dilatation of the veins, and, what is more important,
the cervix of the uierus becomes softened. In women
who have never been pregnant the cervix feels as hard
and firm as the tip of one's nose, but at the end of the
first month of pregnancy it is much softer than this.
There are often marked digestive changes : the appetite
may be capricious, when there will be a craving for
certain foods ; the salivary secretion is increased.
Wherever pigment is found normally, it is increased
in amount in pregnancy; thus, Ihere is often a deep-
brown line running from the umbilicus to the pubes,
and the face nearly always shows alterations in tint.
Occasionally the latter is very much pigmented, and
we have the so-called masque des femmes eim'inUs.
The nurvous system may be influenced in a striking;
manner: sometimes nervous, irritable women become
quiet and amiable, while those who have been even-
tempered and genial become cross and excitable. The
quantity of urine is increased; there may be functional
disturbances, such as frequent, painful, or involuntary
micturition. Albumin is sometimes present — a sign
which always makes a physician anxious; the bowels
may be constipated. Headache, neuralgias, hsemorr-
hoids and insomnia are not uncommon.

The average duration of pregnancy is 280 days, or
about nine calendar months. The probable date of
confinement may be calculated in two or three ways,
but the one considered the most accurate is to count
back three calendar months from the date of the cessa-
tion of the last menses and add seven days. This will

■ ; err

ifMMIEh fW pbccr
the NModmq^ «'
ifMflier and dcM i~

<i J

|[jmv,and there b _-. . u„; ._.._ .

two tlut nutrient sabstaaces comine from the i
and wiute xubManccs from the child rctumtng to t
riiothcr pa*« thrr>ugh easily.

The rjcveiopnicnt of the foetus begins, as we have 1
MjH, Ijy the impregnation of the ovum, u hich, eDtering |
the uteruM, bccomc<i attached to its mucous membrane^ i
unually on the iip[ier part of the anterior or posterior j
tilcrinc wall, Ijut rarely at the fundus. At the point /
of Junction of ovum and uterine mucosa the placenta j
I* formed. The fcetus becomes enclosed in several J

THE PLACENTA.

membranes, the formation of which is too complicated
to be discussed here, but which will be found fully
described in any treatise on embryology.

The membrane nearest to the foetus, and which con-
tains the fluid in which the latter is suspended, is
known as the amnion, the fluid being called the am-
niotic fluid; while the external coat is designated as
the chorion. The umbilical cord contains the blood-
yesseis which run between the fcetus and placenta. A
fully-formed placenta occupies about one-third of the
surface of the mucous membrane of the uterus. It is
round in form, from six to seven inches in diameter,
and about one inch thick; the surface next the foetus
is covered by a smooth membrane, the amnion, while
the uterine or maternal surface is rougher, and is
divided by shallow furrows into fifteen or twenty
smaller arca^i. which are known as cotyledons. The
placenta is connected with the fretus by the vessels of
the umbilical cord, and the fecial vessels communicate
with the uterine vessels of the mother — not indeed
directly, for, as we said, the two bloods nevermix. The
placenta is the organ by means of which the respiratory,
excretory, and nutritive functions of the ftetus are car-
ried on ; the umbilical cord is attached to the placenta
at one end and to the umbilicus or navel of the child
at the other. It is from sixteen to twenty inches long
and about half an inch in diameter. It is covered by
the amnion, and is mainly made up of a peculiar tissue
calbd Wharton' s Jelly ; it contains the umbilical vein
and the two umbilical arteries; the vein carries the
blood from the placenta to the foetus, and the arteries
return it.

The terms used for an uncompleted pregnane)- are

376 ATUxs/fi^c.

abortion, miscarriage, and premature labor. When
the ovum is expelled at any time during the first three ■
months of pregnancy, we say that an abortion has
taken place; when the expulsion occurs at any time
between the third and seventh months {i. c. before the
child is viable), we call it a miscarriage; a premature
labor is one which occurs between the seventh and
the end of the ninth month.

The care to be given in nursing a case of abortion
is, if possible, even greater than that required in one
of normal labor: the latter is a natural, the former a
pathological process. There will be more danger of
hemorrhage and more shock to the nervous system.
The patient must be kept absolutely quiet, and much
attention must be paid to diet and cleanliness. The
symptoms of abortion are pain and ha;morrhage; the
latter may be excessive, owing to a partial separation
of the placenta from the wails of the uterus. Besides,
it is always more difficult for the uterus to regain its
normal condition after abortion than alter labor at
term.

Treatment of Abortion. — In a case of threatened
abortion the doctor should be sent for at once, but if
the symptoms are slight, absolute rest in bed and the
avoidance of all mental excitement may be the only
treatment necessary. If. however, the abortion seems
inevitable and there is much hiemorrhage, the patient
is to be kept perfectly quiet, with the foot of the bed-
stead elevated, and in an emergency the nurse may be
obliged to tampon the vagina. If abortion takes
place before the arrival of the doctor, all discharges
must be saved in a covered basin for his inspection.

The rupture of the membranes some time prior to

LABOR.

labor may be considered as an accident. The patient
should be put to bed, kept perfectly quiet, and the
doctor notified.

Convulsions sometimes occur during the pregnant
state, and too often are the indications of uramic poi-
soning. Nervous patients should be allowed pk-nty of
light, nourishing food and gentle outdoor exercise,
and be kept as free as possible from all worry and
excitement.

Certain symptoms precede the onset of labor, be-
ginning about two weeks or ten days previous to it,
when the fcetus descends somewhat into the pelvic
cavity ; the pressure is now removed from the thoracic
organs to those of the lower abdomen, and may cause
frequent micturition, constipation or diarrhcea ; cedenia
of the lower extremities is sometimes very marked,
owing to the pressure on the pelvic veins. The cervix
secretes a large quantity of mucus, which lubricates
the surrounding structures and prepares them for the
expulsion of the head. The vagina becomes softer;
rhythmical uterine contractions come on in the even-
ings about 6 p. M. and last until midnight These are
not so noticeable in primiparse as in multipara;.

Labor is divided into three stages, which practically
are not sharply separable in normal cases. The first
stage comprises the changes which bring about com-
plete dilatation of the cervix; during the second the
child, and during the third the placenta is delivered.
The dilatation of the cervix is a gradual process ;
when the pains are first felt it may be possible only to
introduce the tip of the finger through the os, but with
each succeeding pain the bag of waters is pressed down
and produces gradual and even dilatation. When a

378 NURSING.

pain subsides, the bag tends to recede into the uterus,
but with each subsequent contraction it continues to
press upon the cervix until the tissues are fully re-
laxed. During this process the surrounding blood-
vessels become congested, and the cervix may be
slightly lacerated, so that the discharge is tinged with
blood. When the external os is three and one-half
inches in diameter, it is time for the membranes to
rupture. The rupture of the membranes should occur
spontaneously, but occasionally it must be artificially
produced by means of a grooved director, a sterilized
darning-needle, or by a sharp finger-nail. After this
the head descends into the vagina, a portion of the fluid
remaining behind; as the head goes back during the
interval between the pains, another portion of the waters
comes away. This process continues, the pains gradu-
ally becoming more vigorous, until all the water is ex-
pelled. In rare instances the head may be born with-
out rupture of the membranes, and the child is then
said to have been " born with a caul." The uterus,
assisted by the abdominal muscles, continuing to con-
tract, causes the child to descend, dilating the parts as
it goes. Finally, the head comes down upon the
perineum, and begins to dilate the vulval outleL At
this stage a certain amount of support should be given
to the perineum during a pain, as the head presses
upon it, .stretching it each time a little more. While
the head is being born the perineum should be sup-
ported by the hand, while at the same time the head
is pushed upward, thus relieving the .strain and lessen-
ing the danger of rupture of the perineum, which
occurs in from 20 to 40 per cent, of all cases pregnant
for the first time.

LABOR. 379

The placental or third stage lasts from the time that
the child is born until the placenta is delivered ; dur-
ing this period the woman may complain of some
slight disturbance, such as chilly sensations, and after
the removal of the child the filling up of the blood-
vessels of the abdomen may cause headache or even
syncope. Before the placental pains come on there is
a period of quiet of from five to fifteen minutes; then
contractions begin aj^ain. and the delivery of the pla-
centa takes place. In a normal delivery the placenta
descends folded vertically in the axis of the womb
through the vagina; after thirty minutes, if uterine
contractions do not take place of their own accord, it
may be necessary to excite them ; this may be done by
gentle friction over the fundus. Five or six gentle mo-
tions will be usually enough ; if after gentle manipula-
tion the uterine walls do not contract, the obstetrician
usually expels the placenta by what is called "Crede's
method." The uterus is firmly grasped in the left
hand, so that an even pressure can be exerted from all
sides and from above upon the body, with the result of
actually squeezing out its contents. The best plan is to
.stimulate the fundus gently by kneading it until a con-
traction is felt, and then express immediately.* Traction
on the umbilical cord should never be made under any
circumstances by a nurse. As the placenta is expelled,
the membranes may be caught in the os ; even now no
traction should be made, but one twists the membranes
gently to prevent tearing, and waits a moment or two
until the spasm of the cervix is over, when everything
will come away, After the delivery of the placenta
the uterus presents at the placental site a large raw sur-

* S« Appendix, Nou ij.

jSo NURSffiTG.

face with open bleeding vessels, from whicli diere
may be haemorrhage if the uterus does not contract
well. After the delivery of the child it is essential
that one hand be kept always over the uterus until
some time after the placenta is born. Occasionally
the doctor will entrust the nurse with this duty.
Any relaxation of the uterine walls must be carefully
watched, as there is no danger of harmorrhage from
the torn placental vessels so long as the uterus keeps
well contracted.

It is the numerous lacerations, small and lai^e, of
the uterus, cervix, vagina, and perineum which make
the puerperal state so dangerous, since these are so
many open pathways for infection with septic material.
For this reason the same precautions must be taken in
treating a patient in the puerperal state as in caring for
any open wound; in other words, the most rigid anti-
septic measures should be enforced.

The average duration of labor in primiparse is seven-
teen hours, in multipar<e twelve hours. The second
stage of labor in the former usually takes two hours,
and in the latter one hour. Labor-pains usually begin
in the evening, and the majority of births take place
between the hours of 13 and 3 a. m.*

When a nurse is called to assi.st at a confinement,
her first duty is to see that the necessary articles are
ready at hand, that the patient is prepared, and that the
room and bed are arranged; she must also make sure
that everything has been provided for the reception of
the child. There must be plenty of hot and cold
water, five basins, preferably of china or granite-ware,
nail-brushes, 100 Bernay's bichloride tablets (four to

•S« Appendix, Nole id

THE LABOR-BED.

a pint making a i-iooo solution), 4 oz. permanganate
of potash, 8 oz. oxalic acid, 4 02. boric acid, sterilized
vaseline, one dozen sterilized towels, one sterilized
sheet, sterilized bobbin for tying the cord, plenty of
clean towels, a bath thermometer, a rubber sheet, a
small old blanket or a piece of an old blanket, a large
square of old muslin or linen, and blunt scissors. A
Davidson's syringe, ergot, and chloroform may also
be required, but the doctor usually provides these.

The labor-bed should be of medium height, and
situated so that it may be accessible from both sides;
a hair mattress is the best, and it should not be hol-
lowed out in the middle; a feather bed should never
be used for this purpose. The mattress is to be pro-
tected with a large rubber sheet, and over this a cotton
or linen sheet is placed; next comes a draw-sheet or
large sheet folded once, which should be kept smooth
and in position by means of safety-pins ; then over this
is placed a second rubber sheet and draw-sheet, which
may be removed after the confinement with little dif-
ficulty, leaving the patient in a dry, comfortable bed.
In addition to these sheets, pads maybe prepared to
absorb discharges: the most convenient size is about
two feet square and two inches thick; they may be
made of either bran, sawdust, or absorbent cotton, the
last being rather more expensive. The cotton may
be covered with cheese-cloth ; soft old linen or muslin
does very well for the bran-pads, the bran being pre-
vented from becoming lumpy by loosely quilting the
pad. These pads may be rendered perfectly clean by
sterilizing in an Arnold sterilizer for half an hour be-
fore using, or by baking in the oven. When used
properly they will absorb all discharges, and may af-

tciwMv DC usny uuliuyca by DMning. locsc pi^~

osticms can, bowcvu, be icBdemf u ami w sM>y iiy

the 09C of the obstctiical pad tsvcnted by Dr. Kelty.

wnicB piCHUKs ai^ sotSag

'"* '* of Ibe bcd-ltBcn. In pcimc

? practice it is osoalty pn>-
vklcd b}- tbc obscctiicia*.
(See Fig. i8.)
The nurse should next pre-
pare the patient by givii^ bcr
a thorough bath, brushing the
hair and braiding it into two
braids; the bowels arc to be
emptied by giving a sinqde
enema, and if the urine is not
voided the patient should be
catheterized. The external
parts should be carefully
bathed with soap and water,
and then with a l-iooo
bichloride solution. The
Svpi-HAi. rkmu cuuio*. patient is best clothed in a
clean night-dress and en-
veloped in a warm wrapper. Light, unstimulating,
and easily digestible food is given, and she is allowed
lo move about the room during the first stage, unless
there should be a previous history of precipitate labor.
The first stage of labor may occupy from 12 to 14
houTH, During the period the child should be fre-
quently palpdUd through the abdominal walls of the
mother, and llic fecial In art counted, as marked
cliiirgcs in it frequently imiicate that the child is in
danger.

LABOR. 383

Owing to the danger of infection, vaginal examina-
tions should be made as rarely as possible, and then
only by the doctor; at least 95 per cent, of all cases
can be conducted by palpation through the abdominal
walls.

The only information which cannot be gained by
palpation is the degree of dilatation of the cervix, and
this can be told in great part by the character of the
cry to which the patient gives expression.

In preparing to make an examination the external
genitalia should be again washed with soap and hot
water, and then with a i-iooo bichloride solution,
being afterwards cooled with a towel soaked in the
same solution.

The hands and forearms of the examiner should
then be carefully disinfected as follows: Soap, hot
water and nail brush for at least five minutes, or until
macroscnp! cully clean ; soak -n hot siiturated solution
of permanganate, wash it offin hot saturated solution
of oxalic acid, and then soak for three minutes in
i-iooo bichloride solution, the hand going wet from
the solution to the vagina,

A sterilized towel is then placed beneath the but-
tocks of the patient, and the examination made under
the guidance of the eye, the labia being spread apart
by the other hand, so that the examining finger may
be introduced directly in the vagina, without coming
in contact with the external genitalia. The examin-
ing finger is introduced into the vagina during an in-
terval between the pains, as the membranes are then
lax and the presenting part of the fcetus can be defined
more easily ; but if one wishes to determine the extent

NURSING.

of the dilatation of the os, it is well to examine also
during a jiain, as the outline can best be felt when the
membran(-"i are pressed against it. Every examination
should be made gently and carefully in order not to
rupture the membranes. The patient should be cau-
tioned not to bear down during the first .stage, as this
only exhausts her without doing any good. When
the OS is fully dilated and the pains begin to follow
each other in rapid succession, she should be put to
bed, a large sheet having been previously pinned about
the hips, while the night-dress is folded neatly and
smoothly up under the arms and fastened in place
with safety-pins. This prevents the soiling of the
night-dress, and the necessity of changing it when
the labor is over may thus be avoided.

When in bed the patient usually lies either on hc;r
side or on her back, but preference is given to the
dorsal position.

The expulsion of the head causes the most pain,
and as long as it is advancing satisfactorily it is not
considered wise tn inlerfL-re. If. however, the head
has been down upon the perineum for two hours and
no progress has been made, the physician usually takes
some steps to terminate the labor. It is in this stage,
when the pains are too strong, that chloroform is ad-
ministered in small doses, since the use of it calms
the patient, weakens the pains, and prevents the too
sudden expulsion of the head. Chloroform .should
never be given in the third stage of labor.

The mo.st desirable presentation is that of the head.
Any part of the body may present, and it is particu-
larly important that the obstetrician see the case early.

LABOR. 38J

since sometimes a faulty position may be rectified be-
fore rupture of the membranes has taken place — a
thing which may be impossible later. We are speak- '
ing here almost altogether of a normal labor, in which
the occiput is the presenting part, and shall not refer 1
to the cases in which another part, such as the face,
breech, foot, arm, or shoulder, presents. These pres-
entations will be found fully described in the text-
books on midwifery, and it is important that a nurse
who attends many labor cases should make herself
conversant with many more facts about the subject
than can possibly be considered in the brief space
allotted to it in this text-book.

When the head is down upon the perineum, one
finds out by means of the finger whether or not the
cord is twisted about the neck, and if such a compli-
cation has taken place attempts may be made to slip
the cord over the shoulder, and set it free during an
interval between the pains, when the head has re-
CL'dcd into the pelvic cavity. If the cord is prolapsed,
efforts should be made to push it back carefully
above the head, as there is danger of its being com-
pressed during the passage of the head through
the vulva, and thus the supply of oxygen to the
child be cut off After the head is born there is usu-
ally a slightly longer interval before the next pain : the
nurse immediately wipes out the eyes and mouth of
the child with pledgets of absorbent cotton soaked in
a saturated solution of boric acid. The shoulders are
born at the next pain, and with them, as a rule, the
whole body. The shoulders in their passage, perhaps
almost as frequently as the head, produce laceration of
the perineum.

As soon as the child is bom it is usually placed oa i
its right side; the old idea was that this assisted in
the closure of the foramen ovale. If the child does
not cry or make some sign of life at once, it should be
slightly shaken and a finger inserted into its mouth to
remove any accumulation of mucus, A gentle slap
on the back may excite inspiration, or a few drops of
cold water sprinkled over it briskly with the fingers
will often cause the child to give a cry. If the.se
means are not successful, tickling the ribs in the region
of the diaphragm acts as a strong stimulant to the
respiratory centre, or a few drops of whiskey or brandy
rubbed into the skin will generally be found effica-
cious.

Unless the child shows .ligns of asphyxia, the cord
should not be cut until pulsation in it has ceased, or
at any rate not until the child has cried. The cord
should be tied in two places, the first ligature being.
placed about one inch from the child's abdomen, and
the second about two inches farther away ; it is then
divided with scissors at some point between the two.
Sometimes it is tied in only one place, but the second
ligature is used as a precautionary measure to prevent
haemorrhage from the placenta, or soiling the bed,
or in case there were still a second child in the uterus
the loss of blood might otherwise be fatal to it.

The child should be at once wrapped in a large
square of old muslin, and again In a flannel blanket,
and laid in a warm place until the mother has been
attended to: she should receive the first care unless
there is difficulty with the chJKJ's bn.-.itliJng, After
the birth of the child the hand should be .ippliedto

CARE AFTER LABOK. 3I7

tlie fundus of the Uterus and kept there continuously.
As lont; as it remains firm and hard there is no danger
of lifemorrhage; but if at any time it tends to relax,
becoming soft and flaccid, it should be kneaded vig-
orously, so as to stimulate uterine contraction. But
as long as the uterus is firm and hard, kneading is
only needless, but absolutely harmful, as it interferes
with the normal separation of the placenta from the
uterine wall. For half an hour after the expulsion of
the placenta the condition of the uterus should be
watched in the same way. If it is necessary to
give ergot at all, this is the time, but this drug
should never be given until after the delivery
of the placenta. The latter should be kept in
a covered dish until the physician has had time
to inspect it If any portion of the placenta is missing,
the physician will seek to remove it, as retained por-
tions are liable to decompose in the uterus and be a
direct source of danger. The safest way to dispose
of the placenta is to wrap it in paper and burn it, (
it may be buried.

The external genitalia should now be thoroughly
cleansed with a i-icoo bichloride solution and a
sterilized napkin made of absorbent cotton and
gauze put on. This dressing is changed once in three
hours for the first twenty-four hours; after that once
evcr>' four or six hours is all that is necessary. The
nurse should remoiibcr ncvtr to do this dressing, catke-
terize her patient, or care /or her after a mimetfient of the
bowels ivithout first thoroughly cleansing her oiva liands
and Idlcing every antiseptic precaution possible. If a
binder is used, the most comfortable will be a Sculte-

388

JVUAS/JVC.

tus bandage, as any degree of pressure desired may^

be made with it ; it is held in place with the perineal f
straps. Sometimes extra pressure is made over the
uterus by means of a folded towel placed under the
bandage. The use of this depends, however, entirely
upon tile wishes of the physician: many do not em-
ploy such a pad, owing to the fact that it frequently '
becomes displaced, in which case it does more harm i
than good. After the patient has been bathed and
cared for. she should be kept very quiet ; no talking
should be allowed, and visitors and members of the
family should not be admitted to see her until after
she has had some hours of rest. A constant watch
should be kept upon the pulse, which at this time
will have fallen to or even below its normal level.
An unusually rapid pulse, such as one of lOO or
more per minute, unless it can be accounted for by
some other known cause, may be taken as indicating
the occurrence of hemorrhage. These " post-pa rtum
ha;morrhages " form one of the greatest dangers to be
encountered after the birth of the child. The haimor-
rhage may come on quite unexpectedly, and it is neces-
sary to be always ready to meet this emergency and
to take prompt measures to check it. The means by
which nature endeavors to prevent post-partum hem-
orrhage are contraction and retraction of the uterus ;
the sinuses are tlius closed and the venous blood-
vessels are occluded.

The best thing to do, and the one which can be done
most quickly, if haemorrhage occurs, is to induce con-
tractions of the uterus by grasping the fundus and
employing a (inn but gentle kneading; the foot of

CARE AFTER LABOR. 385

the bedstead is to be elevated, and ergot may be
given hypodermically ; ice may be introduced into
the vagina or very hot douches given, and the
patient should be kept quiet. If this fails, the hand
and arm should be sterilized and introduced into the
uterus, and the blood-clots removed; at the same
time stimulation of the internal surface of the uterus
with the finger-tips usually causes immediate contrac-
tion; the danger in doing this is that infectious mate-
rial may be introduced unless the hand is rendered
surgically clean. Perhaps the safest and most effectual
method is to inject very hot water (120° F.) through a
long douche-nozzle directly into the uterine cav-
ity. Sometimes astringents may be introduced in the
form of lemon-juice, or vinegar, which can always be
procured. This emergency perhaps more than any
other requires presence of mind and prompt action,
and no time should be lo.st in making every effort to
control the haemorrhage. After we have been suc-
cessful in producing contraction of the uterus, a rub-
ber bag of cold water may be placed on the abdomen
above the symphysis pubis to prevent subsequent re-
laxation. Cerebral ana;mia and faintness from the
enormous loss of blood may follow such a haemor-
rhage. The symptoms and treatcnent are the same
as those given when discussing hjemorrhage as a
surgical emergency.

The puerperal state begins as soon as the placenta
is delivered. Marked changes must take place in the
uterus before it can return to its ordinary quiescent ■
condition. Immediately following labor there is a
period of comfort and relief, which may be followed

390

NURSING.

by a post-partum chill of more or less intensity and^
of shorter or longer duration ; this is not of very great I
importance, as after the birtJi of the head evaporation
from the skin and lungs takes place, producing cliilly
feelings, which soon disappear after the patient has
been made clean and comfortable. ■ The temperature
of multiparous patients may rise from i to ij^° F. in
the puerperal state, and there may be a temperature
of 99.5° F. without the case being abnormal. This
elevation is supposed to be due to organic disturbances
which take place in the uterus, laceration of the cervix
or vagina, or nervous influences. The pulse falls after
labor, ranging between 60 and 70, and on the third
day may go even as low as 40. Frequently this con-
dition is associated with diminished arterial tension,
but its cause is imperfectly understood.

The skin, which is a most active excretory organ, is
constantly exposed to sudden changes of heat and
cold. It is best not to cover the patient too warmly,
but she should never be exposed to draughts, particu-
larly if she be a nervous woman. The urine will be
abundant, and not infrequently a trace of sugar appears
in it. If the milk in the breasts ir. used up as rapidly
as it forms, the sugar disappears. Retention of urine
is a very common occurrence after labor, and is due to
the previous overstretching of the bladder, and also to
a want of elasticity in the abdominal muscles, which
fail to assist the organ in its action. The loss of the
contents of the uterus makes the entire weight of the
body less by one-twelfth than it was before.

Involution, or the process by which the uterus re-
turns to its normal condition, begins with the after-

THE PUESPERAL STATE

39'

pains and continues for several weeks. The change is
gradual, and the normal size and condition is slowly
attained, fatty degeneration of the muscular fibres tak-
ing place. This change produces a decrease in the
weight of the uterus. The cervix quickly regains its
norma! size ; at first it is soft and flabby, but two
weeks after labor it should be about normal. The
vagina is at first smooth and relaxed; by the third
week it becomes much smaller, the change being more
marked near the outlet than internally.

When involution is incomplete and the uterus re-
mains larger than it ought to be, we have the condition
termed " subinvolution." This may often be traced to
getting up too early after labor, and is a frequent source
of trouble to women who have borne children.

Afler-pain."! are due to contractions of the uterus,
and resemble somewhat labor-pains. They cause the
expulsion of blood-clots, and usually continue from
one to four days. If labor Is of short duration, the
after-pains are intense and prolonged, and via: versa;
in multipara; they are apt to be more severe than in
primiparie. If they trouble the patient too m'ich.
they may have to be controlled by small doses of
morphia.

By the lochia we mean the discharges from the ute-
rus and soft parts after labor. At first these discharges
are mixed with blood {lochia rubra), and contain dark
coagula, mucus, shreds of placenta, and pieces of
membrane. From the end of the third to the sixth
day they are paler in color {lochia serosa) ; they contain
less blood and more serum, and epithelial cells from
the cervix and vagina, besides portions of membrane.

392 NUHSfNG.

The lochia after this assume a yellow-greenish color, |
and contain pus and fatty cells, with a small quantity ]
of blood. By the fourth day bacteria are plentiful and
the discharges have a decided odor. The lochia vary
in amount in different individuals; in those who men-
struate freely and do not nurse their children they are
increased.

The breasts on the third day are frequently swollen
and very sensitive to the touch. Women who have
these changes in the mammary glands frequently have
swelling and tenderness in the glands of the axillae,
with chilly sensations and elevation of temperature.
This was formerly thought to be a physiological pro-
cess, and was called " milk fever. " but now i.s supposed
to be due to .some form of infection. The colostrum
is the first milk secreted, and as it comes from the
breast.-i is a semi-opaque fluid which contains a lai^e
quantity of sugar and organic salts. It coagulates on
boiling and is said to have a laxative quality, driving
out of the intestines of the child the meconium or
waste material which they contain at birth.

The characteristic symptoms of the puerperal state
arL'. then, enlargement of the breasts with well-marked
areola: ; the uterus is enlarged ; the vagina and
vulva are swollen and cedematous; there is a lochial
discharge, and frequently there is laceration of the
cervix. If, after the first eight hours, the patient has
not passed any urine, the catheter must be employed,
absolute cleanliness of the parts being observed. The
diet at first should consist of liquid, unstimulating
food, given in small quantities and at frequent inter-
vals ; on the fourth day light diet, such a-s boiled eggs

THE PUERPERAL STATE.

393

and niilk-tuast or custard, may be given, and to this
may gradually be added chops and cooked fruits, as
the latter will aid in keeping the bowels regular. If
there be any tendency to constipation (and this is
usually the case), the bowels should be opened by a
simple or glycerine enema or by one or more doses of
the compound liquorice powder, about 2 drachms, if
necessary, at intervals of three or four hours, or half a '
glass of Hunyadi Janos water may be given three times ■
a day, or a half ounce of castor oil.

The nursing of the child should be begun as soon as
the mother has rested and recovered from the exhaus-
tion, as the stimulation of the breasts by acting reflcxiy
helps to bring on uterine contractions. The breasts
before and after confinement should have special atten-
tion ! they are to be bathed with alcohol and boric acid
Highland morning.beginning two or three months pre-
vious to labor,as this hardens the surface. If the nipples;
are very sensitive, they may be protected with shields.
Before touching the breasts antiseptic precautions
should be observed with the hands, and the nipples
should be carefully bathed betore and after every nurs-
ing of the child with a 5 per cent, solution of boric-
acid, with which the child's mouth should also
be washed out before and after feeding. The
patient should be warned never to handle her
breasts herself, as there is always danger of intro-
ducing foreign material through the nipple opening,
or, if there should be a fissure or crack on the nipple,
infection may take place through it — an accident too
often resulting in abscess of the breast. If the breasts
are very full and hard, the quantity of milk secreted

kc«ptlK^^H

J^ KVtSlXC.

taa>f be reduced by mcuis otf' a breast bandage
witfa evea pfcwiarc Care sbonid be taken to keep
bnaito soft and pKablc by not alknring the dnpo-
glands to remain unemptied.

The lyu^-in period usually lasts until after the
lochia have stopped ; by this time no pain is idt io the
liack and the patient is not easily exhausted. This
takes from ten to fifieen days, or even looger.

Some of the suspicious s^inptoms durii^ the puer-
peral state arc a rise of temperature, a r^d pulse, a
flushed face, a chill, pain and tenderness of the ^xio-
men, an abnormal increase or decrease of the lochia,
haemorrhage, or. finally, an offensive odor of the dis-
charges. At each time of changing the napkin the
amount of the lochia, their color and odor, should
always be noted, and if the discharge presents any
unusual appearance, it should be kept for the doctor's
iRS|K-ctinn.

I'lierperal Fever. — One of the most grave conditions
whicli can occur during the puerperal state is that of
puerperal fever: this results from a septic infection
which has taken place during labor or the lying-in
-period. Every case of puerperal fever arises from the
introduction of infectious material into some wounded
portion of the genital tract. The modes of infection
are two in number: first, the septic matter may be
carried in on the fingers or instruments, and in this
way physicians and nurses may be the agents of con-
tamination. The second mode of entrance is readily
understood when we remember the almost constant
|)ri..scncc of bacteria in the cervical and vaginal struc-
tures and ill the pubic hair. The nurse should see to

ECLAMPSIA. 395

it that this dreaded complication never occurs from
any carelessness or lack of precaution on her part.

If called upon to nurse a case of puerperal fever.
besides carrying out faithfully the treatment outlined
by the physician, the nurso should do everything in
her power to improve the patient's general condition.
The woman should be kept thoroughly clean — she
should be given plenty of fresh air to breathe, and her
linen should be frequently changed. In addition to
these attentions the nurse should see that the patient
has a liberal supply of nourishment.

Eclampsia is the term applied to certain convulsions
that may occur in pregnancy, during labor, or later in
the puerperal period. They may be clonic or tonic.
In the majority of cases, although not in all, premoni-
tory symptoms announce the impending outbreak. Of
these the most important are headache, vertigo, an
unusual desire to sleep, (lashes of light before the eyes,
nausea, cedema of the face and extremities, disturb-
ances of the memory, gloomy forebodings, and finally,
the most important, the presence of albumen and casts
in the urine.

The attacks may resemble somewhat those of epi-
lepsy, but the cry is lacking and the facial contortions
are far more hideous. When they occur during labor,
the first one is often preceded by a short period of
calm, in which the patient ceases to complain ; she
closes her eyes and seems to be asleep ; the pulse
becomes small and the respirations shallow. Then
the convulsive seizure comes on, commencing in the
muscles about the eyes and extending to those of the
face and limbs. The superficial veins are swollen,

fthe ^m
),the ^1

39^ NV/tS/NG.

eyes become blood-shot, and the whole body (yam
Involuntary evacuations may occur. On awakening
from the attack, the patient will complain of headache,
impaired memor>', and pains in the muscles. The
body is often covered with a cold, clammy sweat.
Too often the patient dies in the first attack, or con-
vulsion follows convulsion with lightning-like rapidjt)^
till death occurs from sheer exhaustion.

Eclampsia predisposes to post-partum hemorrhage
and to puerperal inflammations. In fatal cases death
results from asphyxia, due to spasm of the respiratory
muscles or to exhaustion of the nervous system, either
from the direct effect of the ur^emic poisoning or from
the continuous muscular exertion. The earlier the
convulsions occur, the more unfavorable the prognosis.
It is very rare for the convulsions, if they appear
during pregnancy, to cease previous to the birth of the
child. Under such circumstances half the children are
born dead. The routine examination of the urine
of pregnant women is an indi.'ipensable precaution.

Albuminuria calls for special treatment. The utmost
care should be taken to avoid all mental excitement,
anything which would interfere with the digestion, and
sudden variations in temperature. When there is
oedema of the limbs and face a strict milk diet will be
enjoined and suitable medicinal treatment will be
ordered by the physician. The action of the skin is
to be promoted by means of the wet pack, and the
bowels should be kept freely opened by laxatives.

PuerpiTal Insanity. — The insanity which sometimes
occurs during the puerperal period generally takes the
form of melancholia, although genuine mania is not

PUEKPERAI. INSANITY.

39;

uncommon. In the treatment the orders usually are
to check excessive discharges, support the patient's
strength, and ensure perfect quiet and freedom from
mental irritation. Upon the appearance of the first
sign of this complication the child should be taken
from the breast and the patient put upon liquid food
given at frequent intervals. The bladder and rectum
are to be emptied at proper intervals, and attention
given to the regulation of the heat and light of the
room. The skin is kept active by sponging, and the
sacrum watched carefully for the appearance of bed-
sores. AU pictures or articles of furniture in the room
which seem to disturb the patient must be removed.
Dr. William T. Lusk says that he knows of no other
condition in which a trained nurse can be so valuable.
She must see that the patient is kept covered, that she
does not injure herself, and that no member of the
family is allowed in the room. Above all, the nurse
must gain the confidence of her patient and try to
keep her quiet without using force.

Cold to the head is effective for the severe headache
which will often be complained of. The patient must
never be allowed to get out of sight, and, above all, the
mother and child should never be left alone together
for a moment. During convalescence, rest and sleep,
nutritious food and daily evacuations of the bowels are
factors which hasten a return to health.

CHAPTER XXV.

Tkk Nursing of Cuiu}K.i:n. — CoNVAL£&CENr Children.—

TIONS PeCLTUAJI TU CHILDREN. — THKUSH. — CUULERA INFAI

TUM.— Convulsions. — Infantile Pa r alvsis. — Chor ea . —
ETs. — CroDf. — Eczema. — The Infectious Diseases of Chid

The two periods of childhood are infancy, whicl)3
extends from birth to the age of two and a half years,
and childhood proper, beginning at that age and lasting
until the fourteenth or fifteenth year. The conditions
of life during this time are very different from those of J
mature growth, and the principles upon which adultal
may be treated will not always apply to children; norj
is the same kind of nursing suitable, for a nurse who I
may be entirely satisfactory for grown people some- f
times utterly fails in caring for children. Besides tact J
and plenty of patience, there must be a certain sym-;
pathy that children are always quick to feel, and this, I
combined with judicious firmness, will make a nursel
successful in the management of either well or sick 1
children of any age. When children arc sick the j
habit of observation on the part of the nurse is in the I
highest degree important, for, children being helpless ]
and unable to properly understand or explain their
own feelings, we have to depend on signs to tell U3 i
where the trouble is located, and we may be able to J
gather facts of much importance from what are ap- J
parently quite trivial symptoms.

The NEW-BORN CHILD- 399

The first attention to give the new-born is to wash
the eyes as soon as the head is born, and to see that
the pulmonary circulation and normal respiration are
established. It is desirable, of course, that this should
take place before the infant is separated from the
mother. Some obstetricians hold that the cord may
be cut directly the child has breathed a few times,
while others maintain that in normal cases, and in the
absence of any special indication, this should not be
done till pulsation in it has entirely ceased. If respira-
tion is not established after the removal of mucus from
the mouth and contact with the air or by slapping the
child on the back, a few motions according to Sylves-
ter's method of artificial respiration may start the
breathing, or mouth to mouth respiration may be
tried. This may be instituted before separating
the infant from the mother, but. as a rule, the cord
should be cut as quickly as possible, and the child re-
moved while some one else gives the necessary atten-
tion to the mother. Cold water may be sprinkled on
the face and chest, and if this still fails, immersions in
hot water and sprinkling with cold water must be re-
sorted to. Another method of artificial respiration is
that of Schultze. The operator, facing the child's back,
puts an index finger into each axilla and his thumbs
over the shoulders, so that their ends overlap the
clavicles and rest on the front of the cliest, the rest of
the fingers going obliquely over the back of the chest
The child is first suspended perpendicularly between
the operator's knees. Its whole weight now hangs on
the index fingers in the axilla; by these means the ribs
are lifted, the chest is expanded, and inspiration is
mechanically produced. The infant is now swung up-

400

/ifUA-s/yc.

ward till the operator's hands are just above the hori-
;;ontal line, when the motion is abruptly but carefully
arrested. The momentum causes the lower limbs and
pelvis of the infant to topple over toward the operator.
The greater part of the weight now rests on the
thumbs, which press on the front of the thorax, while J
the abdominal viscera press upon the diaphragm. By 1
these two factors the thorax is compressed and we Bet.l
mechanically an expiration. After five seconds thcj
first position is again resumed, and the lungs expand]
and fill with air. This process may be repeated sevcratfl
times until the breathing seems to be going on natu-^f
rally. With delicate infants it should be the last<|
resort.

After respiration has been established, the child i
is wrapped in a warm flannel with hot-water bags ]
or cans near it, and left until the mother has been 1
cared for. Infants at birth are covered with a white I
greasy substance called vernix caseosa, or "cheesy 1
varnish ;" this begins to form during the fifth month, ]
and protects the skin from the action of the amniotic
fluid; it is removed by oiling the child with olive oil
nr vaseline and afterwards rubbing it gently with a soft J
cloth. The eyes and mouth should be washed out j
with pure warm water, separate squares of soft linen I
being used for the purpose. If it be a premature birth 1
or the baby be very small, weak, and undeveloped, an
oil bath should be given, after which it should be
wrapped in cotton wool and kept at a temperature of
not less than So" F. for the first ten days or fortnight, J
In some hospitals incubators are used for this purpose,
but this is not often practicable in private houses.

THE FIRST BATH.

401

To a fully- developed child the first bath may be
given at once. Before beginning, everything necessary
should be ready at hand — a foot-tub bath, warm soft
towels and warm water, castile soap, olive oil or vase-
line, small squares of muslin or linen, dusting powder,
a dressing for the umbilicus and clothing, the latter
consisting of a diaper, a flannel band and shirt, a
loose long-sleeved flannel petticoat, and a simple soft
white outside garment — the two last long enough to
more than cover the feet. The child should be
wrappi d in flannel, and only the part which is being
bathed at the moment should be exposed,

The head should first be washed in warm, slightly
soapy water; but very little soap should be used with
infants, as it is more or less irritating, and is apt to in-
jure the fine texture of the skin. Next, one should
carefully clean the parts behind the ears and the crev-
ices of the neck, axilla: and joints, and those between
the buttocks and thighs. It is well at this time to no-
tice whether all the natural openings of the body are
perfect ; finally, the baby is put down into the tub of
warm water at about 96° F. and washed off The head
and back should be firmly supported with the left hand
and arm during the bath. After a minute or two it is
lifted out, laid on a warm towel, and dried, not by rub-
bing, but by " patting." Powder should not be used un-
less there are signs of chafing in some part. The navel
is then dressed, a hole being cut in the centre of a
square of sterilized lint or linen, which is slipped over
the cord and folded about it; the cord is then laid to-
ward the left side, and over it is put another small ster-
ilized cotton pad which is held in place by the flannel

■ 402

H bandage, the nurse being particularly careful that ti

B is not drawn too tightly. The binder may be kept old

by sewing it smoothly with half a dozen large stitcht
thus avoiding the danger of injur\' from pins. As
matter of fact, it is now held by some of the best ob^l
stetricians that a binder, far from being a necessary
articie, is rather calculated to do harm to the infant,!
from the undue pressure exerted by it upon the ribsl
and upon the diaphragm. It certainly serves a useful f
purpose in retaining the dressings applied to the navel- 1
After the cord drop.s off, the looser knitted bandj
should be substituted. After the first bath the4
child is not again bathed in the tub until after the.l
cord has dried up and is ready to fall off. which will I
usually occur on about the fifth or sixth Hay,^
although the process may be delayed until the ninth*!
day. During the bath the temperature of the room J
should be about 80° F., and the greatest care bej
taken not to expose the child more than is necessary^
to the air. After the bath the infant should be laidV
away in warm flannel wraps on its right side, and it U'l
important that it should be kept in an equable tern- j
perature of about 80° F. for the first two weeks hy
the judicious use of hot-water bags and wraps. If I
care is taken in this particular, it will probably sleep i
the greater part of the time, and afterwards it may J
gradually be exposed to a lower degree of temperature.
Within twent)'-four hours after birth the first dis-j
charges from the bowels should come away; these j
consist of a dark greenish material, and are known 4
as the meconium. If the meconium i*; not evacuated 1
and the child has pain, a .soap suppositorj- held in the]

THE FOOD. 403

re:tum for a few minutes will produce a favorable
result. An old piece of muslin should be laid in the
diaper to catch this discharge, and the whole burned.
as it is ditlicult to wash the stain out of the diaper.
The urinarj' organs should also be watched, and if
urine is not voided, flannel wrung out of hot water
may be applied to the abdomen just above the sym-
physis pubis. Water to drink should be freely given.
The urine of the newborn child, during the first few
days, may contain uric acid in abundance. Such
urine is apt to be scanty, and gives a pinkish stain to
the diaper, while the normal watery urine does not
stain. Such uric acid formation probably represents
a not infrequent cause of colic (renal, not intestinal),
during the first days of life, and suffering and illness
may be prevented by the free use of water. Each
time the diaper is removed the parts should be bathed
in warm water, carefully dried, and a perfectly clean
diapL-r put on. The breasts of babies of both sexes
sometimes become swollen towards the end of the
first week, and contain a fluid resembling milk. Such
a swelling gradually subsides, and should not be inter-
fered with, as inflammation and ulceration may develop
and permanently destroy the functions of these glands ;
all pressure upon them should be guarded against.

All the baby's habits should be made as systematic
as possible; there should be regular time-i for sleep-
ing, feeding and bathing from the very first.

The beat food for an infant is of course the mother's
milk. Certain pathological conditions in the mother,
however, make it injurious; thus the existence of
tuberculosis, typhoid fever, or pneumonia in the

TTSnd Bve. After the first sM
changed to every three hours dufl
at flight. Between meals, if thel
little [^n or sweetened water U
child JA probably only thirsty. VM
regularly to drink in any case. pA
not occur without a cause in tbeJ
and is usually due to indigestion a
from improper food, to gas-accun
cold. Goat's milk i^ the best suU
milk, but it is not easily obtained,
to be used as being the next bcsL
ted with boiled water before being j
more albumin than mother's milk,
water also lessens the percentage
salts; by adding a little cream, i
lime-water in proper proportions th
be overcome. Milk at first shouli
proportion of i part of milk to 3 o
second month Meigs' formula may I
I part milk ;

THE UTEHILIZA TION OF MILK. 405

milk; but of late years the establishment of milk labor-
atories in many of our large cities have made it pos-
sible to secure a food which in fat, sugar and albumi-
noid percentages can be made accurately to corre-
spond to those of breast milk. These laboratories
have their own herds, and take the most scrupulous
care in the handling of the milk to secure its purity.
In the laboratory the milk is separated by a centrifugal
machine, securing a 16 per cent, cream, which is com-
bined with the separated milk, a standard 20 per
cent, solution of milk sugar, and a standard lime-
water solution. The percentages of fat, sugar and
albuminoids can thus be varied, as much as is desired,
the lime-water giving a slight alkaline reaction to the
modified milk. In ordering the food the physican
writes for the percentages desired, for the number of
feedings, and the amount for each feeding, in such a
prescription as the following:
Child of three months.

Fat, 3 per cent. ;

Sugar. 6 per cent. ;

Albuminoids, 1.50 per cent. ;

Alkalinity, slight.

Number of feedings, 8.

Amount at each feeding, 4 ounces.
The food may be heated at the laboratory to any
temperature desired.

When the modified milk cannot be obtained, another
simple formula is, for the first six months, equal parts
of milk and plain boiled water, sweetened with milk
sugar, with . 1 grain of bicarbonate of soda to each

to I f^^H

406 fn/xsnec,

feeding ; after six months, 2 parts of milk 1
cereal water. The cereal water l« made by t
barley or oatmeal, one tablespoonful to a quart of
water ; reduce to a pint by boiling, then strain. These
prqiarations should be sterilized during the hot months
from May until November. Sterilize with steam at
boiling point for ten minutes.

The greatest care should be taken with the bottles,
nipples and stopper's. To have them thoroughly
dean and aseptic, the bottle and nipple used should
be boiled each day in a 2 per cent solution of carbo-
nate of soda for five minutes, and afterwards in plain
water. After each feeding the bottle should be washed
and boiled, after which it is turned upside down and
the nipple kept in a weak solution of boric acid. No
change in the form of food need be made before the
ninth month, but it will have to be given, of course,
ill increasing quantities, and the proportions of the
milk and water must be changed. Unless the milk
is known to be quite fresh, it is safer to have it steril-
ized— that is, rendered free or at least comparatively
free from micro-organisms. A special apparatus may
be had at little expense for this purpose, but where it
cannot be obtained an ordinarj- nursing-bottle may be
used. This is filled with milk and set on a small
square block of wood about one inch thick, which is
placed in a boiler so that the bottle does not touch the
bottom. The water in the boiler should be about an
inch deep, and the latter should be then closely covered
and allowed to steam. The bottle should be plugged
with clean cotton, and the steaming should be continued
at least one hour, when the milk may be put away in a

THE STERrUZATION OF MILK.

AOJ

cool dark place. Several bottles may be sterilized at
one time, enough to last for twenty-four hours, one
bottleful beiny used for a meal ; if any milk is left
over after feeding, it should be thrown away. Milk
for use on a journey of two or three days' duration
may be prepared in the same way, only that the
steaming process must be repeated for three successive
daysjjust as for the sterilization of salt solution, the
preparation of which we have previously described,
Of late there is some evidence to show that children
fed for a long time on this milk (sterilized at ioo° C.)
do not do well. It is probable that the high tempera-
ture produces certain chemical changes in the milk
which lessen its nutritive properties. Subjecting the
milk to a temperature of 60 to 70° C. for half to three-
quarters of an hour — pasteurisation — will destroy the
bacteria likely to be present, thus delaying fermenta-
tion, and secures the advantages without the draw-
backs of heating the food at the higher temperatures.
After birth several physiological changes take place
in the child. The bones, which at first are very soft
and flexible, require some months to ossify and become
firm enough to support the child, so that it can stand
alone. A child should not be allowed to try to stand
before it is a year old, and if permitted to sit alone it
should not be left in this position for any length of
time, unless some support is given to the back, be-
cause curvatures are apt to result if the weight of the
body is thrown too early upon the slender bones. A
child should be very carefully handled, as tossing it
and throwing it up and down may cause serious
injury.

NUKSmC.

The head may be of a peculiar shape, which i
have been caused by pressure during birth. Thc'l
bones of Ihe skull do not unite firmly for some months,,
and the fontanelles must not be pressed upon, but the!
greatest care should be taken to protect them from
injury. The sutures are yielding, and sometimes at
birth the edges of the bones overlap. Very marked
peculiarities in the shape of the head or of its bones
may disappear after a few weeks' growth.

The stomach at first is very small, and very Jittle I
food, one or two teaspoonfuls, will be sufficient for
one feeding ; when too much is taken the surplus
will be regurgitated, a condition often mistaken for
vomiting.*

The skin soon undergoes changes : during the first
few days it is red, later it becomes yellow, and after a
few more daj's assumes its natural color. The yellow
of jaundice may be distinguished from this yellow
color, since in jaundice the conjunclivs are also tinged.

The average weight of a newborn child is seven
pounds ; for the first two days it loses weight, and after
this gains from two to six ounces a week.f

Until after the first six weeks a child should sleep
twenty hours out of the twenty-four. The habit of J
putting it quietly down, and allowing it to go to sleep J
without rocking or nursing should be formed at |
once.

Regular bathing is of the greatest importance to a ^
child's health. One bath should be given daily, not
too close to the time for a meal, in a room of which
the temperature is about 75" F, The temperature of J
the water should at first be 95" F,, but after the child f

■See Appendli, Nale 17. tSea Atipendii, Noie ■}.

DlSOflDEKS OF INFANCY.

409

has reached the age of three months it maybe lowered
to 90° F. During the first three or four months the
child should not be kept in the bath longer than two
or three minutes.*

The disorders common in the newborn are colic,
jaundice, ophthalmia neonatorum, thrush, and aflec-
tions of the umbilicus. An inflammation of the um-
bilicus is probably always due to inf<-ctton, and tht;
physician's attention should be called to it at once.
If any moisture appears about the cord, iodoform, or,
better still, a powder made of i part of iodoform to 6
parts of powdered boracic acid, may be thickly sprin-
kled about it, and a pad of sterilized gauze applied. The
inflammation, unless checked, may prove serious, as
the general strength fails rapidly, abscesses may form,
and the termination be fatal. If granulations appear
after the cord has dropped off^ nitrate of silver in solu-
tion or stick is usually ordered to be applied gently,
the wound being afterwards dressed with the iodoform
and boracic-acid powder.

Colic is a very frequent disturbance, and one that
begins very early in a child's life; it is due to an
accumulation of gas in the stomach or intestines,
and is caused usually by over-feeding, improper food,
or exposure to cold. The pain, which comes on in
paroxysms, is sharp and griping. The child suddenly
utters a sharp cry, the legs are drawn up, and on ex-
amination the extremities are found to be cold. With
care in feeding and keeping the body sufficiently
warm many of these attacks can bo avoided, and fre-
quently, when one does come on, the pain will cease
if the child be held before the fire until it is well

•Sh AppuhUi, Mmc i^

410 /fUKSlNC.

warmed through. Hot flannels to the abdomen hairf
also been recommended, and internally a Httle w«u
water or pepper mint- water may be given for two ■
three doses to relieve or expel the gas. The body mayl
also be well rubbed with warm oil. Stimulants, pare-,
goric, soothing syrups (most of which contain opium) I
should not be given under any consideration, simplel
heat being in the majority of cases quite as effectual.

Icterus, or Jaundice, is often seen during the first and
second weeks of life, but is not considered of much
importance if the general health is good, as it subsides
without treatment after a few days. The bowels should^
be kept freely open.

Ophthalmia nconalomm is an inflammation of the..!
superficial tissues of the eye, particularly of the
junctiv^. In the newly-born the cause is to be sought I
for in an infection during birth from the urethral or J
vaginal discharges of the mother, or the pus-producingj
organisms may be introduced afterwards by careless-. J
ness in handling. To avoid it, the moment the chil(],|
is born and before its eyes are opened, the nursel
.should wipe carefully away all discharges, using fori
the purpose separate small squares of cotton or gauxol
sponges wrung out of a .solution of boracic acid. At J
the first bath the eyes should be bathed first, and thel
same piece of linen should never be used for both. InJ
some lying-in hospitals, especially in suspicious cases,!
as a matter of routine one drop of a 2 per cent. solu->l
tion of nitrate of silver is dropped into each eye. At.j
the onset of ophthalmia a slight redness of the eyelid 1
about its edges is noticed, with a little swelling; this]
condition rapidly becomes worse, and at the end of |

OPHTHALMIA NEONATORUM- 4II

twenty-four hours the swelling has increased, so that
the eye may be wholly closed, and both the eyelids and
the conjunctivze are deeply injected, and pus oozes out ;
in some cases the purulent discharge is very abundant,
and there will be danger of destruction of the cornea
by ulceration and perforation. Upon the slightest in-
dication of redness the eye should be frequently bathed
with a warm weak solution of boracic acid, and some-
times cold compresses will be ordered. In any case
the physician should be notified at once. In bathing
the eyes no friction should be used, and the lids should
be gently held apart without pressing on the eyeball.
When pus appears, the eye should be washed out
every hour, every half hour, or even oftcner. This
may be best done by letting the solution run over it
from a medicine-dropper. After being allowed to
trickle from the outer to the inner angle of the eye, it
will then run down beside the nose, and can be caught
on a piece of absorbent cotton or sponge. Where
there is much pus, the eye may have to be irrigated
in this manner every fifteen minutes, as the only way
to save the cornea is to keep down the inflammatory
process. When this has to be done at such frequent
intervals, a small fountain syringe with a glass nozzle
attached will afford a steady flow of the solution. No
forcible stream should be used. Precautions should be
taken to prevent the other eye from becoming infected,
and no particle of the discharge should be allowed to
touch it ; in very bad cases the sound eye is sometimes
covered. All sponges and cloths used should be at
once burned, and the basin which has held them filled
with 1 : 20 carbolic-acid solution. The nurse's hands

412 KUKS/XC.

should be thoroughly scrubbed m hot water and soap,
and disinfected with the same solution. Touching the
face or hair should be avoided unles-i the hands are
quite clean.

The disease is prevalent among people whose dwell-
ings are unclean and poorly ventilated, and who are
dirty and untidy in the care of themselves.

Thrush, or sprue, is a disease in which small whitish j
spots or ulcers spreading into patches appear on the
tongue, the sides of the mouth, and the gums of
infants; in severe cases the process may extend over I
the entire cavity of the mouth, into the throat, and
even down the gullet into the stomach ; sometimes,
although only very rarely, it has been known to invade .
the intestines. In serious cases the child may die of
inanition, the throat and mouth being too tender and
painful to permit of swallowing, or at other times
death may result from the exhausting diarrhoea, which
may be present. These patches result from the
growth of a yeast-like fungus. Milk should not be
allowed to remain along the sides of the mouth, but
each time af^er food has been given the mouth should
be washed out. The disease is combated with an
alkaline wash, usually a borax solution (gr. xx to an
ounce of water). It .should be applied every two hours
with a camel's-hair brush until signs of improvement
appear. In all cases the child is fretful and irritable,
and in the severer forms there will probably be diar-
rhtca. Thrush sometimes appears in adults in the
later stages of tuberculosis and of some fevers.

Enteritis in children is known according to its form
and severity by diflerent names — viz. acute dyspeptic
diarrhtea, cholera infantum, and acute entero- colitis.

DIAKKIKEA.

413

Diarrhixa is a disorder that occurs among children
chiefly during the hot summer months, and is attended
with a high death-rate. The majority of cases occur
during the first two years of life. It is due, as are so
many children's disorders, to disturbances in the
digestive tract. It is more common where improper
forms of food have been given, and where suffi-
cient attention has not been paid to cleanliness.
Hottle-fcd infants are very liable to it. particularly
among the poorer classes, owing no doubt to igno-
rance on the part of mothers, who neglect to keep the
feeding-bottle clean and the milk pure. As a rule, a
child should not be deprived of the breast-milk during
the hot months of summer, as diarrhoea almost in-
variably follows, but there are cases where the mother's
physical condition is such that the physician is com-
pelled to order an immediate weaning of the child.

With older children the diarrhoea is not only asso-
ciated with the u.se of tainted milk, but frequently
follows the eating of improper foods, such as unripe or
decayed vegetables. In all cases it is believed that
the diarrhosa results from abnormal fermentative pro-
cesses duo to bacteria. Summer diarrhcea may be
first signalled by an increased number of evacuations
from the bowels, with griping pains in the abdomen,
which make the child fretful and restless, or it may
come on suddenly and manifest itself by vomiting,
griping pains, frequent evacuations, and fever. Care
in the diet, giving only rice-water or albumen- water,
and keeping the child quiel in bed, may be sufficient.
Castor oil or calomel, one-sixth of a grain every hour
for six doses, is usually ordered at fir.st to rrniove

US, where ^^M
intestines, ^^M
shed ouL ^^

414 XURSINC.

[lie irritating cause. In the more severe forms, 1
there is much irritation of the stomach c
the stomach and colon are sometimes washed ouL
To wash out the stomach a large soft-rubber catheter
and funnel arc used instead of the regular stomach-
tube, and for irrigating the colon a catheter of the
same size is used, being introduced as far as six or 1
eight inches, and a pint or quart of lukewarm water is
passed in at one time ; if there be fever, cold water may
be substituted. Milk, if given in severe cases, should
be diluted and sterilized; egg-albumen, barley-water,
or rice-water, may be given instead. Beef-juice or
mutton-broth are, as a rule, inadvisable in the hot
summer months. In addition to a strict regulation of
the diet, a change of air will generally prove of the
greatest benefit. The poor emaciated weakling from
the city is often restored in a very short time to health
and vigor if it can be removed to the country.

Cholera Infantum, a disease less frequent than
summer diarrhoea, but one which is extremely serious,
is generally preceded by some mild disturbance of
digestion, but may come on quite suddenly. It-begins
with continuous vomiting and frequent thin, watery
stools, which are at first very offensive. The child has
fever, the eyes rapidly become sunken and hollow, the
features look pinched, and in extreme cases symptoms
of collapse soon come on. The pulse is rapid and
feeble; there is excessive thirst and resdessness at
first, which may be followed by a condition of stupor.
Starch and hudanum injections may be ordered; if so,
they should be given cold and introduced high up. the
starch having been previously well boiled. The child

DYSENTERY. 415

should bt kept absolutely quiet. Plenty of water or
cold barley-water maybe given, and the food for a
time wilt usually consist of egg-albumen with a few
drops of brandy.

EiiUro-colilis, or Calarrlutl Dysentery, is an acute
inflammation of the colon and ileum, and may also
follow an ordinary attack of diarrhoea. There is
constant pain and fever, the stoois are mixed with
blood and mucus, and, in fact, sometimes consist almost
entirely of these two elements. An attack may end
fatally after forty-eight hours. Irrigation of the intes-
__tines may be ordered, and the nourishment is much
the same as in the other diarrhiEas. In any of these
diseases there is apt to be chafing and soreness of the
skin about the hips, which is kept almost continually
wet by the frequent discharges. The bathing may be
done with very thin boiled starch-water in place of soap
and water, and the parts afterwards dusted with bismuth
or o.\ide of zinc finely powdered. A flannel bandage
should be worn over the abdomen and stomach, and
kept on until the child has fully recovered. For the
prevention, as well as the cure, of all such diseases, the
child should always be kept properly clothed, the abdo-
men being more especially protected. Other hygienic
precautions and care arc of the greatest importance.
A nurse, particularly a district nurse, may do much to-
wards this. If she fully realize the importance of hy-
gienic measures, and the results which almost certain-
ly follow, and can induce the mothers to care for their
infants properly, her privileges and opportunities for
saving the lives of young children will be almost
unlimited.*

be due to reflex irritation from teJ
of a pin or the presence of wormsB
vous excitability, and where other
way convulsions may follow. Th
often during the first year of life, I
quite suddenly, or the onset mayl
lessness with twitching and grindT
being premonitory symptoms,
first, and aftenvards the whole bodl
the eyes are staring or rolled up^
moments the muscles relax, and twit
sive movements are seen in the limbs
ually these cease and sleep follows,
seizures may follow each other in
If the physician is present, he usually
during the attack; if the cause be o
the stomach or indigestion, an emcti
followed by an enema. A warm ba
this should be given with care, so a
child too severe a shock. The ter
bath should bej

MENINGITIS..

the brain or spinal cord; it may come on gradually
^iid iiiHidiously, or develop suddenly with continuous
convulsions. It usually comes on in the former manner,
with symptoms of fretfulness, restlessness, intolerance
of light and noise, headache, and vomiting, and, as the
disease advances convulsive attacks may occur. The
bowels should be kept freely opened, perfect quiet en-
forced, the room darkened, and all causes for excite-
ment kept away. Only liquid food at regular intervals
should be given, and plenty of fresh air with thorough
cleanliness is indispensable.

Infantile paralysis (acute anterior poliomyelitis) be-
gins usually with high fever and convulsions, which
are followed in a day or two by a more or less marked
loss of power and atrophy of the muscles. A physi-
cian should be called at once. The treatment at first
will probably be limited to reduction of the fever and
the proper regulation of the bowels. After the acute
stage is over, massage of the affected limb, with plenty
of light nourishing food and fresh air, is recommended.
A nurse may frequently be ordered to apply electricity
for the purpose of maintaining a certain amount of
exercise in the muscles, and so keeping up their
nutrition.

Incontinence of urine is of frequent occurrence,
especially in nervous children. It may be met with in
connection with diseases which are accompanied by
other and more prominent symptoms, or may be due
to an increased quantity or to too great an acidity of
the urine, to weakness of the sphincter muscle.'i, or to
the presence of pin-worm.i in the rectum. The child
should be placed under the care of a physician, and

41 S mntsmc.

r^nlar habits of urinatioa fenoed ; if be is old enoogli,
be sbould be taught to excrdse his will-power. He
sbooM not be allowed to drink much in the evening.
The bladder should be emptied just before going to
bed for tbe night, and the (bot of the bedstead ele-
vated.

Chorea may be defined as a disease in which there
arc irregular movements produced bj- in\-oluntary c
tractions of single muscles or groups of muscles. lb
is commonly spoken of as St Vitus' dance. Young^V
girU and children of a highly nervous temperament ■
dcvclt^ it most frequently. Absolute freedom from
excitement and worr>' should be imposed, besides the
bert of hygienic surroundings, the child being amused
in a quiet way, and in all severe cases kept in bed.
Nurses should know how to manage such cases, as
they often have the care of the patient with only occa-
sional visits from the physician, and a great deal de- J
pcnds upon proper nursing.*

Rickets, or rackiHs, is a disease of childhood, ]
characterized by deformities in the bones, owing to
increased cell-growth in them, with a deficiency of '
limc'Salts. Non-hygienic surroundings and improper
food are the main causes, and the substitution of |
cleanliness, wholesome food, fresh air, and sunshine
will effect more than drugs. The child is generally
pale and delicate-looking. The head may be unusu-
ally large, and the changes in the shape of the long
bones be noticeable; the legs are perhaps more or less
bowed, or the child may be knock-kneed. A most im-
portant point to remember is that deformities may often ]
be prevented in the early stages ifconstant care is taken

*Sa« A>>,MlldlX,NDlt JI.

CKOL-P. 4I9

by the nurse in carrj'ing and holding the child prop-
erly. Among the poor in crowded localities are to
be found the greatest number of such cases.

Croup among children occurs in two forms — the
false or spasmodic, and the true membranous or diph-
theritic croup. The spasmodic form is supposed to
arise from spasmodic closure of the glottis; it comes
on suddenly, and may be the result of exposure to
damp and cold, of excitement, or of indigestion. This
false croup is not dangerous, but the symptoms are
alarming, especially when, as most frequently happens,
the attack comes on during the night : the child wakens
from a quiet sleep with a hoarse cough, difficulty of
breathing, and the mother fears that suffocation is im-
minent, since the face sometimes becomes perfectly
blue. The spasm ceases abruptly and the child goes
to sleep, but the breathing continues to be croupy
during the night. Sponges or flannel wrung out of
warm water are first applied to the throat, and a hot
baih or a mustard foot-bath is sometimes given.
Thi.s will relax the spasm, but does not relieve the
croupous breathing, which, however, is not serious.
Should warm applications fail, a moist-air tent may be
made by fastening a stick to each of the four posts of
the bed and stretching a blanket over the top, so that
it hangs down over the four sides and entirely covers
in the bed, leaving only a small opening at the top of
one side through which to watch the patient. The
spout of (he steam-kettle is then introduced within the
canopy. An emetic consisting of a drachm of the
wine or syrup of ipecac, repeated every half hour till
free vomiting occurs, and a simple enema, are generally

■es OB ft^H

420 .VUSS/fiC.

very d&ctjve. The attack freqnendy comes t
three nighu ia nuxesnoo, an hour or so earlier «
aucceedinff night. One should try to prevent aa
attack bjr taking precautionaiy measures daiiag tbe
day: thus the bowels i^hoiild be Treely opened with a
dose of castor oil, only light forms of (bod be given,
and the child ke^jt in a uniform temperature.

In membranous croup a &Ise membrane is formed
io the larynx, and may thicken gradually until tbe
pauagL- is quite closed between the cords : in such
cases, if the patient does not succeed in coughing it up.
he is liable to die fi-om asphyxia, and even where the
membrane is not so extensive death may result from
exhaustion. It is always well to consider this mem-
brane as due to diphtheria, and to isolate the patient
until an examination of the membrane has revealed
the presence or absence of tht.- diphtheria bacillus.
The symptoms come on gradually with a wheezinpd
sound from spasm of the glottis, and as the mem^f
branc accumulates there is evidence of dcpressioi
throughout the whole system. The temperatun!
may range from 103° F. to 104° F. (although
Homc cases the patient may be apyretic), the puis*
rate may be increased, and the disease may terminal
fatally after twenty-four or forty-eight hours. The a
breathed should be moist ; a steam kettle filled will
lime-water may be kept boiling in the room, with the .■
steam directed toward the mouth from a moderate dis- J^
tancc. Careful attention to the diet is necessary: I
juice and milk and stimulants, if the pulse indicate
tlirm, will be ordered, and tt is usual to allow plenQ
of water to ilrink if the patient is thirsty. While v

ECZEMA. 421

jng for the physician the nurse may make prepara-
tions for intubation or tracheotomy, either of which
operations may be expected at this stage.

Ecscma in children takes on various forms ; the
affection is an inflammatory disease of the skin. It
may occur within a very short time after birth, and
is most frequently the result of improper care on the
part of the nurse. The flannel in which it is wrapped
may be too irritating and rough for the tender, delicate
skin of the child, or even a small amount of friction
may produce chafing or redness. Again, the oint-
ment or oils used may be impure, or the child may
have been kept too warm. Eczema may also be due
to reflex irritation from the alimentary canal.
Further, the fceces and urine are irritating, and unless
the infant be properly bathed and dried an eczema
will be sure to appear. The eruption occurs chiefly
in the folds of the neck, behind the ear, on the head,
under the arms, about the buttocks, and in the groins.
For such patients soap and water should not be used
for bathing purposes, as they are irritating, but somt-
bland mucilaginous wash, such as thin starch-water,
bran-water, a solution of bicarbonate of soda, or flax-
seed tea, should be substituted, as these soothe the itch-
ing which is always present. On the scalp irritation
may soon appear, unless care is taken to remove all o(
the vernix caseosa from the part. As a rule, however,
gentle, careful cleaning, preceded by a good oilinj,'.
will soften and remove it. Besides thorough cleanli-
ness, whatever treatment is prescribed by the physician
.thould be faithfully carried out.

Measles may occur at any agl
quent in childhood; it b an acutfl
dtAca.se. which may be divided inti
those of inva-'iion, eruption, and del
ttvcly. The average period of incufl
which elapses between exposure tol
onset of the first symptoms) is frol
dayi or even longer. The stage of iri
coryza, simulating somewhat an aJ
the running at the eyes and nose b|
by cough, fever, headache, and loss
fever is highest on the third or foi
105" F. or more, and the reddish
usually on the morning of the fourth ■
forehead, then upon the neck and t
the face and entire body may be co'
first small red spots appear, which in
finally run together, and the papules
may be felt distinctly on passing tht
sWin. After two days the eruption b
fever abateSj.aniUlu,^taiiiMi^^^

GERMAN MEASLES. 423

68° F., and the ventilation Innked after; exposure to

sudden changes in temperature should be guarded
against, and if the rash does not come out well, hot
drinks or a hot bath and wrapping the child in flannel
may hasten its appearance. The room should be mod-
erately dark for the first few days, or the eyes should
be protected from the light, as there is generally
marked photophobia. When desquamation begins,
the whole body may be smeared with vaseline or an
oil bath may be given daily, usually in the evening,
and a warm-water balh in the morning; usually some
antiseptic is mixed with the oil or ointment. The
complications in measles arc often more serious than
the disease itself; of these pneumonia is the most com-
mon and perhaps the most dangerous; bronchitis is
also very frequent, and some degree of conjunctivitis
is nearly always present. Isolation is usually ordered,
and the clothing and the room must afterwards be
disinfected as in other infectious diseases.

Rubella (German measles) is a contagious disea.'^e
which spreads rapidly. The period of incubation is
about ten days or a little longer. The initial symp-
toms are coryza, chilliness, pains in the back and legs,
and some fever. The eruption appears first on the
face and chest, and very soon spreads over the body.
In appearance it resembles that of mea'iles ; after two
or three days it fades away. The di.scase is usually
mild, and the giving of a light diet, keeping the bowels
active, and confinement to the hou.se in a room of a
warm equable temperature will be all that is neces-
sary-.

Scarlet I't'rr like measles, is a contagious disease

which has a stage of invasion, one of eruption, and
a third of desquamation. The time of iacubation is
variable, being from one to seven days. The symp-
toms begin abruptly; there may be slight indisposi-
tion for a day, that may be taken for the beginning of
an ordinary cold, but the temperature increases, and
very soon rises to 102° or 104" F. ; a higher tem-
perature than this indicates a grave condition. The
pulse-rate in mild cases is from no to 120. but tn
severer cases it may reach 160 or more. There is
usually nausea and vomiting, the tongue is coated,
and there is more or less dryness and soreness of the
throat.

The rash generally develops on the second day,
appearing first on the neck and chest in reddish spots
and patches, which extend over the back to thf trunk,
and finally over the whole body. In mild forfns the
rash does not change in appearance, but in marked
cases it takes on a vivid scarlet color. The so-called
"strawberry tongue." due to swelling of the papillie,
now appears, the throat becomes red and swollen,
and an exudation may sometimes be present closely
resembling the false membrane of diphtheria. The
duration is variable, depending upon the violence of
the attack. In a tj'pical case the rash gradually fades,
and on about the sixth day desquamation begins, and
is not completed until the twelfth day or even later;
often the peeling takes three weeks or more.

There are various types of scarlet fever, the mild
form lasting a week or so. the most serious kind,
known as malignant scarlet fever, sometimes termina-
ting fatally in two or three days; in the latter form the

SCARLE7 FEVER. 425

temperature may be very high, 109° F. or more, the
pulse rapid, the restlessness extreme. These symptoms
may be followed by delirium and coma in which the
patient dies. The throat symptoms are sometimes
pronounced, and in this form the appearance of a
membranous exudation is not infrequent; the rash is
dark red, and may even be hemorrhagic. The patient
must be completely isolated, and nothing left in the
room in the way of furniture except articles which
are absolutely necessary. In even the mildest forms
the patient must be kept quiet and in bed until after
desquamation has ceased, as nephritis is very liable
to follow even these cases. When the fever is high,
sponge baths are recommended, also tub-baths at a
temperature of So° F,, or the cold pack. The ice cap
should be kept constantly applied in cases in which
there is high fever. Milk and water are to be given
freely.

The physician will probably direct that the urine be
examined daily for albumin, and a careful record
should be made by the nurse of the total amount
passed. The period of desquamation is considered
the most highly contagious, and much time and care
must be taken to prevent the scattering about of the
flakes of skin. When possible, they should be burned,
and all linen should be put at once into disinfectants.
Inunctions of oil night and morning should be given,
the oil being well rubbed in all over the body. A
warm-water bath should precede the inunction in
the morning. Exposure to cold should be guarded
against more especially in this stage, as the skin is
very sensitive, and if the surface of the body is chilled

4^6 KUKSJNG. ^B

and the action of the sweat-glands is checked, nephritis
may follow. Any puffiness of tfre c>-elids or limbs
should be watched for. Particular care during con-
valescence should be taken in these respects, as tbe
patient may feel so well that to him such precautions
may hardly seem necessary, and if left to himself he
IS too often apt to be imprudent

The complications to be watched for and guarded
against, besides nephritis, are inflammation of die mid-
dle ear, extending from the throat, sometiraes result-
ing in deafness, arthritis, or inflammation of the joints,
throat or heart affections, and convulsions. The best
of sanitary conditions should be maintained, and the
general system well nourished. The patient is to I
kept free from unusual excitement, and should be c
ful not to exert himself too soon.

Parotitis, or mumps, is an inflammation of both, mot
rarely of one of the parotid glands, involving also t
surrounding connective tissue; it as an infectious a
a contagious disease. The period of incubation varie)
from eight to fourteen days or more. The onset in
usually marked with a chill, malaise, headache,
some rise of temperature ; in nervous children con'
sions often occur. The disease reaches its height ii
from four to five days, and then the pain and swellinj
gradually subside. Warm fomentations may be ap-
plied to relieve the pain, the bowels should be kej
open, and soft non-stimulating food given. The ven^
tilation should be good and the room kept at an eveHj
temperature. It is best to keeji the child quiet. This
specific parotitis differs from that seen sometimes as i
complication of typhoid fever; in the latter suppura
tion is the rule.

WHOOPING COUCH.

Whooping coi4gh or pertussis is an infectious dis-
ease beginning with a catarrh of the air-passages.
just like an ordinary cold. The incubation period
varies from seven to ten days. There is some fever,
wheezing, and a short dry cough ; at the end of eight
or ten days the cough becomes worse and has the
characteristic " whooping sound ;" this whoop is really
a prolonged inspiration occurring at the end of a par-
oxysm of coughing; the expirations arc short and
spasmodic. At the end of a fit of coughing frothy
mucus is expectorated or there may even be vomiting.
This stage lasts from six weeks to three months, or even
longer. The child should be kept away from other
children, and in bed during the first stage and while
the fever lasts. Inhalations of steam are sometimes
prescribed for the cough, while easily-digested, nour-
i.shing food is given throughout the whole course of
the iUness. In the later stages a change of air is
advisable, as it oiten shortens the duration of the
attack.

A high temperature and a rapid pulse are not con-
sidered such serious symptoms in children as in adults.
The temperature in children should always be taken by
the rectum, and the pulse during sleep will always be
more reliable.

CHAPTER XXVI.

The Urine.

The urinary organs are the kidneys, the ureters, thff
bladder, and the urethra. The ureters convey the I
urine from the kidneys to the bladder, whence it is ex-'
pelled through the urethra. Normal urine is a clear I
watery, yellowish fluid, with an acid reaction and with>l
a specific gravity of from 1018 to 1020; it is composed (
of water (in the proportion of 960 parts in 1000), in-
organic salts, organic constituents, together with some ]
coloring matter and a small amount of mucus. The J
more important inorganic salts are chloride of sodium,
phosphate of potassium, and the sulphates of calcium 1
and magnesium. The organic constituents are chiefly i
urea and uric acid. The urine is an excretion; that is %
to say, it is a fluid which carries off waste particle:
that would be harmful if left in the system. Two im-
portant waste substances of the body arc urea and car-
bonic-acid gas; the former is excreted by the kidneys, j
the latter by the lungs.

In speaking of the physical properties of urine *
have to consider the quantity, color, odor, reaction/l
and specific gravity. The normal amount for an adult (
for the twenty-four hours is from 40 to 50 ounces oi"
from 1200 cc. to 1500 cc. The normal amount in I
health may be increased by drinking large quantities

TUR URINE.

429

of fluids, especially water, by diminished perspiration,
and by emotion. The diseases which may increase the
quantity of urine are diabetes mellitus, diabetes insip-
idus, hysteria, convulsions, and certain forms of Bright's
disease; a temporary increase often marks the crisis
in certain diseases — e.g. pneumonia. As a rule, where
the quantity is large the color is pale and the specific
gravity low. An exception to this will be found in
diabetes mellitus, where the specific gravity is high;
1040 and more, although enormous amounts of urine
may bo passed. Under normal conditions the quantity
may be diminished where only small quantities of
fluids are taken and where the perspiration is increased.
The urine is diminished in amount in fevers, in profuse
diarrhceas, in certain forms of Brights disease, and in
puerperal convulsions. The normal odor of urine is
aromatic. The normal reaction is acid, but the urine
in health maybe faintly alkaline at certain times of the
day. Urine passed in the morning has an acid reac-
tion, a high specific gravity, and a dark color; after a
hearty meal it may be turbid, perhaps alkaline, and of
low specific gravity.

To test the reaction litmus-paper is used; acids
change the blue color to red, alkalies the red to blue.
When urine does not affect litmus-paper, it is said to
be neutral. When it changes slightly the color of
both the blue and red paper, it is said to be amphoteric
in reaction. It is more acid than usual in acute fevers
and in rheumatism. Alkaline urine is of two kinds,
the first being due to the presence of fixed alkalies,
the second to the presence of ammonia. Alkaline
urine is always more or less turbid. If urine is kept

430

NUkSMG.

in a warm place, it decomposes, with formation of t
bonate of ammonia; this decomposition is due to thfl^
breakiniT up of the urea as the result of the action or\
micro-organisms. These organisms may obtain eti-''
trance to the bladder from outside, and a cystitis niayl
be causL'd, or if already present may be aggravated, by!
the passage of a catheter if antiseptic precautions are^
not taken.

Retention signifies the accumulation of urine in the I
bladder, with inability on the part of the patient ta
void it. Stipprcssion TcicTS to tlie failure 011 the part']
of the kidneys to secrete urine ; in the latter case no
urine will be found in the bladder. Incontiiunce of'
urine is the inability to retain it in the bladder.

The color of urine may be spoken of as pale, color-
less to pale yellow or straw-color, amber, high-colored,
reddish -yellow, dark brownish, or blackish. The urine
is pale in cases of hysteria, in diabetes, and also in that
form of Bright's disease in which it is of low specific
gravity ; the urine is high colored in febrile and inflam-
matory complaints, and in some cases of indigestion.
Rhubarb gives it a bright yellow or red color, bile ini- ,
parts a greenish tinge, carbolic acid gives it a dark
brown color with the odor of carbolic acid.

By the spcci6c gravity of urine we mean its weight
as compared with that of an equal amount of distilled
water. The normal specific gravity reckoning that of
distilled water to be looo is, as we said, about 1020,
but may vary in health from 1015 to 1030. The
specific gravity is determined by means of an instru-
ment called a urinometer. Urine should be allowed
to cool before u.sing the urinometer. In health high-

THE URINE.

431

colored urine is of high specific gravity, pale urine is
of low specific gravity.

In describing urine after the qualities already men-
tioned, the absence or presence of sediment should be
noted; a sediment may have the appearance of a fine
powder, or be ropy, viscid, or string)'; we describe a I
sediment as fiocculent when it appears in the form
of soft flakes suspended in the specimen. In strictly

normal l
albumin

albui

not nc(

there

or pus i

is present. The presence of

ly indicate a disease of the

II be albuminuria whenever '

the urine — e.g. in cystitis or \

kidneys; thu>
there is blood
pyelitis.

The principal tests for albumin are —

(l) The Heat and Nitric-acid Test. — To test by heat
take a convenient quantity of urine in a clean test-tube
(where the urine is turbid it should be filtered before
testing), and boil it; if there is a large quantity of
albumin present, it will be precipitated at once; add
two or three drops of nitric acid, and if the precipitate
remain the specimen contains albumin. In acid urine
the albumin is precipitated below boiling temperature,
but in alkaline urine the albumin maybe held in solu-
tion after boiling, and acid is needed to precipitate it.
If alkaline, neutral, or weakly acid urine gives a pre-
cipitate on boiling, this may be due to the presence of
phosphates; if so, these will disappear on adding nitric
acid.

{2) The second, and perhaps most common, test of
all is the acetic-acid-aitd-heal test. The urine in a test-
tube, if not already distinctly acid, is rendered so by
the addition of one or two drops of acetic acid. The

NU/tSJNG.

upper stratum is now heated, and if there is a precipi-
tate, this will show the presence of albumin.

(3) HelU/s Test, or (he Cold Nitric-acid 7>j/.— Take
a small quantity of nitric acid in a test-tube, and let the
urine trickle, drop by drop, down the side of the tube
upon it ; if albumin is present, a white ring will form
at the junction of the acid and urine. Occasionally a
specimen rich in urea will show a ring of nitrate of
urea, but in that case the white ring begins higher up
than the point of junction, and floats off into the urine
like a cloud ; such urine may be diluted until the
specific gravity is 1005, and the test repeated. Fur-
ther, the nitrate-of-urea ring will dissolve on heating ;
the albumin ring will not.

Tests for Sugar (glucose). —

(i) Trominer's Test. — To a given quantity of urine
we add one-third of its quantity of liquor potassze,
and to this, drop by drop, a 10 per cent, solution of
cupric sulphate, until a precipitate begins to form ; the
mixture is then boiled. If sugar is present, red sub-
oxide of copper will be precipitated. The test is not
reliable for small quantities of sugar.

(2) The Fermentation Test. — A small piece of ordi-
nary baker's yeast is put into a test-tube full of urine,
which is placed mouth downward in a tray of mer-
cury, care being taken to prevent the urine from es-
caping by covering the opening with the thumb as
we invert the tube. If sugar be present, fermentation
begins, producing, among other things, carbonic-acid
gas, which accumulates in the upper part of the tube
and gradually displaces the urine.

(3) Nylander's Bismuth Test. — The following solu-

THE URINE. 433 1

tion is prepared : 2 parts of subnitrate of bismuth and
4 parts of Rociielle salts are dissolved in lOO parts of
an 8 per cent, solution of caustic soda. Add I part of
the Nylander's solution to lo parts of urine, and boil
together for a few minutes. If as much as one-tenth
of I per cent, of sugar be present, the mixture turns
black, owing to the formation of an oxide of bismuth.
This is a very sharp test, and is probably the safest for
general use. It must not be employed, though, when
the urine contains albumin, as the latter substance
forms a black sulphuret of bismuth.

Quantitative Test. — The amount of sugar in a given
specimen may be estimated either by using Fehling'a
solution or by the saccharimeter, a modification of the
polariscope. For the methods text-books on the sub-
ject must be consulted.

Sediments. — If normal urine i*; allowed to stand for
a time, a light flocculent sediment, composed of mucus
and epithelial cells, becomes visible; this is not abnor-
mal. The so-called brick-dust deposits are made up
of urates; these occur in urine which is acid and
high-colored, and usually of a high specific gravity.
They are not uncommon even in health, and need not
excite any alarm.

The test for urates is that they disappear when the
urine is heated. They are usually deposited in normal
urine which has been allowed to stand in a cold room,
and in larger quantities more especially in the urine of
fevers and of acute articular rheumatism.

Uric acid occurs in crystals, and forms what is
known as a cayenne -pepper deposit. Uric-acid crystals
only occur in acid and highly concentrated urine.

I
I

434 mjRSING.

Sontetimes the)' are passed in fresh

crystals occasionally form the nucleus for a stone in

the bladder.

Oxabiria is a term indicating the presence in the
urine of a considerable quantity of oxalate-of-h'me
crystals. They are cither envelope- shaped or much
more rarely dumbbell -shaped. The crystals of the
triple phosphate of ammonium and magnesium arc
present in alkaline urine, and may form a lai^e pre-
cipitate; they disappear upon the addition of acid.

Bile in the urine gives to it a decided yellow color,
so that when such urine is shaken the froth has a dis-
tinct yellowish tinge. A common chemical test for
bile-pigment is made as follows; A drop of urine is
spread out on a white porcelain plate, and a drop of
nitric acid (yellow with nitrous acid) placed beside it.
At the point where the urine and acid meet there will
appear a play of colors if bile-pigment is present; the
colors produced arc green, violet, and red, the first
being characteristic. This is known as Gmelin's test.
but it is not always satisfactory.

The sediment in urine may be organized; thus it
may contain epithelium, pus and blood-cells, tube-
casts, accidental deposits, and bacteria. Small amounts
of mucus and epithelium may be found in perfectly nor-
mal urine; pus in the urine indicates inflammation of
some portion of the urinary tract, and always calls for
a careful examination. If the inflammation be in the
urethra, most of the pus wilt be in the urine which is
passed first, and it will be well to collect the urine in
two ves.scl,s. A test for pus in the urine is to add
liquor potassa;, and if pus be present the deposit wil]

THE URINE. 435

ba ropy and viscid. In alkaline urine, without the
adaition of any chemical solution, such a precipitate
will probably prove to be pus. Of course a micro-
scopical examination is the best method of deciding
as to the nature of all such sediments.

To prepare a specimen of urine for examination,
the bottle used must first be sterilized; the urine is
drawn directly into it, through a glass catheter if the
patient be a woman, and the bottle corked with a plug
of sterilized cotton or a perfectly clean cork. It should
be labelled with the name of the patient, the date and
the hour it was taken, and the full quantity passed in
twenty-four hours of which it is a specimen ; if it is
from a ward, the name of the ward should also be
added. The fresh specimen should be drawn before
breakfast ; that taken from the total amount of the
twenty-four hours' urine will give more reliable infor-
mation as to the average specific gravitj', and conse-
quently of the total amount of solid.s which are being
e.vcretcd. In the latter case the jar containing the
urine should be [hornughly cleansed, and must al-
ways be kept tightly covered*

Inflammation of the pelvi.s of the kidney is called
pyelitis; it may bt; caused by calculi, and renal colic
may accompany it. No certain diagnosis can be made
from the condition of the urine.

Hematuria is a name applied to the condition in
which blood appears in the urine; the specimen will
appear smoky, and red blood-corpuscIcs will be found
on microscopical examination. The appearance of the
urine varies in hematuria according to the source and
quantity of the blood.

•SwApptiiiliJi, Nultit

436 JVUXSWG.

HcsmoglobiHuria is characterized by the presence of ]
blood-pigment in the urine, derived from the hx
globin of the red blood-cells. The blood-cells them-
selves are either absent or only found in insignificant I
numbers.

UrtEiuUi is a disea.sed condition caused by retention 1
in the blood of the waste substances which normally
should be carried off by the kidneys; the symptoms 1
may be very marked ; there may be intense headache, J
nausea, vomiting, severe twitchings, or even convul- J
sions and coma; but in chronic cases these indications I
may be so slight that they may perhaps pass unnoticed 1
before an examination of the urine has been made.

For retention of urine, before resorting to catheteriza-
tion attempts should be made to have the urine nor-
mally expelled by hot applications over the region of
the bladder; in women a hot sponge placed over the
vulva will often have the desired effect. Sometimes
ice-water is injected into the rectum, or water is al-
lowed to run down over the pubes. or where retention
is due to nervousness the mere .sound of running water
may succeed in relieving the condition. If the urine
is drawn by catheter, the operation should be repeated
every six or eight hours according to directions, and
the bladder should never be allowed under any cir-
cumstances to go over twelve hours without being
emptied.

Incontinence of urine will sometimes be due to over-
distention of the bladder, and where this is the case
catheterization will be indicated. When rubber urinals
are ordered for incontinence, they should be washed out
thoroughly at least twice in the twenty-four hours in a

THE URINE.

solution of hot water, soap, and borax. In fact, if at
any time there be the least odor from them, they must
be thoroughly scrubbed.

Bnght's disfiise of the kidneys assumes several forms,
and may be acute or chronic. In the acute form there
is an inflammation, which comes on suddenly and may
be the result of exposure to cold or occur as a com-
plication in some of the infectious fevers, particularly
scarlet fever, or after the employment of certain toxic
agents, such as cantharides or turpentine. The most
prominent symptoms are a peculiar paleness of the
skin, accompanied by dropsy, the swelling being first
noticed about the eyes and ankles. There may, how-
ever, be severe kidney disease without much cedema,
though headache, nausea, and other ura;mic symptoms
will generally be present. The quantity of urine is
diminished or there may be total suppression ; albu-
min is always present ; the amount of urea excreted is
lessened, and casts of the urinifcrous tubules are found
on microscopical examination. Every effort should
be made to keep the skin and bowels active. The
physician may order a sweat bath first and plenty of
cream -of- tartar water to drink, which the nurse will
make by dissolving a drachm of cream of tartar in a
pint of boiling water, and adding the juice of half a
lemon and a little sugar; this is to be given cold.
Exposure to draughts and sudden changes in tempera-
ture should be guarded against.

In the chronic form, which may last for many years,
the quantity nf urine is often increased, the specific
1,'ravity is generally low. and in many cases only a
trace of albumin is demonstrable.

438 NURSING. I

A record of the amount of urine passed in the
twenty-four hours will often be of great assistance to
the physician in his treatment of the case in almost
any disease, but where the kidneys are implicated such
a daily record should be considered indispensable.

CHAPTER XXVII.

:s Diseases, — Fevm
ENTERV. — Asiatic Ch
Septicemia. — PvrfiMiA.

NARY TUBERCUI.llSIS.

— TvrHoiD Fever.— Ma 1. ARIA.— Dys-
ii.ER A. — Small-tox. — Erysipelas.—
- Tbtanus. — Diphtheria. — Pulmo-

Fever is present in almost all acute infections; it is
not a disease in itself, but a symptom. The progress
of a disease may oftentimes be estimated and indica-
tions for treatment may often be obtained by watch-
ing the course of the fever. In ail febrile diseases
there is waste of the body-tissues, and this is usu-
ally proportionate to the height and duration of the
fever. In caring for fever cases one should arrange
for absolute rest of mind and body, as exertion pro-
duces not only an elevation of the temperature, but
also an increase in the pulse-rate, and thus adds un-
necessarily to the tissue-waste, while at the same
time it increases the strain upon the heart. The
patient should be made as comfortable as possi-
ble; there should be a constant supply of fresh air;
the bed must be carefully looked after, and always
kept fresh; al! heavy clothing should be avoided; a
night-gown which opens throughout the front for the
patient, and a sheet and a light blanket for the bed,
will usually afford sufficient covering. If regular
sponge-batlis are not ordered to reduce the tempera-
lure, at any rate a sponge-bath should be given every

440 jnrssntG.

■nonui^ and repeated at aigfat if possMe; if the
poitesC is so sick that nothhig more can be flooe.
tJbc bee. hands, and bade at least should be ^xx^ed.
Frequent cleansing of the mouth is desir^^. Dfit
oaiy for comfort, but also to prc\-ent bacterial growth
ia it, and thus (cssen the chances of a ccMnpltcaling
parotitis or an otitis media. The bodily strength
should be kept up by the regular administratioa
of nutritious food, given in liquid forni, milk, as t
rule, being the besL The temperature may be i
duccd cither by medicinal agents or by applications a
cold water ; the latter method is the one most cxi
sively used at present, the majority of physiciai
believing that antipyretic drugs produce too roue]
prostration if continued through a long illness.

These general directions apply to the managemenl
of fever when present in any disease. We shall i
speak briefly of the infectious diseases, by which t
mean those resulting from an invasion of the body fa
micro-organisms.

Typhoid fmer is an acute infectious disease, sup
posed to be caused by a certain organism (Eberth'w^
bacillus). The disease is associated with a fever runnin^a
a definite course, with local inflammation and ulcera-g
tion in the small intestines, particularly of the gland
of Peyer. These Pcyer s patches are scattered through-9
out the mucous coat of the small intestines, bein^l
most numerous in the ileum; the inflammation aiid'l
ulceration may also extend into the colon, in whichfl
case the solitary follicles are chiefly involved. Typhoitt
is most frequent in the late summer and autumn-l
months. The majority of cases occur in individuals^

TYPHOID FEVER.

441

over fifteen and under forty years of age. The period
of incubation lasts from one to two weeks, and the
duration of the fever in moderate cases is about three
weeks, convalescence beginning in the fourth week;
in protracted cases, however, convalescence may not
begin before the seventh week.

The prodromal symptoms are — constant headache
night and day, aching of the limbs, and a dull tired
feeling, with chilly sensations, loss of appetite, and
perhaps nose-bleed. There is usually a gradual and
progressive rise of temperature, with morning and
evening variations, the evening temperature being
higher on each successive day by a degree or a degree
and a half, generally reaching 103° or 104° F. by
the eighth day, where it remains with but slight
variations during the second week. There is also
but little difference between the night and morning
temperature during this time, but in the third week
there is a distinct fall in the morning and a grad-
ual decline in the evening temperature. The pulse-
rate increases proportionately with the temperature,
going to 100 or no or even higher. A bronchitis
with a troublesome cough may be present from
the beginning and continue throughout the attack.
The rash appears from the seventh to the twelfth day
in the shape of rose-colored spots seen on the abdo-
men and thighs, and sometimes on the back, which
disappear on pressure and return when it is re-
moved, each spot lasting about three days. The
rash often appears in successive crops. The tongue
at first is coated and white, but afterwards may be very
dry, dark, and cracked if the sordes that accumulate

rapidly arc allowed to dry upon it The lips may
in ihc same condition and become ver>' sore.
" sordc^ '* u^c OKan the dark -brown accumulatioiis
which ivmain in the mouth, being a mixture of food,
epithelium, and micro-organisms. Thc>' collect thickly
oil ihc tongue, teeth, and lips, but such collections can
be prcvenicd to a great extent by frL-qucnt washing
out of the mouth with antiseptic cleansing lotions and
b>' giving the patient plcntj- of water to drink, espe-
cially aftiir he has taken milk or other food. The
mouth is most easily washed out with small squareqii
of gauze or soft muslin, which after use arc to be
once burned.

CoHStifiUioH or diarrha-a may be present at first,
latter being more frequent, but an average of three
four stools a day during the second week is not ui
common. These stools have a yellowish, pea-soup
appeanince. Notice should be taken if there be any-
thing unusual about them, so that they may be kept
for the physician's inspection ; if there be constipiitioo,
the bowels should be opened daily by an enema,'
which should not, however, be given without tbej
orders of the physician. The care of the excreta ha%
been described elsewhere. The cliaracteristjc odor of
typhoid discharges is prone to cling about the pati
unless scrupulous cleanliness in regard to the body
and linen is observed. Its presence is always a sigitj
of careless nursing. The urine is diminished In
quantity at first, and retention should be watched for;
later the flow is more abundant

HiEmorrhage from the bowels may occur at any''
time after the second week. The first indication

rhe
uit^^l

TYPffOfD FEl'ER.

443

usually a sudden f^ill oi tcnipfralure with symptoms
of collapse, or the blood may appear suddenly in the
stools. The patient should be kept perfectly quiet on
his back, the foot of tlie bedstead elevated, and an ice-
bag applied to the abdomen* A sudden drop in tem-
perature from high fever to or even below the norma!
should be at once reported, as it may indicate either
haemorrhage or perforation. The hicmorrhage comes
from the sloughing through of the wall of a vessel
at the base of an ulcer.

Perforation of titv intestine is one of the greatest
dangers in the course of typhoid fever. The wall of
the intestine gives way. and through tiie hole, which
is often very small, the contents escape into the peri-
toneal cavity, giving rise to a peritonitis which gener-
ally ends fatally. The symptoms are those of collapse,
accompanied by severe pain, with a sudden fall of
temperature, a small rapid pulse, and distension of the
abdomen.

Tympanites. — Distension of the abdomen from gas
in the intestines is frequently present, but is not con-
sidered a serious symptom unless it is persistent and
marked. If turpentine stupes are ordered, care should
be taken to have them well applied. Turpentine
cnemata are sometimes given for the same condition.

A relapse may occur once, sometimes indeed even
two or three times, after convalescence has apparently
begun. Then too, besides a genuine relapse, there are
frequently marked elevations of temperature, lasting a
few hours or days, due to errors in diet, over-exertion,
or excitement. The nurse must be careful about the.se,
and also avoid anything which might put too sudden a

• Sec Appendix, Nuuu-

444 JVUKS/NG.

iArua on the enreebled heart, as some-times death
results froTn heart paralysis.

For iniomnia or other nervous symptoms the ice-
cap may be ordered or iced cloths be applied to the
bead. Sometimes sponging will allay the restlessness.
A delirious patient inclined to get out of bed should
be watched constantly. Among the symptoms which
are considered unfavorable are marked muscular twitch-
ings, subsultus tendinum, excessive tympanites, pro-
longed high temperature, and a rapid fall of tempera-
ture, A gradual fall of temperature, while the tongue
becomes moist and clear about the edges, with return
of appetite, are all symptoms of approaching conva-
lescence.

The treatment usually prescribed, besides the reduc-
tion of the temperature, consists chiefly of good nurs-
ing. The temperature is reduced by the application
of cold water, by means of the tub-bath, spongings, o
the cold pack, all of which procedures have been
already described in the chapter on " Baths."*

Liquid diet is ordered while the temperature re-
mains high, milk being the principal food; from thre
to four pints are usually given in the twenty-four i
hours (from four to six ounces every two hours), being
diluted with either plain or aerated water. Milk may {
be alternated with chicken -broth, beef-tea or mutton- i
broth, albumen -water, or weak cocoa, and plenty of
water should be given to drink, whether asked for or ,
not. Strained lemonade, iced lea. or coffee may be
given occasionally. Whether or not a patient shall
be wakened for his nourishment at night is to be J
decided by the physician.

•S«»App«i"Uii, Nowi*

TYPHOID FEVER.

44S

Soft food, in the form of eggs, milk-toast, custards,
and jellies, is usually ordered when ihere ir. no fever in
the evenings, but physicians do not, a.-i a rule, ullow any
solid food until a week or ten days after the tempera-
ture has become normal, and then it is necessary to
begin with small amounts. Milk or food of any kind
should not be allowed to remain beside the patient or
anywhere in the room. Especial care .should be taken
to disinfect the dishes used for typhoid patients, and
no milk or food of any kind intended for other patients
should be allowed to come in contact in any way with
a typhoid case, as the bacilli which cause the disease
find in them suitable media for growth and develop-
ment.

The ventilation of the room, the cleanliness of the
patient's person and of his bed, the disinfection of the
linen and of the excreta, regularity in diet, — all are
things to be very particular about in caring for a case
of typhoid fever. The patient should be turned from
side to side frequently, and his back supported by a
pillow. Bed-sores must be watched for, and any
evidence of local inflammation or abscess at once
reported.

Typhoid is probably contagious only through the
faeces, but nurses should always be careful to disinfect
their hands thoroughly after working over a case, and
especially before going to meals. Water is one great
source of infection, and should be boiled before it is
used if there is any suspicion that it is contaminated.*

Maliiiia is an infections disease due to animal
organisms that invade the blood and rapidly de.stroy
the red blood-corpuscles. It is characterized by an

•Sec Appendix, Hvvt 35.

tntcrmtttent type of fever, a paroxysm occurring usually
every day or every stcond, third, and much more rarely
every fourth day. There is also a remittent type and
a chronic type. The most frequent form is the ioter-
Riittcnt, in which there are definite chills. Three dis-
tinct stages may be observed : first, the cold stage, in
which the patient has a chill of greater or less in-
tensity, lasting from ten or fifteen minutes to more ■
than an hour, during which time he suffers from la
headache, backache, sometimes nausea, and vomiting;
the temperature rising rapidly; in the second or hoi
stage the patient feels as though he were burning up^l
the face is deeply flushed, and the temperature goes to?
105° F, or higher: after from three to five hours thai
temperature falls, and we have the third stage, ina
which there is profuse perspiration, the headache and'f
other symptoms subsiding, and the patient, thougba
weak, feels better. The attack may come on the nexl
day (more often one day is missed) unless something ii
done to destroy the oiganisms in the blood. During|
the paroxysm the patient may be made b
fortable by hot bags to the trunk and feet, with an ice«l
cap to the head ; for the intense thirst aerated watei3«
or lemonade may be given, the latter being particularly J
acceptable. A sponge-bath is often ordered to be I
given both during and after the fever, and when the 1
patient has ceased to perspire the linen should be J
changed. If the infection persists, a condition known if
as chronic malaria may be established, with develop- J
ment of a marked anarmia from decrease In the number |
of the red blood-corpuscles.*

Dysentery is a disease in which there are frequent I

■S»Appc»dll,NnU}6.

DVSEA'TKfH: 447

stools containing mucus and blood, accomp;inii;d by
tenesmus. The acutu catarrhal form is an inflamniation
of the large intestine. It may begin as a painless
diarrhoea, but in a short time there are griping pains
and straining, the stools consisting chiefly of mucus
and blood. The range of the fever is usually not
high; in the beginning it may rise to 102° or 103°.
There may be nausea, vomiting, and great thirst.
The duration of the disease is from four to twenty-one
days. The amebic or tropical form of dysentery is
characterized by the presence in the stools of an ani-
mal organism called the Anuria coli. It is uncommon
outside the tropics; the stools, as a rule, are frequent
and have a characteristic odor, which may be rendered
much less offensive by the use of permanganate of
potassium as a deodorizer. The patient is to be kept
quiet in bed in all forms of dysentery, and liquid diet,
usually milk, is ordered. If curds appear in the
stools, the amount of milk given is to be lessened, or
egg-albumen and beef-Juice may be substituted. If
injections of quinine or other drugs into the colon are
ordered, they should be given in large qu.-iii titles, high
up and very gently, with the hips elevated. Anti-
septic precautions are to be taken with the tube and
vessels after use, the patient must be kept scrupu-
lously clean and his linen and the discharges must be
.iterllized. Cold applications to the anus sometimes
relieve the tenesmus.

Asiatic Cholera. — From bacteriological studies of
this infectious disease it has been found that it is due to
a certain kind of bacterium present in the evacuations
from the bowels, and that it is probably chiefly conta-

gious through the stools or by the contamination of
water used for drinking and household purposes. In
consequence, rigid disinfection of the stools and of the
linen is necessary, and only boiled water and well
cooked food should be taken when the disease prevails.
The stools of cholera patients are at first yellowish in
color, but soon change to the so-called " rice-water"
stools; they are profuse and very frequent, so that
unless the disease is checked the patient soon falls
into a condition of exhaustion and collapse. Hot ap-
plications may be made over the abdomen and heat
applied about the body ; warm injections of tannic
acid have been used with some success, and sub-
cutaneous injections of warm salt solution (4 grammes
to the litre) are recommended as valuable in that they
supply the loss of fluid from the blood and system
consequent upon the profuse watery evacuations.
Opium is usually given to control the pain, and plenty
of ice-water to allay thirst. There is no great danger*
in nursing a case of cholera if sufficient attention be
given to the food one takes and the water one
dnnks. Very careful nursing is necessary during the
convalescent stage and a restricted diet should be
maintained for some time.

Small-pox, or variola, is one of the most virulent of
diseases. The poison i.s present in the secretions and
excretions, being given off chiefly from the lungs and
skin. The stage of incubation is from seven to four-
teen days ; the disease proper begins with chills, intense
headache, severe pains in the back, and vomiting, the
temperature rising rapidly to 103° or 104° F., with
a full, rapid pulse. On the third or fourth day the

SMALLPOX. 449

rash appears in the form of small red spots, showing
itself first along the junction of the forehead and hair,
whence it spreads over the body. When the rash ap-
pears the temperature falls, and the spots or papules
gradually develop until the sixth day, when they
become pustular. With the suppuration the tempera-
turf again rises, and there is mucli swelling of the skin
about the pustules, with tension and pain, more partic-
ularly in the face. In the discrete form, where the
pustules remain separated, the temperature drops in a
short time and convalescence begins, the swelling sub-
siding, and the pustules drying up and desquamating;
in the confluent form, however, the pustules increase
in size, run together, break down, and form crusts
over the surface of the skin, particularly of the face and
hands, until about the tliird week, when the fever
abates and the crusts gradually dry up and drop off,
provided the patient has survived the attack. In the
confluent form there is great thirst and often delirium;
the danger is greatest in such cases about the tenth
or eleventh day, being in proportion to the intensity
of the eruption. Broncho-pneumonia is a frequent
complication.

In caring for a small-pox patient the best hygienic
measures should prevail, the air being fresh and kept
at a temperature of 65" F. The patient should be
lightly covered. To reduce the fever cither cold
sponging or bathing may be ordered. The food must
be liquid, and water may be given freely. The face
should be protected by a ma.sk made of lint dipped
in cold water or in t per cent, carbolic-acid solution,
and then covered with oiled silk. When the scnb-'i

450

NURSING.

begin to form, to prevent them from scattering and
to keep the crusts soft, vaseline or oil is applied and
warm baths arc given daily. Dilute carbolic-acid solu-
tions arc useful in counteracting the offensive odor.
Particular attention should be paid to the eyes, mouth,
and throat, and all sponges or dressings used should be
burned at once. If possible, the patient should be in
a room with an open fire, which renders this burning a
matter of little inconvenience. Isolation should be kept
up until the skin returns to its normal condition.

Erysipelas in an acute infectious disease, the result
of the invasion of a virulent micro-organism {strepto~
cocais). It may appear from three to seven days after
exposure, and be ushered in by a chill and elevation
of temperature. If it be a wound that has become
infected — and the majority of the cases of erysipelas
arise in this way — a bright-red flush appears about it.*
The patient should be isolated at once and the usual.
precautions taken. The diet must consist of liquids'
or of light, ea.sily digestible food.

The terms scpfUiriiiiu. pyamia, and saprmtnia have
come to have an altogether different significance since
our knowledge of the infectious processes has become
extended. In both septicajniia and pyemia there is
a general blood- infection with pus-producing bacteria,
resulting usually from the infection of an open wound,
accidental or operative. In an acute sepHctsmia the
cocci multiply rapidly in the blood, and are very viru-
lent, causing death sometimes in twenty-four or forty-
eight hours through a direct poisonous effect upon the
whole sy.stem. The symptoms are, as a rule, a sudden
chill, accompanied by considerable elevation of tem-
perature, a rapid, compressible pulse, and vomiting.

In pytsmia. on the other hand, either the bacteria are
less virulent or the patient's tissues are more resistant,
and the disease, lasting longer than acute septicemia,
results in the formation of multiple abscesses all over
the body, particularly in the joints and larger organs.
The fever runs the so-called "choppy" course which
is seen on the charts of pus cases of all kinds, the
temperatu.'e being perhaps normal in the morning, and
going up to 103° or 104° F. at night. There will be
chills, followed by profuse sweating; the patient be-
comes rapidly emaciated, develops a hectic flush on
his cheeks, the pulse becomes small and very fre-
quent, and finally death occurs from exhaustion.
There is no sharp dividing-line between septicemia
and pysemia, and cases apparently halfway between
the two conditions above described have been called
cases of septicopysemia.

Sapramia is an entirely different process. Here the
pus-formation is altogether local, and the bacteria do
not get into the blood and go all over the body.
Severe symptoms, and even death, may nevertheless
occur from absorption of the toxic chemical products
from the local abscess or slough.

Tetanus, popularly known as lockjaw, and formerly
supposed to be purely nervous in its origin, has been
proven to be caused by a peculiar kind of bacillus.
This species is found most often in garden earth, ma-
nure, or putrefying fluids, the poison being conveyed
by the earth or dirt that is carried into a wound either
at the time of its occurrence, or afterward where it
has not been properly protected. The affection be-
gins with stiflTiess in the neck, and a tightness about

^^l -U^ i/Ifc iu^i-.^e- ^^ ^^^^ ,_

- ^«ae^ — fa^ ^T^ isiiiur :=

IT i.:m
an

din ra*if ^ rfe resKu^ ^ar *

^m m^m: fees «KOrsiiBri s^ jr^ g^
*>t iW^fawt Etta as ttte r^^ot o^

af lOM^ rf ;ie ataadis and ^

DIPHTHERIA. 453

The temperature of the room should be about 68*
and thorough ventilation should be secured. The air
may be kept moist by means of a steam-kettle, or a
steam-tent may be arranged over the bed so that the
child may breathe an atmosphere saturated with moist-
ure. Local applications, hot or cold, are made, and
everything is done to keep up the patient's strength,
in order that he may be able to resist the effects of the
poison on the system. Plenty of water to drink may
be given. The food should be liquid, milk, beef-juice,
barley-water, albumen-water and soups. Where there
is difficulty in swallowing, on account of obstruction
and pain in the throat, nutritive enemata should be
used. In diphtheritic paralysis, if swallowing becomes
very difficult, the patient may be fed \vith a stomach
tube in preference to rectal feeding. General prostra-
tion is very marked toward the end of the attack.
Stimulants arc usually ordered from the beginning.
As the disease is very contagious, a nurse in swabbing
out the throat should be careful not to become infected
herself by any discharge that may be expelled during
coughing or when she is applying the disinfectants.
The expectoration should be received in small squares
of muslin and at once burned. The strictest quaran-
tine should be established, and only the nurse, doctor,
and possibly the child's mother, be allowed to come
near the patient. The bed-linen, dishes, and room
should undergo the most rigid disinfection before
being again put into general use.

Temporary paralysis is not infrequently a sequel of
diphtheria. It may be loc;il, aflcctiufj only the mu.sclcs
of the throat and palate, or it may bo more general,

(tlafi Do- use preveiiDvc fi t Jl 1 1 iftit bv \
xoA pfMNibJy taking a tainc : die pfa^
«ee tt> rliM wbere the nurse Etas bot
porTtMrty for daily change of air.*

PiUmonary mderoiiaja lias beaa
c9udeii in thit chapter for the
that has been writteii oo the soiy
vataoMeHpes ve loaC every year bei
MC —ifci'JClBil that one ca.se of Xsd
ffcc eaPMe of aBity a6»tn. and that tj
h co<nmo«ly called " consampdoa,'' c
precatitkMM. be almost entifely s&mpc

The disease may be either acnte or
acute form in the early st^es there a
the loaD^ and later softening or cxcai
lows the liquefaction of the necrotic

The bacilli enter through the i
lodjjc at nomc point on the respirator
moat frequent startiag- place is at the
bronchiole, juvt before it opens into
The apex of the right lung is most oft

PULMOSAA-Y TUBERCULOSIS.

455

cliills, and profuse sweating may occur, especially
when the patient is asleep. The expectoration is
opaque, muco-pumlent, and contains tubercle bacilli,
and in the later stages elastic tissue ; it may be glairy,
tenacious, and streaked with blood, and will become
more profuse when the breaking down of the lung-
tissue has begun; there may be nausea, vomiting, and
diarrhcea, particularly late in the disease. The skin
has a pearly pallor, the hectic flush appears on the
cheeks, and the eyes are bright and glistening. He-
moptysis is sometimes the very first .symptom, and it
may occur at intervals throughout the disease. The
acute form is generally rapidly fatal. In the chronic form
the progress of the disease may sometimes be arrested.
The treatment consists principally of hygienic meas-
ures. Warm flannels, good nutritious diet, a great
deal of outdoor life and exercise, when the patient
can stand it without suffering from over-fatigue, with
a change of climate, especially to a high mountainous
district, — all are valuable.

Tuberculous sputum should be at once burned or
else put in a strong disinfectant solution, as it contains
enormous quantities of the bacilli, which, if allowed to
dry and mix with the dust, become scattered broad-
cast, carrying infection everywhere.

The patients must be made to use sputum-cups;
they should never be allowed to expectorate into a
handkerchief, unless it is made of cheese-cloth or
paper which can be burned at once, or, in fact, any-
where except into the proper receptacles. The
sputum-cups can be sterilized by steam or by being
boiled in a 2 per cent, soda solution. We scarce

,e,ng ^

456

NURSINC.

need the support of a theory of heredity in consump-
tion : when we thinli of a child Itissing a parent, per-
haps jiiany times daily, over whose lips thousands of
tubercle bacilli are hourly passing, and when we think
of that same child inhaling the dried bacilli and their
spores, which always about in the dust of a house

containing tuberci' nts, it would jeem strange

that the disease d< xv still more often.

CHAPTER XXVIII.

Notes os some Medical Diskasks.

Tonsillitis. — Besides the common forms of sore
throat which we term pharyngitis, and the rarer
forms called laryngitis, we frequently meet with an
acute or chronic inflammation of the tonsils. Here
wc find congestion and more or less swelling of the
glands and the parts surrounding them. When in
the acute form the process goes on to suppuration,
the affection is then popularly spoken of as quinsy.
It begins with a more or less severe chill accom-
panying the sore throat, and a temperature of from
102° to 103° F., with headache and backache. A good
carthartic with astringent and aiiti.septic gargie.s are
usually ordered, and when given early enough may
cut short the disease. In quinsy, where the pain is
severe, hot-water applications or poultices will give
relief. In children the remedies to the inside of the
throat are applied with a camel's-hair brush or swab.
The disease rapidly exhausts the patient, and during
convalescence a liberal diet should be given.

Amite gastritis denotes a condition often spoken of
by a patient as a "bilious attack." In some cases it
is caused by overloading the stomach with indigestible
food, or comes on after drinking large quantities

;estible ^M

.vrRsr.VG.

alcohol: any irritant poison taken into the stomach
may set up an acute gastritis. The patient may be
very ill, and death sometimes occurs. He should li
put to bed, his diet restricted to milk, and the phyi
cian summoned at once.

Dyspepsia is a term commonly used to cover j
number of the so-called functional diseases of I
stomach. The patient complains of a sense of oppre
sion and fulness, generally referred to the epigastri
region — of pain, dull headache, and languor; he id
irritable, and is often very much depressed. Thi
symptoms vary in different persons, aud sometimes 11
the same person at different times ; pain may followr^
either immediately after taking food or come on when
the stomach is quite empty, in which case it will be
relieved by eating. Regurgitation or vomiting is a
common symptom in cases of acidity caused by fer-
mentation, and then flatulence and acid eructations are
frequent. Vertigo or dizziness is often caused by indi-
gestion, and constipation is not seldom present.' A
nurse should report to the physician the appearance
of any such symptoms, in order that the necessarj*
restrictions or change in the diet may be ordered.* ,

Dianhcea means the frequent discharge of fject
usually of a soft or fluid character. There are diflR
ent varieties, the principal forms being the trritativt
the symptomatic, the nervous, the chronic, and 1
choleraic.

Irritative diarrhoea usually lasts but a short time, andll
is often due to .some disturbance in the intestinal digca
tion from over-indulgence in the matter of food or thi
eating of tainted meats. The chief symptoms, besidesfl

Appcodix, Ne>ic jg.

blARRH(EA.

459

the frequent stools, are more or less severe griping
pains, nausea, weakness, and. if the disease has lasted
long, great prostration of the patient

Symploniatic diarrhcea occurs in the course of cer-
tain diseases, such as typhoid fever, dysentery, and
tuberculous ulceration of the intestines. In the ner-
vous form the inte.stinat digestion is disturbed by some
strong mental emotion, anxiety, or fright. Chronic
diarrhcea is often due to frequent or continued indi-
gestion or to chronic inflammation or ulceration of the
intestines. Diarrhcea preceding an attack of cholera
may be mistaken in the beginning for a simple
diarrhcea. A very severe form of diarrhcea resembling
cholera occurs in the summer months, and may follow
a sudden checking of perspiration, the abuse of iced
drinks, exposure to sudden changes of temperature, '
or serious nervous disturbances. The attack usually
begins at night with pain in the abdomen, vomiting,
and purging, and in grave forms there are cramps in
the lower extremities and in the abdominal muscles.
These symptoms are accompanied by profuse sweat-
ing, a weak pulse, and a condition of exhaustion,
usually lasting a few hours and terminating rapidly
in recovery.

The diet in diarrhcea should be carefully regulated;
albumen water, milk, or milk and lime-water, may be
ordered at first, and afterwards the more easily digested
solid foods, fruits and vegetables being prohibited en-
tirely even for some days after convalescence. Rest in
bed is a valuable adjunct to the treatment.

The name appendicitis is given to an inflammatory
condition of the vermiform appendix, which may re-

KLJiSINO.

suit in ulceration, perforation, and abscess-formatioa
The chief symptom is severe pain in the right iliac
region, associated often with vomiting and obstinate^
constipation, tenderness on pressure, and elevation of |
temperature. Perforation with a resulting general peri--
tonitis is an accident to be dreaded. Purgatives should J
never be given. Until medical aid can be obtained the J
patient should be kept perfectly quiet in bed, with i
ice-bag placed over the seat of pain.

Peritonitis is an inflammation of the peritoneumf
which may be due to extension of inflammation fromi
any of the organs covered by it or to perforation from I
an ulcer of the stomach or bowels. It is more espe-l
cially to be feared after surgical operations on the I
abdomen if the wound should have been allowed to I
become infected. The main symptoms are severe J
pain, the patient lying on the back with the knees I
drawn up and shoulders raised; there is tenderness l
on pressure over the abdomen, which is generally J
distended ; the respirations are frequent and shallow, I
the pulse rapid, small, and wiry, the temperature J
moderately high ; vomiting begins early, the ex-
pression changes greatly, and the face takes on 1
an anxious and haggard look. The patient should |
be kept very quiet, and all pressure from the bed-
clothes avoided by the use of a cradle.*

By tiscitcs i.s meant a collection of fluid in the peri-
toneal cavity. The abdomen is sometimes tapped if '
the amount of fluid be large. When this is to be
done the instruments must be sterilized and the ab-
domen previously prepared, so that the danger of
introducing septic material will be avoided.

A small _^^|

SRONCHiriS. 461

occlusive dressing should be ready for application after
the operation.

Bronchitis h An inflammation of the bronchial tubes."
The acute form begins as an ordinary cold, which
extends to the bronchi, giving rise to a ^ense of tight-
ness and oppression in the chest. The cough at the
onset is dry or is accompanied by but little expectora-
tion, which at first is mucoid in character, but later
becomes more copious, and is often purulent; the
pulse is quickened and the temperature a little ele-
vated. The patient should be kept in bed in a warm,
well- ventilated room, and a mustard foot-bath and hot
drinks may be given. Inhalations of steam and keep-
ing the air of the room moist will relieve the feeling
of oppression and pain. The bowels should be kept
open, and plenty of light nourishing food given ; mild
cases recover in a few days.

Asthma. — The most common form of asthma is a
bronchial affection characterized by cough, dyspnoea,
and expectoration of a mucous secretion, the attacks
occurring paroxysmally. Although rarely dangerou.s,
it is a very distressing disorder, and in a severe attack
the symptoms may be alarming. Asthmatic subjects
usually carry remedies with them, such as capsules of
nitrite of amyl, which they break in a handkerchief for
inhalation; these should never be used c.vcept by
order of the physician. The patient should have all
the fresh air possible, and a hot foot-bath and hot
drinks may help to give him relief

Croupous pneumotiia is an infectious di.sease due to
a micro-organism which locally produces an acute in-
flammation of the lung-substance, and constitutionally

462 iVCftS/NG.

a condition of prostration, resulting Trom absorption
into the blood of the poisons produced by the bacteria.
It is a serious condition, and is especially fatal in the
case of old people and in individuals who have been
accustomed to the excessive use of alcoholic stimulants.
It is divided into three stages : the first is the stage (rf 1
engorgement; the second, that of consolidation; and I
the third, that of resolution. The lower lobe of the /
right lung is most frequently attacked : in the so-called I
double pneumonia both lungs are involved. Anything]
that tends to depress the vital powers, such as faul^ 1
hygienic surroundings, exposure to cold, and particu- I
larly to sudden variations in temperature may act ]
as a predisposing cause. The onset is sudden : the pa-
tient has a chill, complains of a sharp pain in the side,
and the temperature rapidly rises. The respirations j
are quickened to 30 or 40 or more per minute; the
breathing is difficult; the face is flushed, particularly 1
the cheeks; with each inspiration the nostrils dilate; 1
the cough is short and hacking; the expectoration I
at first may be frothy and mixed with mucus, after- I
ward becoming thick, tenacious, and of a rusty-red ]
color, due to its admixture with red blood-corpuscles.
In alcoholics so much blood may be mixed with the
sputum as to give it a dark reddish-black color; this is J
the " prune-juice sputum." When resolution takes I
place, the expectoration becomes light yellow in color
and more abundant. Through the course of the dis-
ease the temperature ranges from los** to 104°
105° F., being a little lower in the morning than in the \
evening. A sudden fall as early as the third or as late j
as the twelfth dav, accompanied by profuse perspira*

PXEUM0X/.4. 4^3 1

tion, indicates the crisis, after which convalescence I
begins. The pulse is full and rapid, varying in fre-
quency from 90 to 120 beats ptr minute: ii
cases it may even exceed this. Delirium may be |
present from the beginning, and the patient, who may
try to get out of bed, must be carefully watched.
For this symptom the ice-bag to the head or the
cold pack are often ordered. It is necessary that
the nurse make accurate etatements to the physician
with regard to the pulse, temperature, respiration.
and sputum : the last-mentioned should be kept for
inspection. She must also be able to describe the
symptoms, to note any serious change in the condi-
tion of her patient, and to understand its significance.
The ventilation of the room should be carefully regula-
ted, the temperature being kept at 68° F. The mouth
must be kept clean and moist; when there has been a
profuse perspiration the clothes should be changed at
oncCj the body sponged in water and alcohol, and warm,
dry clothes should be put on. The diet during the fever
should be liquid, but concentrated, in order to supply
plenty of nourishment. It is best given at frequi
but regular intervals ; much depends upon the keep-
ing up of the strength of the general system, as heart
failure is not uncommon. Stimulants are frequently
ordered throughout the course of the disease, when
the condition of the heart indicates their use. For
the pain tin.- ice-bag or dry heat is applied over the
affected side. To reduce high temperature, the cold
pack, cold sponging or the tub-bath at 70°F, are often
employed.
Pleurisy is an inflammation of the two surfaces of

[

the serous membrane which surrounds the lungs. It
may be localized or general, dry or accompanied with
effusion. When the inflammation begins there is a
:iharp shooting pain, the "stitch in the side," which is
aggravated by breathing or in fact by any movement.
An exudation (the amount and consistence differing in
different cases) next takes place. Together with the
sharp pain in the side, which is relieved a.s the exuda-
tion increases, the patient may have a slight chill ; the
respirations are hurried and shallow, the patient fear-
ing to take a deep breath on account of the pain ; the
temperature is elevated, and there is a short, dry
cough. The patient should be kept quiet, and where
there is much effusion a dry nutritious diet given,
the amount of liquids being restricted. A light band-
age applied around the thorax or rubber strapping ex-
tending over about two-thirds of its circumfereiipe les-
sens the pain by diminishing the expansion of the
chest on the affected side. An ice-bag may be kept
over the scat of pain. As a counter-irritant I'aquelin's
cautery may be applied or mustard plasters or
iodine used. To reduce the amount of effusion the
physician orders Epsom salts or some other hydra-
gogue cathartic. When the cavity becomes much
distended with fluid, aspiration is performed. Some-
times the exudation becomes purulent, and the condi-
tion is then spoken of as purulent pleurisy or em-
pyema.

A total loss of power in some of the muscles of the
body is ca\led paralysis : when the loss is only partial
we have what is called a condition of paresis.

Hemiplegia means a paralysis by which one whole

TABES.

side of the body is affected. When one limb only Js
paralyzed the term uionoplegia is used. %y paraplegia
we mean a loss of power in both arms or both legs.
By complete paraplegia is meant paralysis of all four
extremities.

These paralyses may be due to various causes — to
lesions of the brain, of the spinal cord, or of the
peripheral nerves. In most cases hemiplegia is due to
thrombosis, embolism, or rupture of a blood-vessel in
one of the hemispheres of the brain.

Where there arc muscular spasms or convulsions
the nurse should watch carefully to see what part of
the body is first affected, since this knowledge may
help the physician in localizing the seat of origin of
the disease.

With good hygienic surroundings, good care, mas-
sage, and electricity, complete or partial recovery in
some forms of paralysis may take place ; great care
must be taken to guard against bed-sores.

Tabes, a disease which is also called locomotor
ataxia, is marked by a loss of co-ordination in the
legs without any marked loss of power in the mus-
cles. It is not a very rare disease, and in it the
gait is unsteady, because the patient is not able to tell
unconsciously, as he naturally would do. how his
muscles are acting, but has to be guided by his eye-
sight. As a consequence, walking in the dark is par-
ticularly difficult. By looking after the general com-
fort of the patient, the nurse can do much towarci
making his life bearable, and besides this should en-
courage him to persevere conscientiously with the
treatment prescribed.

ifA KUKSLVG.

Meningiiis. — ^The meninges arc the membranes
which envelop the brain and spinal cord, and men-
ingitis is an inflammation of these membranes. The
acute form occurs mosl often in childhood, but adults
are also attacked. Tliere is usually violent headache,
severe pain, vomiting, an occasional sharp peculiar
cry, great restlessness, anJ sometimes coni'ulsions.
There may be fever, and usually in the beginning
there is a chill. As these symptoms are aggravated
by bright light and loud noises, the nurse should see
that her patient is kept quiet, the light subdued, and
all visitors kept from the room. Where the house is
near a busy and noisy street it may be necessary in
this and other diseases to cover the roadway with saw-
dust. Noiseless shoes must be worn by all attend-
ants, and the slamming of doors and other unneces-
sary noises avoided.*

Neuralgia means a sharp pain in the course or dis
tribution of a sensory nerve. Among some of the
exciting causes we may mention exposure to damp
and cold, chronic poisonings, decayed teeth, dyspepsia,
constipation, and malaria. The pain may assume a
variety of forms. One of the nerves most commonly
attacked is the trigeminus, or fifth cranial nerve.
When the pain in this nerve is accompanied by sharp
spasms the affection is called tie douloureux. Sciatica
may be due either to a neuralgia or to an inflammation
in the sciatic nerve. In most forms of neuralgia the
diet should be especially nourishing, in order to im-
prove the general condition of the sy.stem.

Delii'mm tremens results from the excessive and
frequent use of alcoholic stimulants. In tiic begin-

THE REST Ci'KE. 467

nrng there is depression and anxiety, sleeplessness and
muscular tremor, with a weak and feeble pulss. After
a few days delusions and hallucinations ap[icar, and in
the paroxysms of fear or fury thus induced the patient
may become dangerous and attack his .ittendants.
Where he is so violent the assistance of male helpers
is necessary. Sleeplessness is a bad symptom, and if
sleep cannot be obtained the termination is usually
fatal. The patient should be kept in a large room,
with the windows and doors guarded and the light
subdued.

Tke Rest Cure. — Upon two very common nervous
affections, which every nurse will meet with very fre-
quently among both rich and poor patients, in hospitals
as well as in private nursing, we have not space to dwell
here. We will only say a few words on a method of
treatment so frequently prescribed in cases of hysteria
and neurasthenia, which has obtained the name of " the
rest cure," and has been so strongly recommended
and so much written about by Weir Mitchell, Playfair,
and others. The patients to whose cases it is particu-
larly applicable are those suffering from nervous
exhaustion, such as is seen in nervous, hysterical
women. The exhaustion in men may be the result of
overwork, excessive brain-wear, continuous care and
responsibility for a long period of time, strain from
anxiety and business difficulties, aggravated by inat-
tention to those habits which tend to keep the body
healthy. In women the nervous prostration more
frequently results from lack of congenial work, in-
dulgence in excessive gayety. or again from nursing a
sick friend, arduous household cares, or social duties.

4S8 NUFSmC.

Where the prostration is severe, in order to procure
much relief the patient must in most cases be removed
from her home and placed in an institution where she
may have the advantages of this " rest-cure treat-
ment" To become expert in dealing with these pa- ,
tients it would be advisable for a nurse, if she intends 1
to devote herself esf)ecially to the care of such cases,
to spend some months in a hospital where the treat-
ment of such diseases is made a specialty.

The first step in the cure is to ensure the complete
isolation of the patient. No one should see her but
the nurse, the physician, and the masseuse. Absolute
rest in bed. massage, electricity, and systematic over-
feeding are desirable. Very little tf any reading, and
no sewing or writing of letters, should be allowed.
Usually the patient is kept in bed for from four to
ten weeks. The massage is an important feature, and \
should be given at first very gently for a few minutes
at a time, and gradually increased. The food should 1
be abundant, easily digestible, and given at regular in-
tervals. For extreme nervousness or sleeplessness
the hot foot-bath, the warm full bath and hot or cold
packs arc used.

The nurse, while very firm, should be especially
jjright, cheerful, and good-tempered, but she must 1
observe a happy mean and be careful not to be over-
sympathetic with her patient. When the nervous
system has become rested and strengthened, It is ad-
visable to allow the patient to return gradually to her
former occupations and habits of life.

Cardiac Disi-asi: — Diseases of the heart are diag-
nosed by physicians chiefly by means of physical \

HEART DISEASE.

signs obtained by inspection, palpation, percussion,
and auscultation : with these, of course, the nurse
has nothing to do, but she will be interested in
noticing some of the general symptoms which oc-
cur. The particular symptoms of the various dis-
eases may best be acquired by observation at the
bedside. The most frequent disorders of the heart
met with are inflammation, valvular diseases, angina
pectoris, and dilatation.

Heart disease is frequently a sequela to other dis-
eases, such as acute rheumatism, or follows acute
infectious diseases like pneumonia, typhoid fever,
diphtheria, or acute Bright's disease.

Pericarditis is an inflammation of the pericardium or
the membrane that envelops the heart. Endocarditis
is an inflammation of the lining of the interna! surface
of the heart. The origin of both diseases can often
be traced to an attack of rheumatism or chorea. Most
of the valvular diseases of the heart, where changes
have taken place in the valves which obstruct the
flow of blood through them, or on account of im-
perfect clo.sure permit a backward flow, are due to
chronic inflammation of the endocardium. Where
the valve is thickened and there is obstruction to
the onward flow of blood, we have a stenosis (mitral
stenosis, aortic stenosis), and in those cases in which the
valves leak, whereas normally they should close tightly,
the valve is said to be insufficcnt (mitral regurgitation
or insufficiency, aortic regurgitation or insufliciency).
A patient with heart disease may often go on for years
without being aware of its existence, though at times
he may notice that he is somewhat short of breath.

470 /•TMSZyG.

Asa rule, it i> not oatil tbe faeait is I
hausted tliat serious ayinptoois begin tc show t

selves. aJtboogb. of coarse, sscfa a patient t
dies suddenly if too much strain is put upoo the heart
by over-excrtioa or en>otioa. The appearance of a
patient suflering from a grave heart ailectioa is usually
very striking when he comes into the ward. He is oAes
very short of breath ; his &ce may present a bluish
appearance (cyano«s) ; tbe legs are often much swol-
len, and the swelling may affect the arms, hands, and
other parts of the body (cedema). Besides the proper
remedies, he will probably be ordered a liquid or very
light diet and absolute rest in bed. If he cannot lie
down, a bed-rest must be provided, or he may be
propped up with a sufficient number of pillows. In
many cases the heart will thus be enabled to recupe-
rate, so that it can do its work fairly well for a long
time. All sudden movements and excitement of every i
kind should be avoided. The patients, especially 1
when they are getting better, are often very much I
averse to staying in bed, and the nurse will have I
to exercise a great deal of tact, combined with iron 1
firmness, in order that the treatment may be thor-
oughly carried out.

Palpitation is a symptom rather than a disease ; there 1
is fluttering or abnormally rapid beating of the heart, J
which disturbs the patient very much. It is often I
seen in nervou.s individuals or in those suffering from |
iin:<:mia or indigestion, and frequently gives rise to i
necessary alarm. It must be remembered that while I
this symptom docs occur in organic diseases of the 1
heart, it is Ijy no means a sign of the latter.

ACUTE ARTICULAR RHEUMATISM.

47"

Angina pectoris is characterized by a sudden agoniz-
ing pain in the region of the heart which extends
down the arm and across the sternum. The patient
grows pale, utters a cry of pain, and fears that he is
going to die, and in fact a fatal termination does some-
times occur. The condition is serious, and a physician
should be summoned at once.

In all these diseases precautions should be taken to
keep the patient perfectly quiet, guarding against ex-
citement and worry as much as possible.

Acute articular rheumatism, or, as it is often called,
rheumatic fever, is one of the most painful affections
which will come under the care of the nurse. Owing
to the complications and the after-effects of an attack
of rheumatism, it must always be looked upon as a
formidable disease.

The acute form begins with a feeling of malaise,
often with sore throat, with more or less severe pain
in the joints, and with fever, the temperature ranging
from 102° to 104° F. The joints become swollen,
hot, and red, and very painful to the touch or upon
the slightest movement ; the perspiration is profuse,
and has a characteristic sour odor ; the urine is strong-
ly acid, highly-colored, and scant}'. The bed should
be made up with flannel sheets above and below, and
the patient should wear a loose flannel gown which
opens down the front and has large sleeves, so that it
can be changed easily without giving him unnecessary
pain. It should always be changed if it becomes damp
with sweat. He should have a daily sponge-bath
(between blankets) of alcohol and hot water; he may
be turned gently from side to side, but should not be

Tmics prelers ice-cold compiH
stantly saturated with ice-wS
pain have subsided. Hot cifl
Fuller's solution (carboaatel
laudanum, l ounce; glycerfl
ounces) are often very eflecl
absolutely quiet, splints are si
should be well padded and!
firmness. Friction is not wl
stage is passed. For high fcJ
cold pack are sometimes ordj
chiefly of milk with alkaline m
adc, not too sweet, oat-meal-
may also be given. Gradual
but for a time should consist r
et.ibles, Kveii in convalesceni
very sparingly.

In the chronic forms of rht
afforded bj' a careful and I
treatment

■ incllitus i

DIABETES.

a ravenous appcti'.e. Care in the diet and hygienic
measures are inipurlant factors in the treatment Die-
taries for diabetic patients have been especially pre-
pared, and should be strictly adhered in. Foods con-
taining sugar and starch are not allowed except in very
limited quantities. The action of the ^V\n should be
especially cared for, and unless the patient be loo
weak or the cedema be marked, a moderate amount
of exercise should be taken daily, or massage may
be substituted for it. An equable temperature is to
be maintained, and freedom from excitement guarded
against.

In diabetes insipidus a superabundance of normal
urine of low speciiic t;ravity is excretetf. It occurs
most often in young people, and may be congenital.
Sometimes such cases may persist for years without
any deterioration in health. It is a disease of nerv-
ous origin, but its nature is unknown.

Hydrophobia is an acute disease of animals, depend-
ent upon a specific virus and communicated by inocu-
lation, usually by the bite of a mad animal, to man.
A variable time elapses between the introduction of
the poison and the appearance of the symptoms. The
incubation is shorter in children than in adults.
Rapidity of onset of the symptoms is greatly deter-
mined by the jiart of the body which may liappen to ,
have been bitten, Wounds about the face and head
are especially dangerous. Those on the hands
are next in order. Puncture wounds are the most
dangerous. Lacerations are fatal in proportion to the
extent of the surface afforded for the absorption of
the virus. The average of the incubation period is

complained oC There may be so
temperature and pulse rate. In th
is great excitability and restlessn<
panied by violent reflex spasms
take water is followed by paii
muscles of the larynx. This is
dreads the sight of water, and give:
phobia to the disease. I

The bite should be carefully J
oughly cauterized with pure carbo!|
potash. The wound should be kept
few weeks. The patient should b
in a darkened room, and allowed to
and physician. Chloroform and n
for the spasms. Sometimes cocaint
throat to reduce the sensitivenes:
patient to take liquid nourishment,
are usually ordered.

APPENDIX.

Note i. Noises, such as banging doors, loud talking, rustling
skirts and aprons, and crealcing shoes, should not be allowed to
disturb the sick room. A nurse's dress should be free from starch ;
her voice should be low. qutet, but distinct ; sitting in a rocking
chair should not be indulged in. Coal can be put on the fire
wrapped in paper, and a wooden ash shovel and poker may be
used in place of those made of metal. Attention to all such details
are aids to the patient's recovery.

Note i. Blood stains on the mattress or blankets can be
removed by applications of laundry starch made into a paste and
allowed lo dry on, being afterwards brushed off. In obstinate cases
this procedure may have to be repealed several limes.

Note 3, The hot pack is sometimes ordered lor nervousness or
sleeplessness. A single blanket is first put to soak in hot water.
The bed is then prepared with a long rubber sheet covered by a
single dry blanket upon which the patient is laid. The blanket is
then wrung as dry as passible out of the hot water and wrapped
about the patient up to the neck. Over alt the dry blanket is
wrapped. Care must be taken that the blanket is not hot enough
to bum the patient ; but, at the same time, it must not be too cool.
Alter twenty minutes the patient is taken out, rubbed dry gently,
and left to rest and sleep.

Note 4. For certain forms of skin trouble, starch, bran 01
alkHline baths may be ordered lo allay Irritation. The starch bath
la made by adding eight ounces of laundry starch to each gallon of
water. For the bran bath the bran is put in a bag which is allowed lo
soak in warm water for an hour before being used, or it may be
boiled for a quarter of an hour and then the Quid drained off and
added to the bath water.

N0TE5. The procedure may also be carried out with the patient
in bed by elevating the head of the bed, protecting the mattress
with two long black rubber blankets and allowing the second lo
hang over the fool ol the bed so that the water drains into a pan.
At first the aprlnkling may be done with tepid water, which may be

in tlir spore form. In order to accomplist
i>l>|Hirlunily is afforded the spores lo gei
jjrna in one or two days al 30° C. T!ie 1
InltTidn] to destroy the bacterid as tliey dcv

The auloelave has been Introduced t
has already been adopted in some hospitals
moist temperature to be easily procured. I
objects are exposed to heal under the preJ
atmosphere and the temperature is raised ta
need of fractional ateriliiation 15 obviated, I
to destroy the reaislant spores as well aslhe '

Note 8, Formalin, the commercial name
solution ol formaldehyde, is a very useful di*
rooms, instruments, etc. It is applied mosi
form ol g:aa which is liberated from tablets coi
which are exposed to the action of specially ci
this way it is applicable to the disinfection
and other closed chambers. Its irritating pro
sary tu employ it only after the sick have
chamber must then be well aired before re-oci
of a solution { 1 ^^ 5 Psr c^"' ) '• ""ay be ap|
infected objects.

APPEXDIX. 477

Note ir. Strict precautions are needed fur the urine in certain
infectious diseases. In typhoid fever, for instance. Ilie urine is
frequentiy contaminate witti the specific bacilli of llie disease.
Il is therefore necessary lo disinfect tliis secretion, which can be
done by adding millc o( lime or carbolic acid in the proper propor-
tions. (See page 167.) The urine may contain other virulent
bacteria, as in blood-poisoning and in cases o\ disease of the genito-
urinary organs.

The act of coughing in diphtheria, pulmonary tnbereulosis,
scarl el-fever, etc, liberates infectious germs. These may he
received on the person of the attendant, on the bedding or furniture,
or remain temporarily suspended in the air. We are not yet fully
informed of all the ways in which virulent germs are thrown off by
the body, but besides those already mentioned there is reason to
believe that they may appear in the sweat and in the secretion of
the lactaling breast in the female. Too great attention cannot be
given to disposing of all the secretions and excretions of persons
suffering frotn infectious disorders.

Note ij. Another injection frequently ordered for shock is a
litre of warm normal salt solution, half an ounce of brandy, together
with thirty grains of carbonate of ammonia.

Note 1 j. The continuous vaginal douche is sometimes ordered
ivhere much inflammation exists, A small bi-valve speculum is
introduced into the v^na and is opened and adjusted wlleil about
half way up the cavity. Around the glass douche nnzile enough
absorbent cotton is wrapped 10 hold il in place inside the speculum.
Hot water is usually ordered. The douching may tie continued an
hour or more, and sliould be given under low pressure.

Note 14. or sheets of lamb's wool. The layers of wool are cut
into the size required and encased in a gauze cover over which is
put a layer of oiled sitlc. The wool makes a very light and durable
iitupe and one that holds the heat a long time. If the wool Is not
obtainable

Note 15, Another excellent method of applying a tuq'entiiie
stupe is as follows : Take of olive oil seven parts, turpentine one
part ; mix well ; apply to the surface of the abdomen once in six or
eight hours ; over this apply the usual hot fomentations every hour.
This method obviates any blistering and can therefore be used
much longer.

Clm% and Mllkr ol Ibr Johoa HopldM Hnpftal, is as In

). C«t the caIgM iato tl
miaaim In ■ llffare«(-eiKM fonn and tie, so llial it may be d
Into a large tcat-tnbe.

a. Brins the calcnt fradaally up to a tempcTaCDre o( So'C »
bMalf o««>, and hold at thia point one hour.

J. T\ace the coljcut in cumol ; suirmmd the lube with a «
bath ; raiae the temperature to t6j*C, and maintain it at thia point J
lir inw hour.

4. Pijur ol! the cumol, and either allow the heal of tbe ai
bulh to itry the catKUt, or transltr it to a hot-air oven at u lempOB- I
lurv of loo'C, until all of the cumol is driven oR.

f,. Trunitter the rings with sterile forceps to tcst-tnbea prevt- ]
Mialy Klrrlliied aa In the laboratory.

Kncmata ol hot salt solution or the subcataoeo
are often used by the aurgeoa. ai
ahould be ri-udy, II pusBible, on his arrivaL

than the patient for whom it is intended, t
that from tip to tip ol his shoulders The fram
broad strips of canvas which are fasltned i

such a way that the canvas is stretched tight,
sagging wliich would occur with a niatlress
Between the two strips an opening is left whi
position uF the buttocks. The patient lies upi
he is conRned by means of a towel pinned <;
straps stretched obliquely over the shoulders,
so that the frame and patient may b« lifted as i
necessary for him to be placed upon a bed-pan
used chiefly lor hip-joint cases in children, whei
the child's body should be kept fixed while ani
going extension. They are sometimes very
Fractures, and also lor confining children whe
desirable after any operation.

Note 34. A liHle cold fresh water or Seltie
given after milk or when food is frequently givi
particles that ding about (he teeth in the comi
takes away the continuous and disagreeable Ha'

Note 35. Immediately after Ihe birth o( tl
should be felt as a firm, round, hard mass,
twtween [he symphysis pubis and umbilicus. T
leaves the uterus in from ten to twenty minutf

APPExnix, 481

H the fundus has not risen up at the etid of halt ar. honr, Credfi'a
method should be employed.

Note a6. In primiparous women the doctor shouid he sent fc*
about sin hours nfter the otisel of labor; while in mnltiparout
women he should be sent for be soon as the pains begin to come on

The nurse should never examine vaginally unless told to do so
by the physician in charge o( the case. For, if she does, no matter
how carefully she may disinfect her hands, and the patient has a
rise of temperature in the puerperium, she is sure to be accused of
infecting the cose, even though the doctor may have examined with
dirty hands.

Note 17. The stomach capacity, however, rapidly increases.
At the end of the first week an average child requires from one to
one and a half ounces at each feeding ; in its second and third week,
from one and a half to three ounces ; in the fourth and fifth weeks,
from two and one-fifth to three and a half ounces ; from the sixth
week to the third month, from three and a half to (our and a half
ounces ; while at six months, six ounces ; and at twelve months,
From eight to nine ounces are required.

Note a8. A baby should be weighed daily during the first
weeks of life, and at less frequent intervals during the year, for Jts
weight is the best Index of its nutrition.

NuTK 19. At the age uf six months it is well in healthy babies
to finish the bath by a splasli of cold water at 65° to 75°, or with a
cool sponging followed by a brisk rub.

Note 30. Constipation frequently occurs in infancy and early
childhood. The bowels should be opened once in twenly-Iour hours.
For an infant a small suppository made of soap field in the rectum
may be sufficient ; or, according to the age of the patient, from a
teaspoontul to a tablespoonlu! of sweet oil may be injected by
means of a small rubber syringe and allowed to remain from half an
hour to an hourand then followed bya small, simple soap-suds enema.
An injection of glycerine given with a mcdicinedroppcrtoan infant
or a lialf teaspoonful to a larger child is also very successful In ■
emptying the lower bowel. The glycerine suppository may be
used instead. It is \w\ safe, however, to depend daily upon these
aids to emptying the l>uwels. It is better to look to Ihe diet and at

482 NURSING.

thp same time establish the child in ref^ular habits by patting !t on
the chamber at tiie same hour ;ach day. Nothingshould be allowed
to interfere with the regularity in such habits. Gentle rubbing or
massage o( the abdomen with circular movements from right to
left with a little sweet oil for ten minutes daily will help to increase
the action of the bowels and bring on a normal movement. With
older children plenty of exercise and a daily cold sponging of the
body Followeil by brisk rubbing are recommended. Little, if aay-
.Ihing, in the way of drugs should be employed for constipation.

Note 31. In severe cases of chorea, when the child loses much
sleep and becomes exhausted, the application of the hot pack
usually relieves the nervous strain and produces sleep.

Note 32. Urine to be tested, if n
first filtered through filter paper or mi

Note jj. Ice may be given by mouth and the quantity of food
reduced for a time ; the bed-pan should be adjusted with the least
possible disturbance to the patient.

NoTB 35. Massage Is a great help in convaleacence in over-
coming emacialion and weakness; it aids in establishing health
and tone more quickly.

Note 36. Quinine best given in solution, but often also in
capsules or wrapped in rice or tissue paper, is the specific remedy
against malarial infection ; from fifteen to thirty grains daily for
three days, given in divided doses, is the amotint Usually prescribed.
Smaller doses are then given for the next two or three weeks.

Note 37. If there is no abrasion the flush first appears on the
nose and cheeks. The face becomes badly swollen, the skin
smooth and tense, and small blisters may appear. A lint mask
may be applied to the face, kept moist with a disinfectant.

Note 38. Immunity to diphtheria may be established by means
of injection of the diphtheria antiloiine. In favorable c&ses ll»
effects of tbesiTUm are seen in the narked amelioration of Imlhthe
local and the Rcnera! symptoms. Within twenty-four hours 1
Bwelling of the fauces subsides aud the membrane begins to i

APPENDIX. 483

^)p«flr. At the same time the temperature falls, the pulse becomes
slower and the general condition of the patient improves in every
way. The earlier the cases come under treatment Ihe belter are the
restllts. Among the untoward eficcts ol the treatment which
are occasionally met with, is the development o( local abscess,
diDuse erythema, urticaria, and nllmmlnuria. None of these
are, lH>wever, serious. Since the use of the antitoxine the mortality
from this disease has been greatly reduced.

Note 39. Lavage Is a favorite form of treatment, jelven either
in the morning before breakfast or late in the day several honrt
after eating. For the nurse's preparations, see "lavage" (p. 333.)

N<rrB 40. If opium is ordered for the pain, the effect should be
careFally watched, as unconsciousness may be Induced, from which
it is hard lo arouse the patient. Hot or cold applications to the
abdomen are also used to relieve the pain. Crushed ice or soda
water may be given for the vomiting. The rectal tube may be
passed to relieve the accumulation of gas.

Note 41. Bronchitis is usually due to sudden change* of tem-
perature, exposure lo damp and cold, over-fatigue, overheated
rooms, together with improper fixid. In the young and in elderly
pefsons it is always to be regarded as a serious affection.

Note 43. An ice-cnp or iced compresses should be applied to
the head, and the bowels kept well opened. The (ever may be
reduced by cold spongings. If the vomiting is obstinate, recta!
« may be needed to keep up the a

VOCABULARY.

MEDICAL.

r height of a disease.
I' disease, one in which the onset, prog-
c rapid. Applied to pain. ikuU means

Aome, ak'me. Cri^s o
Acute, A-kut'. i\n a
ress, and tern) in at ion a

AfRi'moD. A pouring u[ion ; f, ,f. atfusions of water are used i

to reduce temperaluie.
Alyiri. al'jid. Cold, chilly.
AlimeDt'ary. Pettmning to nutrition.
AnatiTfiiii, an-6'me-.ih. Dciiciency in the numlxT of red on

puscles or of the coloring ni;tncr of the blood.
Alials^HtB. an-al-ic'se-ah. Insensibility to pain.
Anasar'ca. General dropsy.

An'gina Pec'tc»is. Pain and oppression about ihe heart.
Anodyne, ut'onlin. .An ^eni which Tclieves p»in.
Anorexia an-or-eks'e-ah. Loms or diminution of appeme.
AntipTTefio. {siiii.\ An agent which reduces kwr; (*^) I

fever redudng.
Aphwtim. ab-fa'ne-ah. Partial or complete loss of the pa>Ba- 1

AfJwwM ob-loo'e-^di. Loss of voice.

Ap'fvl^Ky. A sudden piualysb i gene^ly from niptOR a

a cerebcal vessel I.
ApTTCXia. ab-pi-reks'e-Ak. A stale of freedon Iran fam.
t. An abnomul c>>(ki:tMO of Ami i

VOCABULARY.

4Ss

from lack of o

lilts by means of

ABphyx'ia. Suspensioi

the blood.
Ajspira'tion. A method of witlul rawing' t

ABthema, ah-slhe'ne-ah. Loss of slrcnyth. Weakness.
Ataxia, atax'e-ah. Incoordination of muscular aclion.
Atrophy, at'ro-fe. Wasting of a part from Uck of nutrition.
Aura, 6'rah. A peculiar sensation, such as usually precedes an

epileptic fit.
Aliscultatioil, os-cul-ta'ahun. The act of listening lo sounds

produced in organs of the body, usually iIil- heart and lungs.
Benign'. Mild, not malignant.

Borborygrmus, bor-bo-ryg'mus. Rumbling in the intestines.
Cachexia, kak-ex'e-ah. A depraved condition of nutrition.
Cada'ver. The dead body.
Centigrrade Thermometer. A thermometer the scale of

which is divided jmo too pans or degrees, o" representing the

free ling- point and too" the boiling-point of water.
Chore'a. A disease characterized by involuntary muscular

twitchings ; St. Vitus' dance.
Chronic, kron'ik, Lxing continued, often opposed to acute.
Clinic, klin'ik. Bedside instruction.
Collapse'. Complete prostration of the \ital powers.
Co'ma. A state of profound stupor.
Co'ma-vigil. A condition of unconsciousness nnd delirium

in which the patient lies with open eyes.
Conta'gion. The communication of a specific disease by

Coordina'tion. ll.irmoniou^ action ; r.^. of muscles.
Contraindication. Indication against.
Corpuscle, kor-pus-l. A minute body ; a cell.
CriBia, kri'sis. The turning-point in a disease.
Gyano'sie. Bluish color of the skin, due to imperfect

dation of the blood.
Decubitus, de-ku'bi-tus. The recumbent position. A I

of bed-sore.

;e, de-fer-vcs'uns. Decrease of fever.

Deeqaamation, des-lcwa-ma'^hun. I

Diagno'sis. The recognition of

syniplom=.
DiatheeiB, di-aih'e-sis. A preiIi^>osiU(
Dicrotic, di-ltrol'ik. A icnn applied
a double beat for

Dyepncsa, disp-ne'ah. Difficult at Ubi
Em'boliHm. The obstruction of a bloo

Empyema, em-pi'e-mah. A collection

Bpistaxis, cp-i-stak'sis. Hsmorrhage
II EructAtioD, e-nik-ta'shun. The bringi

Exacerbatioii, eg-zas-er-ba'shun. !ncr>

Excreta, ck^-kre'tAh, Natural discharg
Expectant, eks-pek'lant. Awaiting; e.

of treatment by non-interference.
ExpiratioD, eks-pi^ra'shun. Tlic act of
Pfflces, fc'sfe. The dischari;es frnmjhs

VOCABULARY.

487

Gastritis, gas-trl'lis. Inflammation of (he stomach.

Oavaere (Fr.) Forced feeding.

Glo'bus HTSter'iouB. Sensation (in hysteria) as of a ball in

the ihrodt.
Hsematemesis, he- mat-em 'e-sis. The vomiting of blood.
Heemoglo'bin. The coloring matter of the red corpuscles.
HEemoptyBiB, hem-op'ti-sis. The spitting of blood.
Hsemorrlui^, hem'or-aj. Flow of blood from the vessels.
HsemoBtatic, hem-o-stat'ik. Arresting hsmorrbagc ; {subi.)

an agent to slop hamorrhage.
Hectic, hek'tik. Pertaining to wasting or phthisis.
Hemiplegia, hem-i-pleg-e-ah. Paralysis of one wdc of the

Hepatiza'tion. Change into a liver-like substance.

Heredity, her-ed'i-te. The transmission of traits of ancestors
to their offspring.

Hiccough, hic'kup. The spasmodic contraction of the dia-
phragm with sudden closure of the glottis.

Hydrop'athy. Treatment of disease by the use of water.

Hydrothorax. A condition in which there is a watery fluid in
the pleural cavity.

Hygiene, hi'je-en. The science of health.

Hypertemia, hi-per-e'me-ah. Exces; of blood in the vessels

Hyperpyrexia, hi-per-pl-reks'e-ah. A.n excessively high tem-
perature of the body.
Hyper'trophy, An abnormal increase in the siie of a part or

Hypnotic, hip-not'ik. Sleep-producing; (jkK) an agent which

produces sleep.
Hypoder'mic. Under the skin— applied to the injection of

medicines under the skin.
HyperEBsthesia, hi-per-es-thc'ze-ah. Excessive sensibility.
Icterus, ik'ter-us. Jaundice.

Idiosynorasy, id-i-d-sin'krd-se. Individual p^uliarily,
Inem'tion. Exhaustion from starvation.

488 VOCABULAR Y.

IncoordinatioD, in-c6-or-din-a'shun. The stale of inability to

produce coordinated muscular movements.
lucubatioQ, in-ku-ba-shun. The period which elapses between

the imroductioD of the contagium and the development of the

symptoms.
In^es'ta. Substances introduced into the body by the mouth,
lofect'ion. The communication of the germs of disease.
InoGula'tion. The introduction of a specific virus into the

system.
Insolation, in-sola'shun. Sunstroke.
Inunc'tion. The act of rubbinf in an ointment.
Lactom'eter. An instrument for measuring the specific ^rav-

Lac'toBCope. An instrument for testing the quality of milk.

Liaryngismus Strid'ulua. Spasmodic contraction of the
glottis ; false croup.

La'teDt. Concealed, not manifest.

Lavage (Fr.) Irrigation of the stomach.

Le'sion. A morbid ch.inge in the function or structure of a
tissue from injury or disease.

Leth'argy. A condition of drowsiness.

Lysis, li'sis. Gradual dechne. more especiaJly of a febrile disease.

Macera'tion. Steeping in fluid to produce softening.

Marasmus, mar-az'mus. A wasting or emaciation.

Metastaeia, mei-as'ia-sis. Change in the seat of the di^ase.

Me'grim. Neuralgia or headache of one side of the head.

Narcot'io. Producing narcosis; {mbs.) an agent which pro-
duces a condition of lethargy or sleep.

Nepbritia, nef-rl'lis. Inflammation of the kidneys.

Neuraethenia, nii^ras-ihe'ne-ah. Exhaustion of nerve-force.

Neurosis, nu-ro'sis. A nervous affection of a function^

Non Com'poB Men'tis. Of unsound mind.
Nostalgia, nos-tal'je-ah. Homesickness.
CEdema, e-de'mah. Accumulation of serum i

eys.

)f nerve-force.

f a function^^^

n the cellidj^H

VOCABULyiJiV, 489

Ophthalmia, olir-thal'iiie-ah. Inflammation of the conjunc-

Orthop€B'dic. Pertaining 10 the correciion of deformity.
Orthopnce'a. Difficulty in breathing, relieved only by the

upright position.
Osmo'sis. The diffusion of fluids through membranes.
Pfediatrics, ped-e-at'riks. The treatment of the diseases of

children
Palliative, pai'i-a-tiv. Mitigating, relieving.
Paracentesis, par-a-sen-te'sis. The operation of puncturing

a cavity of the body (in order to draw ofl' fluid).
Paraple'gia. Paralysis of the lower half of the body.
Paresis, par'es-is. Slight paralysis. Partial loss of muscular

Paroti'tis. An inflammation of the parotid gland. The
mumps.

Pathoffen'io. Causing disease.

Percus'aion. Light tapping or striking on anypait of thebody
for diagnostic purposes.

Peristal'sis. Undulating movements of the intestines.

Pertus'sis. Whooping cough.

Photopho'bia. Abnormal sensitiveness to light.

Pro'dromes. Precursory symptoms.

Prophylaxis, pr6-fil'aks'is. Prevention of disease.

Ptomaines, lo'ma-ins. Alkaloids formed during the decompo-
sition of organic matter.

Quotidian, kwol-id'i-an. Occurring every day ; c. g. quotidian
fever in which the paroxysm occurs every day.

Rad'ical. A form of treatment meant to destroy a disease.

Beac'tion. Recuperation or return of power after depression.

Hecur'rent, Returning at intervals.

Be'flex. A term applied to an involuntary action produced by

RegTirgita'tion. The flowing hack or the rejection of the

contents of a hollow organ.
Relapse'. Recurrence o( the disease before complete conva-

J *40

rOCABCLAJtV.

tbdrnoniH^^I

Remit'teot. AJtemaiei]' abaiii^; and leturtung.
Reeolil'tioil. The gradual return of ibc tisHies to tbdr a

icoudiUQD after inflamcnalory conditions,
ftetchinff. Attempts at vomiting.
Rhythm, Hthm. A measured n
Rijfor, ri'gor. A chill. Rigidity.
Kgor mortiB. The muscular rigidity which ocean shordf

after death.
Satura'Qon. A term used to denote that a fltiid contains as

much of a solid substance as it can dissolve.
Sequela, s^-kwel'ah. Abnormal condition fcdlowing the de^J

cline of a disease.
Smfful'tus. Hiccough.
Sopor, so'por. A drowsy condition.
Sordea, sor'-det The brownish deposit that tends to

laie about the teeth in disease.
Sporad'ic. Scattered, or occurring in isolated cases or groups ^
Steno'sis. Constriction or narrowing.
Stercoraceous, ster-ko-ra'she-us. A term applied tovomilBd J

matter containing feces.
Ster'toroufl. Breathing with a snoring sound.
StomatitiB, sio mai-i'tis. Inflammation of the mouth.
Strabis'mus. Squint. Condition of the eyes in which ti

visual axes do not meet at the desired objective point.
StridulotlS, strid'u-lus. Making a harsh or strident sound.
Subacute'. Midway between acute and chronic.
Subeul'tus Ten'dinum. Muscular tremor or twitching.
Sudorific. Sweat- prod ucing ; (j«i*/.) an agent which induce* J

sweating.
Syn'theeis. Formation of a compound by the uniting of its
Syn'cope. Fainting or swooning. [elements.]

Tabee, la'bei. Progressive emaciation.
Tabes doraalis. A disease of the nervous system, sometimes \

called locomotor ataxia.
TeneB'mUB. The painful desire, coupled with straining, to i

mpty the bowels or bladder.

VOCASVLAJ! y.

49'

• relating to the applic;

Therapeu'tics. Ihe mcilic

lion of remedies.
Thenuoci'eter. Instrument for measuring Inicnsiiy of heat.
Thrombo'sia. The formation of a blood-clol in a vessel.
Tor'mina. Griping pain in tlie bowels.
Tox'io. Hoi so no 115.

Traumatic, traw'mal'ic. Perlainrng to a wound.
Tub'sIb. a cough.
TympaniteB, tim-pan-i'tei. The distension of the abdomen

with gas.
Urtica'ria. Neitle-rash.
Vaccina'tion. Inoculation with a virus obtained from cows to

protect against small'pox.
Variola, va-ri'6-lah. Small-pox.
Vas'cular. Pertaining to vessels.
Ver'tUro. Dizziness.
Ves'icle. A small blister.
Vicarious, vi-ka're-us. The term applied to the assumption

of the function of one orgiin by another.
Vol'atile. Readily evaporating.
Vifi'coue or Viscid Glutinous. Ropy.

SURGICAL.

Abra'edon. Excoriation of the skin or mucous membrane.

AcupresBure, ak'u-press-ur. The compression of blood-ves-
sels by means of needles.

Ac'upunc'ture. Puncture of tissues with needles for ihe
relief of pain.

Adeno'ma. A glandular tumor.

Adhe'sioD. The growing together of two surfaces or parts.

Amputa'tion. A removal of a part of the body.

Ansesthe'sia. A condition in which sensation is lost

Anaetotno'sis. The junction of vessels.

Angio'ma. A tumor formed of blood -vest els.

Aslcylo'sis. Stiffness of joint due to adtiesions between it^
surfaces.

Aa'pirator,

492 VOCAlWLAkY.

Antjaep'tic. Preventing i!il- ^rowili of ort'iinisnis which prA<^

Awcc piitrericiion.
Apposi'tion. In contact.
Arthritis, ar-thri'tis. Inflammation of a joint.

'he absence of septic matter,
em for withdrawing fluids from cavities.
AtheromatouB Degeneration, ath-e-ro'ma-tus. Fatty <

generation of arlerisl walls, with deposition of lime salts, I

rendenng the vessels brittle.
Bifurcate, bi-fer'kat. To divide into two branches
Bistoury, bis'loo-rc. A narrow.bladed knife used in surgery.
Bougie, boo-zhe'. Cylindric;ii instrument for dilating canals.
Cal'louB. Hard.

Cal'lUB, New bony deposit about a fracture.
Cann'ula. A small tube.
Carcinoma, kar-se-no'ma. Cancer. A malignant form of |

Ca'ries. A local death of bone.

Caus'tic. liurning ; (jii£.i.) a substance which destroys living j

CellulitiB, sel-u-li'tis. Inflammation of the cellular tissue.
Cicatrix, si-ka'lriks. The scar which remains after tho healin^l

of a wound.
Cicatrization, sik-a-tri-za'shun. The process of healing.
Circumduc'tion. Circular movement of a limb.
Clon'ic. Applied to spasms with alternate conlr.^ction■i and

taxations,
Coagula'tion. A clotting.
Coapt&'tion. The adjustment of edges of wounds or frac-

turcd bones,
Comminu'tion. Breaking into pieces.
Colot'omy. Incision into the colon.
Contu'aion. A bmise.
Coun'ter-ezten'eion. Opposing traction upon a limb ii

Crep'ituB. The grating of the cmls of fraciurt-d bones.
Cystotomy, sis-tot'o-me. A cutting into the bladder.

vocABULApy. 493

Demarca'tion (Line of], ihe line dividing dtad from living

Disarticula'tion. Ampulation of a limb al a joint.

Dors'al. Pertaining lo the back,

Emphyse'ina. Distension of tissues with air or other gases.

Empyema, em-pi-e'mah. A condition in which there is pus in
the pleiir.il cavity.

Enucleation, e-nu-klee-a'shun. The peeling out of a tumor
from its ^ack. {Of the eye.) The excision of Ihe eyeball.

Epithelioma, ep-i-the-ie-o'mah. A cancerous growth of the
skin or mucous membrane.

Es'char. The dry rnisl of dead tissue.

Bs'march's Bandage. Elastic rubber bandage used to pre-
vent or control hn:morrhage.

Ever'aion. The folding outward.

Excia'ion. Act of cutting out or away.

Excoria'tion. Abrasion of the skin.

ExcreBcence, eks-krcs'ens. An abnormal o

Exten'edon. Traction upon a fractured (.
The opposite of flexion.

Bxtirpa'tion. The removal of a part.

Extravasa'tion. Effusion of fluid into the liss

Exuda'tion. The oozing out of fluids.

Fenes'trum. An opening.

Fistula, fis'tii-iah. An abnormal opening beti
of the body.

Fixation. A making tirm or rigid.

Flexion, flek-shun. The process of bending.

Fluctua'tion. Wave-like motion.

Graft. Transplanted living tissue.

Granula'tions. A reticulated framework of tissue containing

embryonic cells.
HEematoma, hem-at-6'mah. A tumor containing blood.
Her'nia. I'rotrusion of any viscus from its normal cavity
through normal or artificial openings in the surrounding

Dutgrowih.

r dislocated limb.

4SM VOCABULAkV.

Immobilization. The aa of fixing a pait in such a n

.IS lo remler il immovable.
Itupao'tion. The condition of being wetlged together
Inoia'ion. -A cutting into. A cut.
Ilidura'tiotl. Hardening of a part.
Inflamma'tion . The response of living tissue to injury.
Intuba'tion. The insertion of a tube into the larynjc
Inver'sion. The turning of an organ inside out or up

LiVid. Having a dusky bluish color [due to congestion).

NsoroeiB, ne-kro'sis. Death of tissue.

Ns'oplasm. A new growih.

Oootusion, ok-Iu'shun. A seating or blocking up.

Ossiflca'tion. Kormation of bone.

Ostalgia, os-tal'je-ah. Pain in bone.

Osteoiiiyeli'ti&. Inflammation of the bone, (lit. i of the mar- J

row of the bone.
Osteotomy, osteoi'omy. A cutting operation on bone.
PerforataOD. An opening or penetration.
Phlebitis, fle-bi'tis. Inflammation of a vein.
Flaa'tio Operations. The engraftinR of lisijue from one pait I

to another,
Prona'tion. Position of the arm when the palm of the han^

is turned downwards.
Pyeemia, pi-e'me-ah. Septicaemia with abscess- formations.
Resec'tion. Excision of a portion of bone.
Resolu'tion. The gradual disappearance of inflammatory I

products without the formation of pus.
Retrac'tion. Shortening. Drawing backward.
Sapree'mia. Septic intoxication. Blood- poisoning. |

Sarco'ma. A malignant tumor having the structural charac- <

tcristics of connective tissue.
Boariflcation, skar-if-ik-a'shun. Ttit operation of making ]

numerous small superficial incisional in a part.
Bep'tic. Relating to putrefaction.
Sequestrum, se-kwes'trum. A fragment of necrosed bone.

VOCABVLARV.

495

Slough, sluf. A portion of dead tissue which comi

after an ulcerative process.
Strangilla'tion. Constriction. Choking.
Stricture, strik'tur. A contraction of a duel or tube.
Styptic, stip'tik. Astringent; (subs.) an agent which slops 1

haemorrhage.
Subcuta'neoUB. Under the skin.
Suffii'aion. Slight diflTused congestion.
Supination, su-pin-a'shun. Position of the arm when the I

palm of the hand is turned upwards.
Su'ture. Junction of cranial bones. In surgery, a stitch.
SynovitiB, sin-o-vi'tis. Inflammation of a synovial membrane,
Tax'is. The manual reduction of a hernia.
Ten'aion. Tightness. A condition of being drawn tight.
Tor'sion, A twisting.

Tourniquet, loor'nik-et. An instrument to compress arteries.
ToXEemia, loks-e'meah. Poisoned state of the blood.
Traction. A drawing or pulling.
Transftision. The injectit)n of blood from the vessels of one J

person into those of another.
Transuda'tion. An oozing through.
Traumatic, iraw-mat'ik. Pertaining to a wound.
TriBmUB. Lockjaw.
Trocar. An instrument consisting of a itJIette contained ii

melal tube, used for evacuating fluids from cavities.
Tume&ction. Swelling of a part.
Turgeecence, ter-ges'ens. Swelling or enlargement of an '

organ.
Turgid, ler-jid. Swollen.
Ul'cer. An open sore.
Varicose, var'ik-os. A term applied to dilated and t

Veneeec'tion. The operation of openin
Ves'iole. A small blister or sac.

VOCABUl-AKV-

GYN^COLOGY.

Adnexa. Appendages — i.e. the lal[opLa.n tubesand ovaries

AmenoiTtics'a. Iiregul-iriiy or suppression of n

Anteflexion, an-te-flek'shim. A bending forward.

Antever'sion. A turning or leaning forward.

Catiunenia, kai-a-me'ne-ah. The menses.

Climao'teric. A critical period in life. Generally tised U> I

signify the time of life at which the c
Cyst, sist. A sac containing fluid,
CystODele, sist'o-sel. Vesical hernia.
Ijefeca'tion. Evacuation of the bowels.
Douche, doosh. A stream of water direiled forcibly against a 1

DTBmenorrfacea, dis-men-6 re'ah. Painful n

Endometaii'tis. Inflammation of the lining membrane of the ]

Oea'u-pectoral. Pertaining to the knee and chesL
Heematosal'pinx. Distension of the Fallopian tube wtdi \

LeucorrhcBa, iG-kor-e'ah. Whitish discharge from the v^na. I
Menorrhagia, men-or-a'je-ah. Excessive menstrual flow.
Mens^, men'sei. The monthly flow from the uterus.
Men'opaiise. The end of the menstrual life.
Metri'tis. Inflammalinn of the uterus.
PatulotlH, pat'u-lus. Expanded. Open.
Ped'icle. The stem or narrow portion of a lui

is attached to a part.
Pes'sary. Instrument placed in the vagina

r by which it
support the

ProIap'sUB Uteri. Protrusion of the uterus as

beyond the vulva.
Retroflex'ion. A bending backwards.
Retro ver'sion. A turning or leaning backwards.
Sal'pinx. The Fallopian tube.
Subinvolution. Insufficient involution.
Superinvolu'tion. Excessive involution.

far i

VOCABULAKV.

Tu'bal. Pertaining to the tube or oviduct.
U'terufl. The womb.

Vagina, v.i-ji'nah. The canal from the vulva Ic
Vagini'tis. Inflammation of the vai'ina.
Vul'va. The exiernai female genitals.

OBSTETRICS.

Abor'tdon. The expulsion of the embryo at any lime during

Che first three months of pregnancy.
Accoucheur, ah-koo-shur'. An obstetrician.
Am'mon. The inner embryonic membrane.
An'te-Part'um. Before delivery.
Ballottement, bal-lot'mong. A method of exainina.tiDn for

pregnancy.
Caul. F(£tal membranes covering the head. The amentum.
Chorion, ko-re-on. Outer membrane enveloping the fcetus.
Oolostrum, ko-los'trum. The first milk secreted after labor.
Congen'ital. Existing from birth.

Craniot'omy. The operation of breaking up the f<Dtal skull.
Decidua, de-sid'd-ah. Membranous envelope of ovum in the

Deliv'ery. Childbirth.

Fimbrbe, fim'brc-e. Threads or filaments ; a fringe.

Pce'tUB. The unborn child.

Fontanelle (Fr.) Membranous space at the junction of the

cranial bones in an infant where ossification is incomplcie.
Genita'lia. The organs of generation.
GestatioD, jes-ta'tion. Another term for pregnancy.
In'cubator. An apparatus kept at a uniform temperature' of

86° to 88°. devised for the rearing of premature chililren.
Intra-u'terine. Within the uterus.
Involu'tion. The process by which the uterus returns to its

normal condition after pregnancy.

498

VOCABULARY.

A tearing.

k term used to mean the period during which the J

Cjftoera'tion,
Lacta'tion.

child nurses

LanugD, 1an-ti'^. Downy hair on the new-bom.
Liquor Amnn, U'kwor am'ne-l. Fluid surrounding the fcetuiL
Lochia, lo'ke-ah. Vaginal discharge after labor.
Mam'mary. I'ertaining lo the breasts.
Maeti'tis. Inflammation of the breast.
Meoonium, me'ito-ne-um. First fecal discharge of the new-

Multdp'ara. A woman who has borne several children.

Nee'vus. Birth -mark (generally due to the dilatation of blood-
vessels), A mole.

Omen'tum. A fold of peritoneum covering the viscera.

Palpa'tion. Kxploradon with the hand (for diagnonic pur-
poses).

Parturi'tion. The act of giving birth to young.

Phle^ma'sia Dolena. (Edema of the leg from venous ob-
struction ; milk- leg.

Hacen'ta Prte'via. Presentation of the placenta before the

flEtUS.

PreBenta'tioQ. A term used to denote which part of the fcetus

comes first to birth.
Primip'ara. A woman pregnant with, or who has borne only,

her first child.
Puer'peral. Pertaining to child-bearing.
Quiok'eningr. y\r%X. perceptible movements of the fcetus in

Secundine. sek'un-din. The after-birth.
Subinvolu'tion. Imperfect involution.
Symphysiotomy, sim-fii-e-ot'o-me. Section th

symphysis pubi^s,
Ver'nix Caeeo'sa. The cheesy in.-tierial which <

Ver'aion. Turning of the io:Ius in uiero.
Vi'able. Capable of hving.

VOCABULARY.

URINARY ANALYSIS.

Acet'ic aoid, C,H,0,. Acid of vinegar.

Albuminu'ria. The presence of albumin in the urine

Amorphoua, a-morf' us. Formless. Non-cryslallized.

Am'yloi<l- Starch-like,

Anal'ysis. The resolution of a body into its elements.

Anuria, au-u're-ah. Absence or deAciency in amount of

Bil'iary. Pertaining to the bile.

Blood-casts. Abnormal microscopic bodies in urine, being

moulds of urinary tubules made up of blood-cells.
Cal'OUlUB. A stoiic-hkc concretion found in the body.
Gal^oulus, Re'nal. Stone found in the kidney.
Cal'ouluB, Ves'ioal. Stone found in the bladder.
Chyluria, ki-lu're-ah. The passage of milk-like urine.
Cysta'tis. Inflammation of the bladder.
Cystot'omy. Incision into the bladder.
Diaphoret'ic. An agent which produces perspiration.
Diuresis, di-u-re'sis. Excessive secretion of urine.
Diuret'io. An agent which increases the flow of urine.
Di:op'sy. The effusion of fluid into tissues or cavities of the

Dysuria, dis-u're-ah. Difficult or painful micturition.
Enuresis, en-fl-re'sis. Incontinence of urine.
Piltra'tion. The process of straining or filtering.
Q-lomer'ulus. A knot or small tult of vessels (particularly in

the kidney),
Olycoeuria, gli-kos-u're-ah. The passage of sugar In the

Qxav'el. .S;ind-like deposit in the urine.

Hcematuria, hem-at-ii're-ah. The passage of blood in the .

Eippu'ric Aoid. An acid normally found in small quantities
ill liuni.iti urine, and in l.iq;cr qu.inlitics in the urine of her-
bivorous animals.

Inoon'tinenoe. Involuntary evacuation of the urine or f^ces.

500

VOCABULARY.

Lith'io. Pertaining to stone.

Lithot'oiny. Cutting into the bladder for stone

Lithot'rity. Crushing a aione in the bladder.

Lit'mus. Blue pigment turned red by %ciA \ or red pigment

turned blue by alkaUes.
Mea'tus. A pass:ige or opening.
Meatus Urinaxius. The opening into the urethra.
Metamor'phosie. Transformation ; structural change.
Micttiri'tion. Tht act of voiding urine.
Nephrec'tomy The operation of cutting out the kidney.
Nephritis, ncf-tl'tis. InHammation of the kidneys.
Nephrot'omy. The operation of cutting into the kidney.
Opac'ity. N on -transparency.
Pig'tnent. Organic coloring matter.
Pipette, pip-ei'. A small glass tube for taking up fluids.
Polyuria, pol-e-u're-ah. Excessive secretion of urine,
Precip'itate. Anything changing from a soluble to an insol-

xible form in a solution.
Pyelitis, pi-el-i'iis. Inflammation with formation of pus in

the pelvis of the kidney.
Pyuria, pi-Q're-ah. The presence of pus in the urine.
Quan'titative. Pertaining to quantity.
Bea'g^nt. Anything producing a reaction.
Reten'tion. Holding back. The act of retaining urine in

the bladder.
Baccharometer, sak-ar-om'et-cr. An instrument by means of

which the amount of sugar in a solution can be estimated.
Sed'iment. Matter which settles at the bottom of a liquid.
Specific grav'ity. Weight of a substance compared with

thai of distilled water.
Strangury, stran'gu-re. Painful urination in drops.
Stric'ture. A contraction existing in a duct or tube.
Suppres'sion. Concealment ; failure of the kidneys to secrete

Transuda'tion. Oozing of a Huid through the pores of [he

Urs'mia. Toxic condition of the blood, due to the non-fiso^
Cion of elTele substances ^(oimcrl^ ^u^^^med to bu urcft].

VOCABULARY.

501

Urates. Sails of uric acid.

Urea, u-re'ah. Chief solid constituent of urine ; a nitrogenous I

product of lissuu'iiecoinposition.
Ur'eter- The tube which carries the urine from the kidnc

the bladder.
U'ric ac'id. An acid normally found in small 3

human urine.
Urinoni'eter. Instrument for measuring the specific gravity 1

of urine.

BACTERIOLOGY.

Aero'bio. Living only in the presence of oxygen or air.
Amce'ba. A colorless protoplasmic minimal micro-organism.
Anaero'bic. A term used of micro organisms which are prO' 1

duced or which hve in the absence of oxygen.
Aut'oclave. Instrument for sterilizing by means of sii

heat under pressure.
Bacil'li (sing. Bacillus). The most important griiuj) of ]

bacteria, so called from their resemblance 10 imall rods.
Bacter'ia (singular. Bacterium). A general term for the 1

lowest form of vegetable micro-organisms which multiply by ,

Bacteriol'o^. The science which treats of bacteria.

Conta'srium. Septic matter or germs of specific disease.

Cul'ttire. A term loosely applied to the product of the \
propagation of germs in suitable fluids or other media.

DiplococcUS, dip-lo-kok'us. Cocci united in pairs.

Fermenta'tion. The process of decomposition due to the J
action of hvinK organisms or of an unorganized ferment.

Prac'tional Storiliza'tion. The process of sterilizing for a ^
fixed time on more than one uccasion.

Fis'&ion. Reproduction by splitting into two ot more equal
parts.

FomitoB, fo'mitji. Substances capable of £,bsorbing conta-
gious matter.

Qerm. The special virus or spore by whicli a disease becomes
communicable.

VOCAHUlAKy.

Ger'niicido, An agent which destroys germs.
Immu'nity. Freedom from risk of infection.
Inouba'tdon. The period which intervenes betwcenS

plantation of the virus and the appearance of the disease.
Infec'tion. The process of cummunicating the genns

Infec'tiouB. Capable of infecting.

Inocula'tion. The act of introducing a specific virus ititOj|
the system.

Mocrosoop'ical. Visible to the naked eye.

Me'diiim. That in which anything lives.

Mi'crobe. A micro-organism.

MicroCOC'cUB. A spherical bacterium.

Microscopical. Not visible lo the naked eye, but on'y
through the microscope.

Nu'clear. Pertaining to the nucleus.

Paateuriza'tioii. The name given to a special kind of ti
ment of a substance, e.g.. milk, with a view lo the destruc-
tion of microbic life in It, and thus preventing decomposition.

Pathogen'ic. Having the property or power to cause disea

Phagocyte, f:ig'o-5it. A cell possessing the property of ab- 1
sorbing and digesting bacteria.

PhfLgOCyto'sis. Destruction of microbes by the 3
phagocytes.

Putrefikc'tdon. Organic decomposition.

Saprogenic, sap-ro-gen'ilc. Pus-forming.

Spiril'llun. .\ genus of bacteria.

Sporad'ic. Scattered ; occurring in isolated cases.

Spore, The form of reproductive body in cryptogams analo- J
gous to the seed.

Staphyloooo''oi (sing. -us). A class of microbes.

Streptotsoc'tn (sing. -us). Bacteria arranged in strings.

Ther'inostat. Any automatic device for regulating tempera-

Vi'rUB. A poison whirh ci
any pathogenic microbe.

I morbid piocess or disease;

^^^^^^_^^_

^^^H^^^H

^^^^^^^^^^^^^1

^^^^^^^^^^1

INDEX. j

Appendicitis, 459.

Abbreviations, 937.

Applications, external, 100.

Abdominal disease, position in.

Approximate measures, 139.

360.

Aqua ammonia, .ipplication of.

214.

preparations for, a8o.

Arnold's slcriliier, 163, 370.

AMomiiial sect ion ciise, after-

Artificial infant foods, 404.

care of, 259.

Abortion, 376.

Marshall Hall's method, 315,

treatment of, 376.

Schulue's method, 399.

Accumulative action of drugs, 833.

Sylvester's method, SH-

Acetic-acid and heat test for albu-

Ascites, 460.

Asepsis, 341,

Actual cautery. 119.

Asiatic cholera, 447.

Acupressure, a86.

Asphyxia of the newborn, 399.

ARusLons, cold, 143.

Aspiration, preparation lor. 33*.

After-pains, 390.

Aspirator. 331.

Air. nature of. 107.

Asthma, 198, 461.

Air-bed, toi.

Astringent enemala, 109, 176.

Air-cosh tons. 100.

Alomiier, 931.

Albumin, Bcetic-actd and heat teat

Auscultation towel, 331.

lor. 431.

Autoclave, 476.

Heller's test for, 433.

nitric-acid and heat test for.

431-

Bacillus. 340.

Bacteria, 160.

in puerperal state. 396.

prevention of con lam mat ion

Alcohol, eiternal use of, 127. US.

by, 161.
Bacteriolc«)'. 159-

Alcoholic stupiir, 311.

Amnion. ,,75.

Bandages, 397.

claaaificalion of, 198.

care of patient after. 351.

crinoline, 303.

local, 353.

figu,-i-o/-S. 301.

preparation of patient for.

flannel. 300,

346.

handkerchief, 303,

Anesthetics, 345.

making of, 3,9-

local, 333.

mnalin. 397. 399.

Angina pectoris, 471.

plaster of Paris, 301.

Antisepsis. »4».

Bandaging, 397.

Antitoxin in diphtheria, 483.

Barley water. 406.

Aortic insufficiency, 469.

n-gurgitalioii. 469,

Bnth for the new-born. 401,

stenosis. 469.

Biitlis. 133.

Apoplectic (it, 311.

bran, 475.

A|>»1herarks' mcasuri-, 3j8.

cl.issificalion of, 133.

weight, 338.

cold, 133, 141,

^^^V^^^^^^^B^H

V 504 ^^^^H

^M Baths, rantlnnous surgical, 146,

Books of reference, 91. ^^^^^^^|

■ M7.316

^^^^^M

■ lor clt^anlineas, 133.

Brand's meth^iU, 143. ^^^^^^H

■ In fever. 141.

Breasts, care of, 393. ^^^M

■ foot. t36.

Breattiing, see Respiration, 196. ^^M

■ hot, 133, 137.

Brighl's disease, 437' ^^H

■^ in Hkin diseases, 475.

Broths, 342. ^^M

" local, .40, .47.

Broncliilis, 461,433. ^^H

mustard, 136

Bruises, 346. ^^H

phyBioIogical, action of, 137.

salt, 140.

^^M

sponge, 14:.

Burns, 314. ^^H

tepid. 133-

classification of. 314. ^^H

vapor. 138. 203.

treatment of, 315. ^^^H

warm. 133. 303.

Bath-tub, portable. 144.

Bed. change of. 103.

cesarean section, 268. ^^H

coverinfis for, 90.

Caiitharidal blister. iiG. ^^M

fracture, 95.

Carbolic acid, 149, l64> 353- ^^H

mattress for, 89.

Carboliied poultice, 304. ^^H

method of making, 90.

Carcinoma of cervix uteri, 365. ^^H

preparation for an operation,

Cardiac disease, 468- ^H

patient's, 93,

Castor-oil, administration of, 3>3-'^^H

Catgut, ligatures of, 174. ^^H

Bteriliiation of, 478. ^^H

Bed-bath. 113, 134.

Catherization, 178. ^^^|

Bed-cradle, ijg.

Cautery, 319. ^^^^H

Bedding, disinfection of, 16K.

Celloidin solutions, 378. ^^^^|

Bt-d-pans, disinfraion oF, i6g.

Centigrade scale, 184. ^^^1

Bed patients, appliances for, 95.

Cereal water, 406. ^^M

care of, 99-

Cervix uteri, amputation of, atfi-^^^M

moving of, 101.

carcinoma of. 365. ^H

Bed-side record, 199.

laceration of, 163. ^^H

Bed-sores. 99.

Charcoal poultice, 305. ^^^H

Charting temperatures. 189. ^^H

treatment of, :iS.

Cheyne-Slotes- respiration, 197. ^^H

Bedstead, care of, Sj.

Children, 39S. ^^H

choice of. 87.

Chills, 363. ^H

iron, 87.

Chloride of lime, 364. ^^H

Bichloride of mercury, iji, 156,

Chlorinated lime, 164. ^^M

164.

Chloroform as an anesthetic, 35 ( ^^^|

Bile, in urine, 434.

as a rubefacient. 3is. '^^^1

Bismuth gauie, *4S.

inhalers, ^53. ^^^H

Bladder, lavage or irrigation oT,

Cholera, Asiatic. 447- ^^H

»6a. 478.

infantum, 4r4. ^^^1

"Bleeders," 294.

Chorea. 418. ^^H

Blister, cantharidat, 116.

Class-work for nrst year, 94, 44(^^^|

dressing of, 217.

^^^1

Blistering, 317.

Bluod stains, removal of, 475.

third ^^^1

^^1

^^^Bi^HB ^^

INDEX 50J ^1

Clavicle, fracture of, 309-

Cruupy cough, 366. ^^|

iJltaiiliiiess, in relalion to germs,

Cupping, zij. ^H

Cyanosis, 470- ^^H

surgical, 143.

Cystitis, a63. ^^H

Clinical ihermomeler, 184.

Cyslocele, 365. ^^^H

mode of testing, 185

rules lor cDnverting scale of,
.84.

Clothes of patient, ij[.

Dead, care of the, 130. ^^H

ClothcE-tug, 111.

Delirium tremens, 466. ^H

Clothing, disinfection of, 166.

Dermoid cysl, 367. ^^H

Cocaine, 353.

Diabetes insipidus, 473. ^^H

Coeliotomy, 966.

mellitus, 471. ^H

Coils, ice-wwer, 109.

DiarrhtEB, 4j8. ^^H

Cold, action of, 207.

in children, 413. ^^H

in typhoid fever, 441. ^^^|

applications. 907, aoS.

Dicrotic pulse, 194. ^^1

bath, 133, 141.

Diet, 334. ^H

iiKht, ^m

pack, 143.

Disinfeaant solutions, 149. ^^H

Colic, infantile, 409.

absolute alcidiol, 15a. ^^H

Collapse, 305.

boric acid, isi. ^H

Colles' fracture, 309.

carbolic acid, 149. ^^|

Colostrum, 393.

corrosive sublimate, 131. 156. ^H

Colpocele, 165,

oxalic add, 15a. [6j. ^H

Coma, 333, 369.

permanganate of potassium, ^^H

Coma-vigil, 369

Compresses, cold. aoS.

Disinfectants. 163. ^^^|

hoi, ao6, 107.

Disinlection of bed pans, 168. ^H

iced, »o8.

or bedding and clothes, 166 ^H

Conception, 369.

of room, 165, 166. ^H

Constipation, in children, 481.

of sputum. 167. ^^H

in typhoid fever, 441.

of sputum-cups, 167. ^^1

Contused wound, 245, 146.

of stools, 166. ^^H

Convalescence, 138.

Diphtheria, 420. 453. ^^H

paralysis after, 453. ^H

eclamptic, 397.

Dislocations. 313. ^^H

in pregnancy, 377.

classification of, 312. ^^H

Cough, 366.

Distilled water, 373. ^^|

Counter-irrilants, an.

Dorsal position for gymecologlcal ^^1

mild, a. 3.

patients, 255. ^^1

Dosage, rule for, 133. ^^H

Crane, 97-

Douche, 177. ^^H

^^H

CrlHis in lever. 1B8.

nasal, 177. ^^H

Croton oil as a counter-irritant.

vaginal, 177. 477. ^H

Drainage. 275. ^^m

Croup. 4>9-

Drainage lubes, a?]. ^^H

membranous. 410.

^^H

rubber, 375. ^^H

H ^^^^H

^^^^^^M

^^^^^^^H

^H Uri:3sings, surgiFal, 376.

^^^^^M

^^1 Drip sheet, 143.

^^^^^m

^H Drowning, 33J-

Eryaipelu, 450. ^^^^^^H

^H Drug habit, 333.

Ether cone, 348- ^^^^^H

Bpray, ^^^^^^^^M

^1 3J3-

Etiquette, 67, ^^^^M

^B loleralion of, 133.

Excreta, disposal of, 166. ^^^H

^B DrycupB,3i3,ii5.

Eihaustion due to cold, 316. ^H

^H Dry heat, loo.

^B application ol, 201.

H DyKentery, 446,

Eye, foreign bodies in, 317. ^^H

■ amcebk, 447.

^P in children. 41J.

^ Dyapepsia, 4S8-

Uyspncea, 198, 360.

Face, eipreaaion of, 361. ^^H

Fahrenheit scale, 184. ^^H

Faintins lit. 321. ^^H

tj.r. foreign bodies in, 31R.

symptoms refi;ralile to. 365.

Eiirachc, 318.

Fever, i3S. ^^H

Gclampsia, 395.

continuous, 188. ^^H

Eczema in children, 431.

crisis in, 188. - ^^M

Emergencies, medical, 320.

intermittent, 18S. |^^H

surgical, 304-

lysis in, 188. ^^M

Empyema. 464.

remittent. 188. ^^^H

Endocarditis, 469.

323- ^^M

Endometritis. 163.

typhoid, 440. ^^m

Enemata, 169.

First year or junior clMB-U'OTfc^-,^^H

amisepiie, 169, 447-

^^M

Fit, apoplectic. JM. ^^H

aalringent, 169, 176.

epileptic, 391. ^^H

Fits in children, 416. ^^H

Flatulence, 368. ^^M

glycerine, 171.

Floors, care of, 83. ^^H

hot water and brandy, 175.

ice-water. 175.

Fonientaliuns, 105. ^^M

laxative, 169. lyi

Food, administration ot, 33S, ^^H

method of Kivin^, 170.

preparation of, 334. ^^^H

nutritive, 169. 17*-

Foods for infants, 403. ^^^H

oil, .71.

lor the sick, 341. ^^H

purgative. 169, 171.

Foo|.bath, 136. ^^M

sedulive, 169, .75.

method of giving. 136. ^^^1

simple, 169, 17a,

Foreign bodies in car. Jtk ^^^1

starch. 176.

^^H

in nose, 317. ^^H

to relieve thirst, 170.

Formalin, 476. .^^^H

turpentloe, 172, 176.

Fracture beds, 95, a^^H

^^KS^^^t ^^

IXD£X 507 ^M

Fr.irtures, .1116.

rinsai Mention uf, 306, J07.

Culles", 309.

secondary, 3S8. ^^M

Pott's, 309.

traumatic, 383, 38S ^H

Tecagnition ol, 306.

3S4- ^M

irealmenl of, 306. 308.

KrcquenI piilac, 193.

Hair, care of pnlients', 134. ^H

Handkerchief bandage, 303. ^^^|

Head nurse, duties of, 58, 75 ^H

Gaslritia, aculc. 457.

Head-rest, 96. ^^M

Heat, 300-307. ^^M

bismuth. 349.

iodoformized. 376.

permanganate, 277.

exhaustion, 333. ^^M

for vxginal packs, sjG.

external applications of, 3<3o. ^^^|

Cm-age, 333.

moist, 303-3O7. *^m

Gelatin capsules, aa6.

Heel-cushloii. 100. ^H

Heel-r»t. 300. ^H

Germicides, 163.

Heller's test fur albumin, 433. ^H

Glass drainage tubes, 175.

Hemiplegia, 464. ^H

Glass noiiles for douches, 177.

Hospital etiquette, 67. ^H

Glycerine enemata, 171.

Hospital ward, 54. ^^H

■ Glycerine, iodoformixed, ajj.

duties of head nurse in, 5^- ^H

Gmelin'5 test for hile, 434.

order of work for nnrses in, ^^^|

Granulation, 347.

Grecnstick fractures, 307.

relation of assistants to head ^^U

Gyna:cotogical patients, ija.

dorsal position for, 355.

schedule of maid's work in, ^|

knee-chest position for, 355.

lateral position (or, 354.

scheduleoforderly'sworkin, ^H

preparation for examination

of- 354. 355.

Hospital private ward, 56- ^M

preparation for operation on,

Hydrophobia, 473' ^^M

35s, 380.

Hydrosalpinx, 36 7. ^^H

upright position lor, 355.

Hygiene in sick-ronm, 105. ^^U

Hypodermic medication, J37. ^^M

method of giving, 338. ^^1

Himateniesis, »«-

Ilamaloma of ovary. 367

syringe, care of, 339. ^H

Hematosalpinx, 3G7

Hysterectomy. 967. ^^M

vaginal, 365. ^^1

Hamoglobinurin, 436.

Hemoptysis, 394.

Hysterorrhaphy, 36S. ^^H

Hemorrhage, 383-396.

arrest of. 384. »93.

^^H

arterial. 384. 293.

Ice. cnuhlng of, 309. ^^^|

capillary, 384.

Ice-bags, 3oS. ^^M

intestinal, 195-

^^^M

post-partum, 388.

Iced compresses, 308. ^^M

primary, a 88.

tce-ivater coils, 309. ^^^H

^^^H^^^^^^^IHI

508 ^1

IcteniB, infantile, 410.

Labor, care of patients after, 3S7<^^^|

IJios)nicrasy, ajj.

duration of, 380. ^^H

Inipacted fratrturt.-. 307.

preparations for, jSu. ^^^|

symptoms preceding. 377. ^^1

Incontinence of urine, 430, 436.

stages of, 377. ^^m

inctiildren, 417.

lemperalure after, 390. ^^^H

Infant bathing. 401.

Lacerated wound, 24s, 246. ^^H

feeding, 403.

Laceration of cervix uteri, 363. ^^H

Infantile jaundice, 410.

perineum. 264. ^^H

paralysis. 417.

Infected wound, 241.

Lavatory, care of S3. ^^H

Inlection, blood, 241.

Lateral position for g>-na!Co1iimJ- ^^^|

Infectious diseases, 439.

cal patients, 154. ^^^|

Lavage of bladder, 261.478. ^^H

causes of, 249,

stomach, 331. ^^H

characters of, »49.

Laxative enemaU, 169. 171- ^H

Inhalations, 331.

Lectures for junior year, 31. 46- ^^H

Insects in ear. 3:8.

intermediate year, 48. ^^H

Insolation, 323.

senior year, 39, 50. ^^M

Insomnia in typhoid fever, 444.

Leeches, 218. ^H

Ligatures. 273. ^H

dressings, 357.

catgut, 274, 478, ^^m

Instruments lor operations, prep-

274- ^H

aration of, -na.

silk-womi gut, 374. ^^H

Intermittent fever, 188.

silver wire, 375. ^^^H

pulse, 193, 194.

Intoxication, alcoholic, 3*a.

Linseed poultice. 303. ^^^^^^H

Inunction, 331.

Lochia, ^^^^^^H

^^^^^^1

Iodine applications, 314.

serosa, 391. ^^^^^^^H

Lockjaw, ^^^^^^H

Inhalers for chloroform, 338.

Locomotor ataxia, 460. ^^^^^^^H

lodoforniized gauie, 976.

Lotions. ^^^^^1

glycerine, 377.
oil, 277-
Irregular pulse, 193.

^^^^^H

^^^^H

^^^^B

Mattress, care of, 86. ^^^^^H

^^^^^H

Jaw, fracture of, 309,

^^^^^H

Meconium, 40a. ^^^^^^B

Medication, rectal, 175, 330. ^^^1

Keith's dressing, 150.

subcutaneous, 317. ^^H

Kncf-chest, position for gymeco-

Medicines, 333- ^H

logical patients, 333.

administration of 22]. ^^H

Knee-cushion, 98.

by mouth, 225. ^H

incompatible. 334. ^^H

time of giving, 234. .^^1

Labor, 377.

Medicine closet, 53, 336. ^^H

bed, 3S1.

Membranes, rupture of, 37C ^^H

^^^B^^^l ^^1

INDEX

509 ^1

'■

Meningitis. 416, 466.

Obstetrics, 371.

Metric system, 153.

(£denia, 470,

Metritis. 263.

Oil enemata, :?!.

Micrococcus, 340.

Oophorectomy, a67-

Milk diet. 34>-

Operating room, care of, 178. ^^^|

(ever, 392.

linen list (or, 378, 979

of lime, 164.

Operation, care of patien

after,

modification o(, 404.

344. »59'

in private houses, a8i

sterilization of, 406.

nourishment after, 345

Miscarriage, 376.

preparation ol patie

ts for,

Mitral insufficiency, 4^-

343. »S8,

regurgitation, 469,

Ophthalmia neonatorum, 4

stenosis, 469.

Orthopncea, 19S.

MonoplcRia. 46s-

Ovarian cystoma, 167.

Mouth of patient, care of, 115-

Ovariotomy, 367.

Mouth-washes, l»S-

Ovaritis, 366,

Mumps, 416.

Ovary, abscess of. 366.

Mustard foot-bath, 136.

cystoma of. 267.

leaves, aij.

poultice, aia.

Myomectomy, 367.

Oxalic acid. IS3, 165.
Oialuria, 434.

Nephritis. 437.

Pads and cushions, 98, 100

Neuralgia, 466.

Pack, cold, 143.

New-born, bathing, 401.

hot, 475-

care of, 3B6, 399.

Pain, 361.

skin in, 408.

Palpitation, 470.

sleep for, 408.

Paquelin cautery, 319.

New-patients, treatment of, 1 18.

care of, an.

Nightingales, 199-

preparation of, a»o.

Night nurse, duties ol, 74.

uses of. 321.

Nipples, care of, 393,

Paralysis, 464.

Nitric-acid test for albumin, 431,

Paraplegia, 463.

433-

Paresis. 464.

NItriteof Amyl, 93a.

Parotitis, 436.

Non-infected wound, 346.

Parovarian cyst, 368.

Normal salt solution, 971.

pericarditis, 469.

flask for, 172.

Nose, foreign bodies in, 317.

care of patients after.

260,

Nose-bleed, 390.

Nurse, outlines of ward work for,

Perineum, laceration <A

364, H

62.81.

378. 38s-

recreation hours for, 7a.

Nurse's toilet basket, 79.

Permanganate of potassiu

>5«, ■

Nutritive enemata, 169, 17a.

'65.

Nylaniler's lest for sugar, 43a.

1
1

^^■^B

^^■^H

510 ^^^1

Pessary. ri'tiiovBl of, as7-

Pj-icmis, 451-

PilK, adininlstralion o(, iid.

i'ydiii!s,435.

Placenta, 374. 375-

Pjcr's iialtlii-s in typhoid le*

care of. 387.

440,

delivery ol. 379.

Pyosalpin;<, i66.

Plaster or Paris bandames. 301.

Pleurisy. 463-

purulent, 464.

Rachitis, sec Rickets, 418.

Reaumur scale, :a4.

Rectal medication, 175, 330.

corrosive, and antidotes, 327

irritant, and antidotes. 388.

Reclocele, a66.

narcotic, and Bntidotes. 33S.

Relaxed vaginal outlet, 964.

Poisons and antidotes, talile of.

Remittent (ever. 188.

3»ft-330-

Report, night, 370.

Polypi, uterine and cervical, 265.

nurse's weekly, 53.

Post-parlum hsmorrliage, 388.

Respiration, 196.

artificial, 334,

165.

cliaraclere of, 197.

Pu-t's (ratture, 309.

Cbeyne-SloJus', 197.

fuulticea, 203.

BtcrtorouB, 197.

carboliied, 1^a^.

taking the, 197.

Rest cure, 467.

linseed. 103.

KelL-nliun of urine, 430.

starch, J05.

Rheumatism, acute, 47'-

Pregnancy, 371.

Ribs, fracture of, 309.

changes during, 371, 37^-

Rice-water, 343. 4'>6-

eWra-uterine. 268.

Rickets. 418.

rule for calculation of, 373.

RiK'"-». 363-

Rounds, gynsecologicat, »57

medical, 333.

Puerperal fever. 394.

surgical. ^49-

insanity. 396.

Rubefacients, aia.

state, 389.

Rubella, 413.

albuminuria in, 396.

signs of, 39>.

Salpingitis, 166.

Pulse, 190.

Salpingitis and ovaritis, 166

Salpingo-odphorectomy, Jfi?.

dicrotic, 194.

Salt bags, 30I.

frequent, 193.

Salt bath, 140.

inlennittent, igj.

Salt solution, 17 c.

irregular. 193.

flask for, 173.

strong, 193.

Saprsemia. 451. ^^J

tension of, r94.

^^^^m

types of, 193.

Scarlet fever, 413. ^^^^^^^H

Pulse and respiration, 196.

Sciatica. 466. ^^^^^^H

Purgative enemota, 169, 173.

Scultetus bandage. ^S^S^^^^H

Pus-formation. 141.

Second year clasa-worti, ^^^^^^1

Pu« in urine, 434.

^^^^3^H^I ^^1

511.^1

Seplicaemin, 341. 4,i;n.

Suppression of ttrine. 430.

Shock. 301, .105,

Stirsicnl liressiiigs. 176.

Sick, lifting and mnvini! of Iht,

Surgical emergencies, 304, 308.

Surgical operaling-rooni, 369. 178.

Silk ligatures, 874.

care of, 178.

Silkworm gul. 174.

linen list (or, 378,

Silver wire ligatures, J7S.

Surgical rounds, preparationa foTi

Sim's position, J54.

149.

Skin, condition of, 365.

rubber cushion, 382.

diBinfection of, 143,

Suture materials, 373.

grafting, 247.

Symptoms, objective, 357.

Sleep, record of, 364-

observation of, 355.

Sniall poj, 44a.

subjective. 357.

Solutions, preparation of, 155.171'

S|>eculuni, 356.

Splinls, 310.

S|>ongebalh, 141.

Tabes, 465.

S|>ongcs, a77-

Tampons. 156.

preparation of. 177.

Sponges for mouth, iss-

365.

S|.r«in.,3,3.

Teeth of patients, care of. us.

Sprue, 4".

Temperature. iSi.

Sputum-cups, 116, 455.

abnormal, 183.

Sputum, precautions with, 117,

charting of, 1B7. 189.

455.

mode o( taking, 185.

Starch bandages, 397.

mouth. 185.

hath, 475.

nnrmnl, i8a.

poullite, i.i.i-

parado.ttcal, 18S.

SIfnosis at os uteri, 163.

rectal. 185.

Slcriliiation, 163, 476.

Temperature of body, varialloni

of mil k, 406-

of. .84-

Sleriliier, i6j, 270.

Tensionof pulse, 194.

Stertorous breathing, 197.

Tetanus, 451.

Text -books, la.

Slamach, capacity of, 481.

Thermic fever, 313.

washing. 33a.

Stretcher, 119.

care of, 1S6.

Stupe, aos. !"4. 477-

Throat, obstruction in, 319.

Stupe- wringer, 306.

Thrush, 412.

St. Vitus' dance. 418.

Subcutaneous medication, «7.

Tonpie, condition o(, 364.

Tonsillitis, 457.

Sugar in urine, tCBtB for, 43a.

fermentation test (or, 431.

Training, two years' course. iS,

34-42.

43»-

three years' course, 42-51.

qu&nlitative lest (or, 433.

Training school, 17.

Troramer's test for, 431.

admission ol pupils Id,

Sunshine, importance of, 116.

Sunstroke. 3*3.

books o[ reference for.

Suppositories, ajo.

512 ;^'DEX ^H

Training school, class- work, 94, ss.

Urine, sediments in, 431, 453,

division ol tirnc, iS. U-

specific gravity of. 430.

fiiTi year, or junior tlnss-

specimens of, 180. 435.

«ork, i+, 44, 46.

suppression of, 430.

intermediate year, 44,

Uterine hsEmorrhage, 292. 388.

48.

of^nization and man-

agement, 17.

Vapor bath, ij8, 903.

schedule for junior lec-

Vapors, 231,

tures, 31, 46.

Vaginal douche, 177.

schedule for intermedi-

examinations, 383.

ate lectures, 48.

hysterectomy, 365.

schedule for senior lec-

outlet, relaxed. 964.

tures, 39, 50.

packs. 156.

senior j'ear-s work, 33.

Variola, 448.

43-

Venesection, 339,

Triangular bandage, 30*.

Ventilation, 107.

Triturates, 227.

artificial, 112.

Trornmer's test fi)r sugar, 439.

Tuberculous sjiulum, 455,

Vesicants, 917

Tuberculosis, pulmonary-, 454.

Vocabulary, 484-309,

bacillus of, 3(17, 4S5.

Vomitus, 368.

Turpentine enemata, 17a, 176.

Turpentine stupes, jr4, 465.

Wafers, 226

Typhoid fever, 440.

Ward, booic lor general suppiie*

baths in, 14., 143.

79-

constipation in. 442.

care of bed in. Sj.

care of utensils in, 86.

diet in. 444.

daily care of, 81.

hsmorrhagc in, 44s.

floor, care of, 81.

linen book. 78.

perforation of intestines in.

private, 56.

443.

supplies. 77,

Pyer's patches in. 440.

temperature of, 106.

relapse in. 443 -

ventilation of, 107,

tympanites in, 443.

weekly care of, 84.

Water in febrile diseases, 34a.

Water-bed, 101.

Umbilical cord, 375, 385. 386. 399.

Wei cups, 215.

Umbilicus, bleeding from, 194.

Whooping cough, 427.

care of the. 401.

Wound-infection, 941.

Upright condition for gynaecolog-

Wounds, 241.

ical patients, ajS-

aseptic. 947.

Ursmia, 436.

classilication of, 945.

Urine. 41S.

contused, 145.

bile in, 434.

healing of, 245-947-

color of, 430.

incised, 245.

incontinence of, 417.430, 436-

infected, 241, 142. 246

1 procaulions with, 477.

lacerated, 24s. 246.

h reaction of, 4*9

iion-infeded. 946.

■ retenlioB of, 391. 4J0, 436.

punctured, 243.

m^H

^* LANE MKUICAL LIBRARY

J5jf1 To avoid fine, this book should he rflun^.l
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